The Encyclopedia of Asthma and Respiratory Disorders (Facts on File Library of Health and Living)

THE ENCYCLOPEDIA OF

ASTHMA AND RESPIRATORY DISORDERS

THE ENCYCLOPEDIA OF

ASTHMA AND RESPIRATORY DISORDERS Tova Navarra, B.A., R.N. Foreword by Charles K. Dadzie, M.D., F.A.A.P., F.C.C.P., Director of Pediatric Pulmonology and Critical Care Medicine, Jersey Shore Medical Center, Meridian Health System; Clinical Assistant Professor, Pediatrics, U.M.D.N.J., Robert Wood Johnson Medical School

The Encyclopedia of Asthma and Respiratory Disorders Copyright © 2003 by Tova Navarra All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information contact: Facts On File, Inc. 132 West 31st Street New York NY 10001 Library of Congress Cataloging-in-Publication Data The encyclopedia of asthma and respiratory disorders / Tova Navarra ; foreword by Charles K. Dadzie p. cm. Includes bibliographical references and index. ISBN 0-8160-4467-8 1. Respiratory organs—Diseases—Encyclopedias. 2. Asthma—Encyclopedias. I. Title. RC732 .N37 2002 616.2’38’003—dc21 2002002445

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To Vincent Paul Fleming, my first grandchild, whose every breath reinforces and imbues my life with all manner of inspiration.

CONTENTS Foreword

Preface

Acknowledgments

xiii

Introduction

Entries A–Z

Appendixes

215

Bibliography

377

Index

381

FOREWORD pig in her bedroom. Sometimes she even let the guinea pig on the bed. When I did a radioallergosorbent test (RAST) on her, I found her to be a Class 6 for allergy to guinea pigs! I believed she should get rid of the pet, but it’s very hard to tell a kid to do that. So she takes Serevent and other medications that help ward off asthma attacks. Parents of children who have been diagnosed with asthma, as well as those parents who have been questioning the validity of giving their children drugs to control asthma, will find this book extremely informative and useful. This book will help in understanding some of the basic concepts and definitions of asthma that have boggled their minds for a while. Tova Navarra has a knack for making complex concepts and definitions easy to comprehend. This quality is easily appreciated in perusing her previous publications The Encyclopedia of Allergies, Second Edition and The Encyclopedia of Vitamins, Minerals and Supplements. She has written this book, The Encyclopedia of Asthma and Respiratory Disorders, with both professional and lay public in mind because they can all benefit from reading it. No one with interest in asthma should be without this book. Tova Navarra, an erudite clinical professional, has done it again!

sthma is a very common problem worldwide with incidence in the United States on the rise, especially among children. I remember a 12-year-old patient of mine some years ago whose pulmonary status was that of severe obstruction. I first saw him when he was in the intensive care unit, but he refused to come for continuous care. He took his medications at home. He was a tough kid—one of the toughest I’d ever encountered—and he was angry and did not accept that he had life-threatening asthma. I warned his parents, and I sat down with him to tell him with proper treatment he could be like any other kid. He said, “I’m not like any other kid, and I won’t go to the emergency room.” Unwilling to seek preventive measures, the boy died. A preventable death. Another patient of mine, about nine years old, thought he had only mild asthma. I’ll never forget him, because he wanted to go to a slumber party with his friends, much to the dismay of his mother, who was accused of being overprotective. He needed treatment episodically, and his mother agreed to let him go to the party as long as he took his inhaler with him, which he did. The group then went to a recreational facility similar to Great Adventure, where the boy must have felt sick but was hiding it because he didn’t want to have to leave the party. He collapsed. By the time people got him to the ER, he was brain dead. Again, preventable. A somewhat happier story involves a 13-yearold girl I was treating with continuous nebulization for frequent asthma attacks. She kept a pet guinea

—Charles K. Dadzie, M.D., F.A.A.P., F.C.C.P., Director of Pediatric Pulmonology and Critical Care Medicine, Jersey Shore Medical Center, Meridian Health System; Clinical Assistant Professor, Pediatrics, U.M.D.N.J., Robert Wood Johnson Medical School

PREFACE 548,000 people in the United States and 20 million worldwide. Today, flu and pneumonia combined are the sixth leading cause of death in America, which warrants many physicians’ urging their patients to get a “flu and/or pneu” shot each year well before the difficult cold weather is able to stress the human system a bit more than warmer temperatures do. It seems, too, that when hay fever lets up, the common cold rushes in. The “heat” is on to protect our respiratory systems in an age that claims to be more aware and knowledgeable about prevention, but, unfortunately, prevention remains the most elusive of common medical and hygienic practices. Organizations such as the American Lung Association and others seek to answer as many questions as they can as a way to educate the general population, sponsor research toward cures and treatments, and keep tabs on the trends and statistics related to respiratory disorders, lest we become complacent and thereby vulnerable to whatever new or old strain of microorganism may be waiting in the wings. This book’s “reason to breathe” is to promote prevention and add comprehensively and accessibly to the literature on diseases that affect our airways, which more often than not we take for granted.

reath is life, and breathing disorders threaten life. Lung disease is the third leading cause of death in America. Over the last decade, the death rate from lung disease has been growing faster than the death rate from almost any other leading killer. Approximately 30 million people in the United States suffer from some form of chronic breathing disorder, which generates a cost of $85 billion in health care a year. It is important to realize that 5 percent of all adults and 10 percent of children in the United States suffer from asthma, according to the American Medical Association. Asthma is the most common diagnosis among children’s diseases, and it seems to be on the rise because of increased air pollution and, possibly, increased stress factors. More than 5,000 people die from asthma each year, a good portion of them children and blacks. In addition to asthma, other enemies of breath are still lurking among millions of people all over the world. Tuberculosis has made a comeback with resistant strains of the Mycobacterium. Lung cancer and emphysema haven’t ceased to haunt persistent smokers as well as strike nonsmokers for some known and some unknown reasons. Influenza, bronchitis, and pneumonia continue to loom large every winter, particularly for infants, the infirm, and the elderly. In 1918, a flu epidemic killed

—Tova Navarra, B.A., R.N.

ACKNOWLEDGMENTS

henever I face the daunting task of writing a book that must be scientific, accurate, comprehensive, and accessible, I realize the importance of those who encourage me and provide valuable assistance. For their generous help with this volume, I heartily thank my daughter and journalist/lyricist, Yolanda Fleming, the late Myron A. Lipkowitz, R.P., M.D., my former coauthor, and Martin Corbo, who provided important reference materials. I offer a very special thankyou to Jim Reme. Many thanks to Dr. Charles Dadzie for praising my work so highly and adding his distinguished name to this book. In addition, Facts On File’s James Chambers and his staff are excellent, diligent editors with whom I am honored to work, and my agent Faith Hamlin deserves high praise for making a “perfect match.” Thanks also go to Frederic C. Pachman, director of the medical library at Monmouth Medical Center in

Long Branch, New Jersey. I am also infinitely grateful to Victor Zak, Paul Boyd, Bunny Schuler, Mona Wichman, Dorothy Fox, Johnny and Mitzi Navarra, Guy, Amanda, and Wesley Fleming, Jacquie, Tony, and Matthew Munoz, Lilo Meany, Sallie and Stan Tillman, Jordan Stinemeyer, Trista Clayton, Richard Conley, Dr. Andrea Campbell, and Betty Sorrentino, who lighten and brighten my days, do me endless favors, and tolerate a lot of whining. Finally, I feel moved to acknowledge a CD entitled One Single Breath, produced in 2000 by my daughter and son-in-law (Yolanda and Guy Fleming) as I began to write this book. The music is meditative and nothing short of awe-inspiring. The group itself, called One Single Breath, hopes to promote and raise money through its music for a charitable organization that focuses on asthma and breathing disorders.

xiii

INTRODUCTION Losing my breath again, never wanted to, what am I to do, can’t help it.

of breathing by conducting an exercise in which people were instructed to breathe in rhythm with each other. If nothing else, the exercise induced a keener awareness of taking in and letting out that all-important air, and brought to mind the 1974 pop song performed by the Hollies whose refrain ends with the line, “All I need is the air that I breathe and to love you.” Inspiration also means, perhaps more literally than we think, having ideas, decisions, or other concepts “breathed” into our minds from “nowhere,” usually toward a creative goal. “Breathtaking” is often the adjective that applies well to the panoramas of the Rocky Mountains, Michelangelo’s David, and other wondrous accomplishments. To be deprived of breath seems the ultimate enemy. Impaired breathing of any sort, frequently explained within the categories of various respiratory disorders, may be as symbolic as it is physical and is employed heavily as an artistic motif. In emergency medicine, one relates immediately to the choking victim’s hand at his throat—an image instinctively meant to alarm others—indicating that he can’t breathe. Similarly in literature and other arts, the plight of society’s victims may well be intensified by a respiratory disorder. Mildred in Somerset Maugham’s Of Human Bondage and Thomas Mann’s protagonist in The Magic Mountain suffered from tuberculosis. The leading female characters of the 1937 film Camille, Kathryn Hulme’s The Nun’s Story, and Puccini’s opera La Boheme also had TB. In the television series

—from “Falling in Love Again,” the signature song in the film The Blue Angel

Inspiration. From the Latin inspirare, to breathe in, we inherit a word that has dual meaning. First and foremost, it gives verbal acknowledgment to the most fundamental of all human activities: to take in the air our bodies crave in order to live. It tops the medical list of priorities commonly known as “ABC,” a mnemonic for assessing the status of emergency patients’ airway, breathing, and circulation. Breathing ranks supreme in religious teachings as well. In The Upanishads: Breath of the Eternal, part of the oldest Hindu scriptures, it is written: “O Prana, lord of creation, thou movest in the womb, and art born again. To thee, who, as breath, dwellest in the body, all creatures bring offerings.” Pranayama refers to yoga exercises during which one concentrates intensely on breathing patterns. The Incan word for God is expressed as “ha” in a forceful puff of air without the need for any more than a whisper-like sound—as much a reverence for the Greater Power as for the very ability to breathe. The exchange of oxygen for the exhaled carbon dioxide, then, goes far beyond the human requirement for the preferred gas, as author Dannion Brinkley put it, to symbiotic breathing described as “in for me, out for the universe.” He pointed even more emphatically to the significance

xvi The Encyclopedia of Asthma and Respiratory Disorders I, Claudius, the demented Caligula solved his intolerance of a young boy’s chronic cough by having him beheaded. On the lighter side, the hapless Adelaide in Broadway’s Guys and Dolls sneezed endlessly and worried about catching “la grippe” because her fiance, Nathan Detroit, kept eluding a wedding day. One may speculate whether the character called Wheezer in The Little Rascals had asthma or some breathing or allergy problem. In one episode, he suffers a coughing fit when he is near ducks. Many a dark-humored line in television sitcoms refers to an asthmatic child’s missing inhaler. Monmouth University photographer Jim Reme remembers his Little League coaching days during which one of his players had asthma. Before each game, the boy would give Jim custody of his inhaler and forget to retrieve it afterward. Late into the night, Jim would receive a call from the boy’s mother asking for the inhaler’s safe return. Real-life stories offer as much drama and impact as fictional ones. In December 1988, artist Linda Troeller exhibited 20 photocollages entitled TB-AIDS Diary at the City Without Walls Gallery in Newark, New Jersey. The images drew biting parallels between the disease that attacked her mother and countless others in the 1930s and the disease of the 1980s that initially burst into the male hom*osexual community. In both cases, the artist said, the diseases are deadly and infectious, and the victims have been stigmatized by people around them out of ignorance and fear. Dr. Richard Conviser, then health policy analyst of the State Department of Health in Trenton, New Jersey, praised Troeller’s exhibit, which won the PhotoMetro portfolio award in 1987 and other recognitions. On the everyday scene, one woman recounted to a group of friends that after she had legally parked in a spot designated for those with handicapped symbols on their cars and walked to a store, a man confronted her and said angrily, “You don’t look handicapped to me!” “Sir,” she replied, “I have a breathing disorder.” Asthma—the disorder synonymous with a chronic delicacy of constitution and the bane of famous individuals including French novelist Marcel Proust—beleaguers one of William Golding’s

protagonists in Lord of the Flies. In the book’s first chapter, Piggy, as he is called, admitted his physical ineptitude to the robust leader, a boy named Ralph: “‘My auntie told me not to run,’ he explained, ‘on account of my asthma.’ ‘Ass-mar?’ ‘That’s right. Can’t catch me breath. I was the only boy in our school what had asthma,’ said the fat boy with a touch of pride. ‘And I’ve been wearing specs since I was three.’”

The impact of asthma is clear, particularly for children who are set apart by it. Representative Nita M. Lowey of New York referred to the number of children suffering from asthma as “nothing short of a crisis,” following news reports in May 2000 that about 130,000 children in New York City are afflicted and that asthma is the leading cause of absenteeism from school. The recent film As Good as It Gets, which earned actors Jack Nicholson and Helen Hunt Academy Awards, focuses on a woman’s son who has severe asthma, and because she has limited resources and keeps taking him to the emergency room for treatment, the child receives no continuous medical care or follow-up until the protagonist appears and offers to pay for the doctors. This is not unlike situations that actually happen, and, unfortunately, all too often. On a larger scale in real life, as historian Paul Boyd wrote, there is the “well-documented phenomenon called ‘the toxic ghetto.’ The term reflects the fact that where there’s a dirty manufacturing plant, a smokestack industry, a landfill or a dump looking for a site, disproportionately, the selection falls on poor neighborhoods. The result is that bad-ecology illnesses are poverty illnesses in toxic ghettos, probably with asthma as one of the top outcomes.” The Centers for Disease Control and Prevention (CDC) reported in a 1998 survey that black children were 31 percent more likely than white children to have had an episode of asthma or an asthma attack during the previous year. Lara Akinbami, of the CDC’s National Center for Health Statistics, said, “In 1998, 68 out of 1,000 black children had asthma versus only 52 out of 1,000 white children. Black children are much more likely to be hospitalized or die from asthma.” So the

Introduction xvii racial gap expands for young people with a chronic respiratory disease. In addition, more inner-city children fall victim to asthma triggered by co*ckroach and mouse allergens than by cats, dogs, and house-dust mites, according to a federally funded report. Researchers at Johns Hopkins University found that in eight urban areas studied, 95 percent of the tested homes harbored mouse allergens, and 18 percent of the children who live in them are allergic to mice and tend to have severe asthma. In 1996, information from the National Cooperative Inner-City Asthma Study conducted in Baltimore, Washington, the Bronx and Brooklyn in New York City, St. Louis, Chicago, Cleveland, and Detroit brought forth the discovery that, of the 1,528 children ages 4 to 9 in the study, all had asthma and lived in communities in which 30 percent or more household incomes dipped below the 1990 poverty level. Hence, “inner-city asthma” has become a bona fide diagnosis attributable to insects, rodents, and the rank of the underprivileged. Urban areas in which there is a significant amount of industry—and the bad air that accompanies it—thunder into the picture as well. The New York Times reported on February 28, 2001, that the U.S. Supreme Court unanimously decided “in setting national air quality standards, the Environmental Protection Agency must consider only the requirements of public health and safety and may not engage in the cost-benefit analysis that a coalition of industry groups sought to import into the (Clean Air Act) statute. . . . The decision today dealt with new standards for two pollutants—groundlevel ozone, which causes smog, and fine airborne particles, commonly known as soot—that the Environmental Protection Agency issued in 1997.” At last, facing the grim toll taken by asthma, bronchitis, and other respiratory disorders caused and/or aggravated by air pollution, the federal government has rejected an industry attack in one of the most important environmental rulings in years. The Asthma in America: Executive Summary, conducted by Schulman, Ronca & Bucuvalas, a national research firm specializing in health issues, took the asthma connection a few steps further into the realm of what might be called the “secondary smoke” of the condition: “Nearly half of the

American public (48 percent) have had asthma themselves, or in their household, or in their immediate family. Another three out of 10 (29 percent) know friends, coworkers, or someone else personally who has asthma. Hence, nearly four out of five Americans (77 percent) are affected.” It stands to reason that if the person next to you, familiar or unfamiliar, suddenly starts gasping for air, your psyche will be moved. “‘I didn’t want to wake up this morning,’ said Northwestern coach Randy Walker, still fighting back tears and trying to control his emotions yesterday afternoon. . . .” in the Asbury Park Press’s August 5, 2001, story about a college football player. “The breathing problems that forced Rashidi Wheeler out of a conditioning drill didn’t seem to be any different from the 30 other asthma attacks he’d had while playing football the past three years. But the Northwestern safety was never able to catch his breath Friday afternoon and later died. Bronchial asthma was the preliminary cause of death, the Cook County coroner’s office ruled yesterday.” Boyd also points out that asthma has been dubbed “The Breath Robber You Can Stop.” Numerous self-help books for adults and children with asthma pepper the shelves, including Go Blow Your Nose, Robert! by Nancy Sander, president of the Allergy and Asthma Network/Mothers of Asthmatics, Inc., based in Fairfax, Virginia. In addition, the pervasive disorder prompted a movement called “asthma-friendliness” in schools, and asthma camps provide a tremendous service for children who may not otherwise be able to enjoy summer outdoor sports and activities. Modern literature and scientific advances stand as the fine result of an entire time-line of effort and study so people can “breathe easier,” as the saying goes. As early as the second century A.D., Aretaeus of Cappadocia described “bronchial asthma,” a term widely used for hundreds of years. In 1565, Leonardo Botallo described an asthma-like condition he called the “Rose Cold.” J. B. van Helmont in 1607 wrote of “spasmodic attacks of difficult breathing” with symptom-free periods between attacks. In 1713, Ramazzini recognized a hypersensitivity-pneumonitis-like lung disease in grain workers. The English physician John Bostock in 1819 was one of the first to describe multiple cases

xviii The Encyclopedia of Asthma and Respiratory Disorders suggestive of hay fever, which was called “Bostock’s summer catarrh.” Eleven years later John Elliotson noted a patient’s observation that pollen might be responsible for his symptoms. In 1890 Robert Koch discovered and extracted the tubercle bacillus, Mycobacterium tuberculosis, that causes tuberculosis. A worldwide malady transmitted by the inhalation of minute droplets from the cough or sneeze of an infected person, tuberculosis is still one of the chief causes of death in Third World countries. Even animals, such as cattle and other domestic animals, are susceptible to certain forms of TB. During the early 20th century, poor hygienic standards and periods of war and catastrophe resulted in high death rates from tuberculosis, but the drugs rifampin, isoniazid, para-aminosalicylic acid, and streptomycin eventually came about to fight it. Before the drugs were developed, sanatoriums operated to foster good nutrition, hygiene, fresh air, and exercise for the prevention and treatment of the disease. Potions falling under the moniker of folk medicine had their day, too. Until 1905 when coca leaf extracts were eliminated from Coca-Cola’s original formula, which contained “a little something to put color in your cheeks,” as Dr. Sigmund Freud put it, heroin was a popular over-the-counter cough suppressant. No doubt it was so effective that some patients saw to it they never coughed again. Recently, tuberculosis made a gruesome comeback in Japan, particularly in the elderly who had at one time been exposed to the infection but did not previously exhibit symptoms. A New York City television newscast of February 11, 2001, reported that Japanese officials were embarrassed that a disease for which there has been effective early detection and treatment for decades re-exploded among the frailest of their population. Tuberculosis has also presented as a complication in AIDS patients, in which the victim’s immune system cannot effectively ward off the invader, and in emigrants from certain countries who arrive in the United States with the infection, who do not understand contagion, and may refuse to comply with hospital treatment that seems to them like a punishing incarceration. Professionals as well shared in some of the misunderstandings that unwittingly allow disease to

flourish. After Dr. Alexander Fleming of St. Mary’s Hospital Medical School in London brought forth penicillin in 1928, it languished unused for nearly 10 years. By 1943, people had to pay $20 per 100,000-unit dose of the drug that proved effective against pneumonia and a host of other diseases. About 30 years passed after Austrian chemist Paul Gelmo discovered the white crystalline sulfanilamide in 1908, derivatives of which were eventually recognized as enemies of Staphylococcus and Streptococcus infections, pneumonia, meningitis, dysentery, and leprosy. The history of pathology always includes an evolution of sorts, for as one “devil” is recognized and perhaps conquered, another appears. In the late 19th century, Henry Salter concluded a correlation between asthma and hay fever and animal exposure. Sir Henry Dale discovered histamine in 1910 while working on rye poisoning by ergot. He noted the shock-like drop in blood pressure histamine caused by its effect on smooth muscle. Three years later, W. P. Dunbar reproduced the symptoms of hay fever using pollen extracts. Also in the 1900s Charles F. Cole established a test for histamines, and in the 1920s, Kern, Cooke, and Storm van Leeuwen demonstrated that many asthmatics had positive skin-test reactions to house dust. Storm van Leeuwen also removed asthma patients from their homes to demonstrate that changing one’s environment could improve asthma. Medical studies progressed. In 1942, the French produced the first antihistamine safe for human use—phenbenzamine (Antergan), closely followed by pyrilamine maleate (Neo-Antergan). In the United States, researchers developed diphenhydramine (Benadryl) and tripelennamine (Pyribenzamine). In 1950 corticosteroids were first used to treat asthma. The history of medicine continued to make stride after stride in the effort to treat or eradicate both major and minor infections and to understand the body’s immune system and why it suffered repeated attacks of determined microorganisms. Enter the “super bug” of the 21st century. “Shortly after the introduction of penicillin-G in the 1940s, it was recognized that certain strains of staphylococci have a potent enzyme called ßlactamase which inactivates penicillin,” writes

Introduction xix Jacqueline Fuccello-Breuer, R.N., in the February 5, 2001, issue of the New York-New Jersey Nursing Spectrum. “In patients with such staphylococcal infections, penicillin-G has no therapeutic effect. Since then some organisms have not only developed resistance to one antibiotic, but have developed resistance to many. Pharmaceutical companies in the 1970s and into the late 1980s developed newer and stronger antimicrobial agents—three generations of cephalosporins and the fluoroquinolones. These antibiotics were considered sophisticated enough to control bacterial infections; and drug development efforts were redirected to cardiovascular, metabolic, and psychoactive drugs.” Fuccello-Breuer goes on to describe the toll of “super bugs” as a major new health problem and how we’ve set the stage for their success: “Ninetyfive percent of physicians in office practice issue one or more prescriptions to a patient diagnosed with the ‘common cold.’ Similarly, a hospital study revealed that there was no evidence of infection in as many as 70 percent of patients who received antimicrobial therapy.” In the category of “super bugs” also stands the problem of vermin- and insect-related incidences of asthma, particularly in New York City, where the respiratory environment is compromised. In the article “Asthma: A Public Health Partnership Tackles a Neighborhood Terror” (Columbia University Magazine, Winter 2001), author Dodi Schultz says the Columbia Center for Children’s Environmental Health (CCCEH) was established in 1998 “with the far-reaching mission of preventing environmentally related disease in children. It receives support from the National Institute of Environmental Health Sciences (NIEHS), the Environmental Protection Agency (EPA), and several foundations. Its ‘patients’ are the children of northern Manhattan and the South Bronx. Its special areas of concern are three: low birthweights coupled with impaired growth and development; unusually high, and inexplicably rising, local rates of childhood cancer; and—the primary child-health concern as perceived by both researchers and residents themselves, based on community surveys—the devastating impact of asthma. Asthma levels in the Columbia study area are startling: In the South

Bronx, 17 percent of all children—two of every dozen kids—are asthmatic.” The study expects to involve 600 African-American and Latino women and their children through prenatal clinics. CCCEH director Frederica Perera said this is a pioneering study to examine prenatal and perinatal influences on the children’s medical status through analysis of the home environment, and blood and other body-substance analysis. Reported exposure to tobacco smoke, for example, may be assessed through cotinine levels (cotinine in the urine is considered a biomarker for exposure to nicotine). The study also plans to include environmental factors such as pollutants—ozone, oxides of sulfur and nitrogen, particulates (ash and soot), etc.— because they affect the quality of breathable air. “Particulate matter—known in the trade simply as PM—broadly includes all small airborne solids, ranging in size from visible smokestack effluent to the tiniest microscopic bits,” according to Schultz. “It’s the latter category that worries pulmonary specialists and public-health researchers, in particular those particles known as PM2.5; that designation denotes those with a diameter of 2.5 microns or less. Larger particles, as irritating as they are, are relatively harmless, since they’re trapped, coughed up, or blown out of the nose. The smaller particles, though, easily penetrate the bronchial tubes and even the lung’s small passageways. Researchers have repeatedly found these particulates statistically associated with markedly higher risks of disease and death.” Diesel and other exhaust fumes from vehicles are another concern to be addressed by the Columbia study, along with dust mites, co*ckroaches, pets, and other aspects of what has been dubbed “the toxic home.” The leading investigator on the CCCEH asthma project is Jean Ford, M.D., chief of pulmonary medicine at Harlem Hospital. He also heads the Harlem Asthma Research Team (HART), which operates (in affiliation with Columbia) under a grant from the National Institutes of Health. Ford is also a member of the National Heart, Lung, and Blood Institute’s expert panel on asthma management, and sits on the board of West Harlem Environmental Action (WE ACT), an activist group dedicated to environmental justice.

xx The Encyclopedia of Asthma and Respiratory Disorders While New York City, with the highest asthma mortality rates in the country, combats asthma and respiratory disorders, the diseases exist all over the globe. Schultz goes on to report that “scientists are more and more inclined to believe that, while who you are (family, race) may play a part, what you do and where you live may play far more significant roles. Speculations have postulated roles for factors ranging from day care and too many (or too few) childhood infections to junk food and use of computers. But we are, after all, talking about the lungs. The most significant factor of all may be the air you breathe, both indoors and out. The ethnic groups with the highest incidence are chiefly city dwellers. Even within broad ethnic groups, noted differences—again, particularly in acute-attack data—may be suggestive. Asthma mortality rates, for example, are markedly higher among Hispanics from the Caribbean; the rate among Puerto Ricans is approximately four and one half times that of Mexican Americans.” New drugs are being investigated to help fight all the entities that terrorize the respiratory system, but risk is always at hand in well-meaning research. A June 15, 2001, article in The New York Times reports that a 24-year-old healthy volunteer in a Johns Hopkins University breathing study died June 2 after inhaling hexamethonium, a drug used to determine how the lung protects the airways from narrowing, which plays a crucial role in asthma. The drug had been used in several studies of lung physiology at leading academic medical centers without any unexpected ill effects, said Johns Hopkins, but volunteer Ellen Roche died from progressive lung and kidney failure brought on by hexamethonium inhalation. The day after the chemical was administered to her, Ms. Roche

developed a cough, fever, runny nose, and fatigue. Before her death, the article says, “a CAT scan revealed that her lungs had the appearance of ground glass, indicating severe damage, and two days later she was put on a ventilator.” The study has been suspended, and the case is now under federal investigation. One may conclude that breathing, which ought to be easy, is all too frequently impaired either voluntarily or involuntarily. Alexander Lowen, M.D., said, “Most people are poor breathers. Their breathing is shallow, and they have a tendency to hold their breath in any situation of stress. Even in such simple stress situations as driving a car, typing a letter, or waiting for an interview, people tend to limit their breathing. The result is an increase of their tension.” Furthermore, Paul Bragg said, “Shallow breathers poison themselves,” and Hans Weller, M.D., said, “Nearly every physical problem is accompanied by a disturbance of breathing. But which comes first?” Andrew Weil, M.D., agrees that “improper breathing is a common cause of ill health.” According to the teachings of Tibetan mystics, “mastery over breath conquers all passion, anger and carnal desires, acquires serenity, prepares the mind for meditation and awakens spiritual energy.” Thich Nhat Hanh adds, “Without full awareness of breathing, there can be no development of meditative stability and understanding.” Given that we take between 17,000 and 20,000 breaths each day, it seems reasonable to believe that breathing truly does create a bridge between body and spirit. We all are breathing beings. It is our responsibility to honor and respect each breath and the intriguing physical system that facilitates it.

ENTRIES A–Z

A acquired natural, or “active,” immunity results when B cells and T cells of the immune system are “programmed” at the time of first exposure to an invading microorganism. In response to a foreign antigen, B cells and T cells manufacture antibodies that remember and attack the invader if it is encountered in the future. Mounting an immune response depends on one’s inherited disposition to do so to a particular antigen. Vaccinations (immunizations), as well as invading infections, can stimulate acquired active immunity. This immunity then prevents a manifestation of a particular disease, or, in the event immunity develops in response to having an active disease, or from contracting the disease again. Active immunity differs from passive immunity in that preformed antibodies injected into the body allow a more immediate protection. The advantage of active immunity is its longer lasting, perhaps lifelong, protection. A disadvantage is the delay between administration of a vaccine and its effectiveness. Active immunity is the basis for the immunizations known as “baby shots” because infants are usually immunized shortly after birth against a variety of diseases. Vaccines contain killed, modified, or parts of microorganisms in sufficient amounts to trigger an antibody response without causing the actual disease. In rare cases, a subclinical infection, a weakened manifestation of a disease, is produced by the vaccine. Some live-virus vaccines have been sufficiently diluted to render them safe for immunization. The medical breakthrough of genetic engineering has allowed the manufacture of safer vaccines. The duration of immunity depends on the type of antigen, quantity encountered, and its means of entering the body, but active immunity generally

acapnia

The absence of carbon dioxide. From the Greek word akapnos, meaning smokeless, acapnia indicates a level of carbon dioxide lower than the normal amount found in blood and bodily tissues, such as the level resulting from voluntary overbreathing or hyperventilation. Symptoms of acapnia include depressed respiration, giddiness, paresthesia, cramps, involuntary contractions of the fingers and, on occasion, seizures.

Accolate The trade name for the drug zafirlukast, which is used to treat bronchoconstriction. See also ZAFIRLUKAST. acidosis, respiratory

An excess of acidity in body fluids. Also known as hypercapnic acidosis, respiratory acidosis may be the result of diabetes, renal disease, or an excessive loss of bicarbonate (or alkalinity). The body requires an acid-base balance for optimal functioning. Therefore, when the hydrogen ion concentration increases, the pH decreases and causes an imbalance, or acidosis. Carbon dioxide acidosis is another form of excessive acidity caused by carbon dioxide retention, particularly as a result of drowning or a situation in which there is decreased respiration.

acquired immune deficiency syndrome (AIDS), respiratory complications of See AIDS. active immunity

Protection from disease via the body’s production of antibodies in response to a foreign, potentially pathogenic, organism. In the fifth century B.C., Greek physicians observed that persons who had recovered from the plague were immune to subsequent attacks of the plague. This

2 acupressure lasts from many months to a lifetime. Active immunity requires an inductive (latent) period between immunization and the development of protective antibodies. This process could take from several days to several months and may require “booster” doses of the vaccine. Some immunizations that produce active immunity are tetanus, diphtheria, pertussis, poliomyelitis, measles, mumps, Rubella or German measles, Haemophilus influenzae type b, viral influenza (flu), pneumonia, and hepatitis vaccines. These immunizations are given according to a schedule recommended by the Centers for Disease Control and Prevention. See also ALLERGY SHOTS; INFLUENZA; IMMUNITY, PASSIVE; AND VACCINE.

acupressure

Similar to acupuncture, a technique involving use of the fingers to press on the appropriate body meridians to unblock stagnant energy at painful sites. See also ACUPUNCTURE.

In an article in the National Auxiliary Publication Service (NAPS) (from the American Society for Information Science), Bryan Frank, M.D., president of the American Academy of Medical Acupuncture (AAMA), said, “Treating allergies with medical acupuncture stimulates the immune system to help the body more efficiently heal itself, diminishing the frequency and severity of allergic reactions.” A medical acupuncture session includes an extensive medical history and physical examination, possibly a prescription for medication, and the stimulation of points on the body that correspond to the symptoms experienced by each individual patient, which “customizes” the treatment. The AAMA encourages allergy sufferers to consider acupuncture treatments in conjunction with allopathic treatments. The AAMA’s patient referral service may be accessed by calling (800) 521-2262 or visiting www.medicalacupuncture.org.

acute mountain sickness

See

ALTITUDE SICKNESS;

PULMONARY EDEMA.

acupuncture

An ancient Chinese technique for reducing pain and/or promoting restoration which calls for the insertion of extremely fine needles into the skin over points related to other parts and functions of the body. A point near the wrist, for example, is associated with respiration. Acupuncture is said to be effective in treating sinusitis, asthma, pains and addictions (including depression), and many other digestive, nervous, musculoskeletal, and respiratory conditions. Traditional Chinese medicine refers to the qi or chi (pronounced chee), the life force or a flow of healthy energy along specific channels or meridians. Disease is thought to be caused by the blockage in one or more of these meridians, and the goal of acupuncture is to relieve the blockages at any of the 14 major “acupuncture points” or meridians. Each meridian contains numerous points and serves as a site for the insertion of the needles. Studies suggest that acupuncture stimulates the release of the body’s natural, opiate-like substances called endorphins. Endorphins act as painkillers, sometimes as effective as morphine or anesthesia, and are thought also to contribute to the feeling of well-being.

addiction A physical and often psychological dependence on a substance such as a narcotic, alcohol, or tobacco that affects the central nervous system. Repeated use and abuse of these substances may lead to substantial debilitation of one’s health and well-being, and increased dependence may lead to overdose and death. When an addict does not get the substance his body craves or when use of the substance is discontinued, withdrawal symptoms (also known as delirium tremens, or DTs) occur. Individuals who smoke, for example, develop a dependence on nicotine, which frequently leads to mouth, throat, lung, and other serious illnesses. Treatments abound for addictions of all types and include behavior modification, in which an individual is counseled psychologically as well as weaned off a particular substance by using increments of smaller and smaller doses until the dependence is gone. See also LUNG CANCER; SMOKING, PASSIVE; SMOKE POISONING. adenoids

Lymphatic tissue, the same as the pharyngeal tonsils, named from the Greek word for

aeroallergens 3 “glandular.” This tissue forms lymph fluid that contains nutrients and lymphocytes (white blood cells that help form antibodies), which fight infections by attacking pathogenic bacteria. Lymph is found throughout the body. The adenoids located on the wall of the nasopharyngeal area, often become overactive and swollen, resulting in nasal stuffiness. They can be removed by surgical adenoidectomy, or, when removed with the tonsils, a tonsillectomy, known as a “T and A” procedure. This is not routinely recommended as it was years ago, probably because it may be more advantageous to keep organs serving the immune system intact and also to avoid the risks of anesthesia. See also ADENOTONSILLECTOMY.

adenotonsillectomy A surgical procedure in which the tonsils and adenoids are removed. See also ADENOIDS. adult respiratory distress syndrome (ARDS)

A lung disease that causes difficulty in breathing, rapid breathing, rapid heartbeat, excessive sweating, pink, frothy sputum, rhonchi, and changes in the level of consciousness. Affecting approximately 150,000 people each year, with a statistic that half of these will die despite treatment, ARDS is attributed to abnormal permeability of either the pulmonary capillaries or the alveolar epithelium. Most patients diagnosed with ARDS have suffered a severe infection, trauma, or other illness, and the disease often strikes young patients who were previously healthy. Treatment includes assisted ventilation, the administration of oxygen, antibiotics effective against the infecting microorganism, tests for continuous positive airway pressure and positive end-respiratory pressure, adequate nutrition (parenteral [injected] nutrition if required), prevention of side effects of the patient’s immobility, and emotional support for anxiety of both the patient and his family.

adverse drug reactions

Hypersensitivity to medication that causes various symptoms, ranging from unpleasant to life-threatening, and may preclude a medication’s use as treatment. New medical guide-

lines have been established on drug hypersensitivity by a national task force of allergists/ immunologists and were published in the American College of Allergy, Asthma and Immunology’s (ACAAI) December 1999 Annals of Allergy, Asthma and Immunology. The guidelines, titled “Disease Management of Drug Hypersensitivity: A Practice Parameter,” are one of a series that includes asthma, allergy diagnostic testing, immunodeficiency, rhinitis, atopic dermatitis, anaphylaxis, immunotherapy, insect stings, and sinusitis. They are designed to help prevent medical errors. Risk factors for drug hypersensitivity include the chemical properties and molecular weight of a drug; dosage; route of administration; duration of treatment; repetitive exposure to the drug; concurrent illnesses; and a patient’s age, gender, atopy, and genetics. The new guidelines include components for clinical evaluation and diagnosis of drug hypersensitivity, including history, physical examination, and clinical tests. Parameters stipulate that prevention of allergic reactions may be accomplished by attention to: 1. 2. 3. 4.

A careful history to determine host risk factors; Avoidance of cross-reactive drugs; Use of predictive skin tests when available; Proper and prudent prescribing of drugs (especially antibiotics) frequently associated with adverse reactions, and 5. Use of oral medication in preference to parenteral (injected) drugs when possible.

aeration

The process of exchanging carbon dioxide for oxygen in the blood of the lungs. Aeration also refers to “airing” something out and to putting gases into a fluid.

aeroallergens Substances that, when transported through the air, are capable of causing an allergic reaction when inhaled by an allergic individual. Airborne allergens include pollen grains, fungal spores, and the so-called inhalant allergens such as house dust (which is actually a mixture of many allergens), dead dust mite bodies and pellets of their fecal waste, human and animal danders, and flakes of dead skin. Animal proteins from saliva

4 aerobic and urine become aeroallergens as they are absorbed into the environment. Cooking odors of highly allergenic foods and allergenic industrial chemicals behave in a similar manner. Most airborne allergens range in size from 2 to 60 microns (1 micron = 1/25,000 inch), but some are even smaller. Finer aerosolized particles may pass into the distant terminal bronchioles, but ragweed-sized pollen grains do not usually reach that far. Since most pollens do not reach the areas where bronchoconstriction is greatest, it is thought that reflex mechanisms occur when the allergen comes in contact with mucosal surfaces within its reach in the upper air passages. For some reason so far undiscovered, this triggers a spasm of the bronchial tubes and an asthma attack.

aerobic The characteristic of an organism or microorganism able to thrive in the presence of oxygen. Aerobic exercise, therefore, means physical activity that specifically uses and metabolizes oxygen to produce energy (as opposed to anaerobic exercise, which does not require inspired oxygen for energy and is limited to short bursts of strenuous activity; an anaerobe is a microorganism that can thrive in an oxygen-free atmosphere). Aerobic training fosters aerobic conditioning, generally with exercise three to five times a week for 20 to 30 minutes per session and at a level intense enough to produce a heart rate of 220 minus the age of the individual. Aerobic training is typically incorporated into cardiac and other rehabilitation programs. AeroBid

The trade name (also Nasalide) for the corticosteroid drug flunisolide, which is used to treat rhinitis, allergies, and nasal polyps. In metered doses obtained via nasal spray, flunisolide suppresses the migration of polymorphonuclear leukocytes. Contraindications include administering the drug to children younger than six years and to anyone with hypersensitivity to flunisolide. Precautions include nonasthmatic bronchial disease, bacterial, viral, or fungal infections of the mouth, throat, and/or lungs, respiratory tuberculosis, any untreated infection, pregnancy, and glaucoma. Flu-

nisolide is available as a nasal solution of 25 micrograms (Nasalide) or 250 micrograms (AeroBid).

aeropathy A disorder or condition caused by a significant change in atmospheric pressure. See also CAISSON DISEASE; EDEMA, PULMONARY. aerophobia

Morbid fear of fresh air or a draft.

aerosol

A solution administered in the form of a mist from a spray bottle or can. Aerosol therapy refers to the inhalation of beneficial aerosolized solutions, such as corticosteroids or mucolytic agents, by patients with asthma, bronchitis, emphysema, and other respiratory disorders. Aerosol devices include pressurized canisters called metered-dose inhalers, hand-held nebulizers, machine-powered jet or ultrasonic nebulizers, or dry powder inhalers. There are several types of aerosol nasal sprays. Aerosols are also used in the cosmetic and other industries. See also INHALATION THERAPY.

aerotherapy

The treatment of disease by using air, particularly changes in composition and density of air, such as a decompression chamber and hyperbaric oxygen. See also HYPERBARIC OXYGEN THERAPY.

aerothorax agonist

See

PNEUMOTHORAX.

A drug that mimics the body’s own regulatory function. An agonist binds to a cell’s receptors and stimulates the receptors’ function. There are at least two different receptor systems, alpha and beta. Alpha-adrenergic receptors are associated primarily with excitatory functions, such as the constriction of smooth muscle in blood vessels, bronchi, and the urinary bladder. They also cause relaxation of smooth muscle in the intestines. Stimulation of these receptors may raise blood pressure and increase heart rate. Beta-adrenergic stimulation primarily affects the airways or air passages by allowing smooth-muscle relaxation. There are beta1 and beta2 receptors and drugs that have very broad actions affecting both beta1 and beta2

AIDS 5 receptors. More selective drugs react primarily or only with the beta2 receptors. These medicines have fewer side effects and are the most frequently prescribed for the treatment of asthma.

AIDS A life-threatening disease caused by the human immunodeficiency virus (HIV) and characterized by a breakdown of the body’s immune defenses. The disease was first recognized in 1981 in a group of hom*osexual males in California, who were diagnosed as having a rare form of pneumonia, Pneumocystis carinii, seen only in immunosuppressed individuals. Then a rare cancer, Kaposi’s sarcoma, which affects the skin and other parts of the body, was reported in alarming numbers in this same population. In 1984, French and American scientists identified HIV as the virus responsible for AIDS. Persons at the highest risk appear to be hom*osexual or bisexual men and their partners, intravenous drug abusers, patients who received blood transfusions from unscreened donors (before adequate screening was available), and children of infected women. Heterosexuals are becoming increasingly infected, although heterosexuality itself still poses a somewhat lower risk. AIDS is not present in all patients who are infected with HIV. One to 5 percent of people who have a positive blood test for HIV but have no symptoms may eventually develop AIDS. Less than 1 percent of those infected with HIV appear to be immune to developing AIDS, and the virus and antibodies to it disappear spontaneously. Once the diagnosis has been confirmed, it is considered a fatal illness. Death usually results from an opportunistic infection such as P. carinii (a protozoan one-celled organism) or tuberculosis. Opportunistic infections are caused by commonplace organisms that do not usually trouble people whose immune systems are healthy, but take advantage of the opportunity provided by an immunosuppressed, or debilitated, person. Some individuals infected with HIV may remain well. In others, minor illness suggestive of infectious mononucleosis may occur between three weeks and three months following exposure to HIV. Symptoms including fever, sore throat, malaise,

muscle and joint aches, swollen glands, fatigue, weight loss, diarrhea, rash, and thrombocytopenia (decreased blood platelet count) appear suddenly and last about two weeks. These symptoms persist in many individuals, and up to 25 percent of those with this persistent condition, known as AIDSrelated complex or ARC, may progress to AIDS within one year. Those with AIDS may have one or more of a variety of disorders, including anomalies of the nervous system; severe and unusual infections, such as P. carinii pneumonia, fungal, tuberculosis, herpes simplex, and zoster (shingles), and oral yeast infections (thrush); cancerous tumors, such as Kaposi’s sarcoma, non-Hodgkin’s lymphoma, or primary lymphoma of the brain. A positive HIV-antibody test result in a person with signs and symptoms of an opportunistic infection or tumor characteristic of the disease must be confirmed by the Western blot blood test. A negative test result may occur in someone recently exposed to HIV. If that person is at high risk for developing AIDS, a repeat test should be performed in six months or sooner. AIDS is a contagious disease. Any person infected with the HIV can transmit the infection, even if that person does not have AIDS or ARC. It is spread by sexual contact, by direct contact of the HIV with the bloodstream from re-use of contaminated needles or accidental needle-sticks, and from mother to her unborn child through the placenta. Adequate screening at blood banks has made the blood supply for transfusions in the United States virtually free of HIV. The transmission of this disease requires intimate contact, such as sexual intercourse, in which an exchange of infected body fluids takes place. Researchers currently believe that HIV is not transmitted through casual or social contact. There is no cure for HIV infection or AIDS, and mutant strains of HIV have already emerged. However, attempts to develop a vaccine are under way. Various antiviral agents, such as zidovudine (Retrovir), formerly called azidothymidine, or AZT, appear to inhibit the progression of the disease. There are serious side effects from these drugs, including anemia, granulocytopenia, dizziness, and severe headache. It is often difficult to differentiate between adverse drug reactions and effects of the illness. Antibiotics and antifungals

6 air have been known to be effective against some of the opportunistic infections. Chemotherapy with interferon has shown promise in early studies, and radiation is used against Kaposi’s sarcoma and other malignancies. The 1990 Behavioral Risk Factor Surveillance System, or BRFSS, a government-sponsored study, assessed public awareness of HIV/AIDS. In random telephone interviews, 81,556 adults in 44 states and the District of Columbia were surveyed. Results are listed in the table below. Have you heard of the AIDS virus HIV? Are you aware that drugs can lengthen life of persons with HIV? Are you aware that infected individuals can look normal? Do you think that persons giving blood can get AIDS? Do you think that AIDS can be transmitted by insect bites?

83.0%

Yes

46.6%

Yes

67.7%

Yes

72.2%

83.9%

Source: Journal of the American Medical Association, 1992.

air A mixture of gases consisting of approximately 78 percent nitrogen and 21 percent oxygen, water vapor, carbon dioxide, and traces of ammonia, argon, helium, neon, krypton, xenon, and other gases. Clean air is odorless, tasteless, invisible, and surrounds the entire Earth. Alveolar air refers to air in the alveoli, or air sacs, of the lungs. Complemental air refers to the volume of air available over and above the air taken in by the deepest possible inspiration. This is also known as the inspiratory reserve (supplemental) volume. The amount of air remaining in the lungs after one exhales fully is called residual air. After a normal, full exhalation, approximately 1,600 cubic centimeters of air are available in an adult. This is known as the expiratory reserve volume. In an adult male, an average of 500 cubic centimeters of air flows in and out with each normal respiration, and that volume is called tidal air. Air that fills the structures of the respiratory system’s passageways but is not available for exchange of gases with the blood is called dead space air. When a lung collapses with the thorax (chest cavity) open, the small amount of air trapped in the alveoli is referred to as minimal air.

air bronchogram sign In pulmonary edema and pneumonia, a radiograph or X ray of the lung that shows a bronchus filled with air as it passes through an area of increased anatomic density. A diagnostic technique, bronchography is accomplished by instilling a radiopaque substance into the trachea or bronchial tree so the lung may be viewed by X ray. air conditioning The use of a ventilation device that controls air temperature and humidity, particularly to lower the temperature and humidity during the warm seasons. Air conditioning may prove beneficial to individuals with respiratory disorders because cool air is easier to breathe and may help shrink swollen membranes of the airways. On the other hand, there are dangers that certain infectious lung diseases may be spread by contaminated spray water from commercial air-conditioning systems. Actinomycetes are one cause of hypersensitivity pneumonitis, an allergic disease. Legionnaire’s disease is an infectious pneumonia also spread by contaminated water in cooling systems. Air-filtration systems, such as the high-efficiency particulate air (HEPA) filters, are available to keep the air clean and free of contaminants. They also may actually worsen exposure to allergens by lifting them into the air where they can be inhaled, so it is best to seek the advice of a physician or other health care professional when air purification is considered. air curtain

A method of directing air currents around a patient in order to divert air that might otherwise irritate or contaminate the patient with dust-borne allergens and other undesirable microorganisms.

air flow, laminar A system of filtered air flow in areas such as operating theaters, nurseries, bacteriology work areas, and places designated for food preparation. The system helps prevent bacterial contamination of the air and collects chemical fumes that may be harmful. air hunger A common term for shortness of breath or dyspnea (difficulty breathing), especially rapid, labored breathing.

airways 7 air pollution

Any contamination of the air we breathe, including industrial waste, fumes and exhaust from vehicles, and the spraying of pesticides, insecticides, or other noxious substances. Air pollution is also known as smog.

air quality

The degree of purity or pollution in the atmosphere in which we breathe. According to the American Lung Association, its new report, State of the Air: 2000, provides easy-to-understand summaries of the quality of the air based on concrete data and sound science. Cities and counties are assigned grades “A” through “F” based on how often the air quality exceeds the “unhealthful” categories of the U.S. Environmental Protection Agency’s Air Quality Index. The report confirms that air pollution remains a major threat to Americans and contributes substantially to the nation’s ill-health burden. The report also says more than 132 million Americans live in areas that received an “F”—approximately 72 percent of the nation’s population who live in counties where there are ozone monitors. Of the 678 counties examined, nearly half (333) received an “F.” Furthermore, in “F”-rated areas, there are an estimated 16 million Americans older than 65, more than 7 million people with asthma (5 million adults and 2 million children), 29 million children younger than 14, and 7 million adults with chronic bronchitis. According to the report, “while emissions of some air pollutants have generally gone down and the nation’s overall air quality has improved over the past 30 years, much of that progress has been in eliminating obvious pollution and sources, bans on open burning, for example. Many of the pollutants that are literally invisible, such as ozone, have been reduced far less, and as understanding of the health effects of air pollution has advanced, it has become clear that much of the nation still faces major air pollution problems. State of the Air is the first annual ‘report card’ on America’s air quality. It focuses on the most widespread air pollutant, ozone, sometimes called smog . . . among the most dangerous of the common air pollutants. . . . Many major metropolitan areas in the United States are plagued by high levels of ozone. As of 1998, almost 100 million Americans still lived in areas classified

as not meeting the earlier one-hour national ozone standard.” The American Lung Association has also declared May “Clean Air Month,” which will involve national and local events designed to emphasize the link between environmental conditions and respiratory wellness: “The quality of the air we breathe, both indoors and out, has a great impact on lung health. Fragile lung tissue is easily damaged by pollutants in the air, resulting in increased risk of asthma and allergies, chronic bronchitis, lung cancer and other respiratory diseases.” (May 28, 2000) See also OZONE.

air travel (related to impaired pulmonary function) Individuals with pulmonary impairment may require supplemental oxygen (appropriate to their respiratory system’s functional capacity) when traveling by airplane, and those with blocked sinuses or eustachian tubes may be advised not to fly until the disorder has been resolved. Anyone with an infectious disease that can be transmitted to others by the airborne route is advised not to fly. air vesicle See also

airways

An alveolus of the lung. ALVEOLUS.

Passageways allowing air from the atmosphere to reach the lungs, beginning at the nostrils and mouth, and gradually branching into bronchi and bronchioles. They end at the alveolar sacs in the lungs, where oxygen is absorbed into the bloodstream. During an asthma attack, the airways narrow or become obstructed by either constriction or mucous plugs. At first, muscles in the walls of the bronchioles constrict or go into spasm, called bronchospasm. If this is not relieved immediately, spontaneously, or with medication, blood vessels in the airway dilate and fluid leaks into the tissues. Resulting swelling (edema) further narrows the airway. This is followed by an inflammatory response and secretion of mucus, restricting airflow even more. Wheezing may not be heard until there is at least a 50 percent narrowing of the airways. However,

8 albuterol in extremely severe obstruction, there may be no audible wheezing. This can be misleading in a lifethreatening situation. In an emergency room or doctor’s office, the degree of narrowing of the airways can be measured by a spirometer or a peak flow meter. Inexpensive peak flow meters are available so patients can measure their peak flow at home, school, or work. Peak flow meters also aid physicians in making treatment decisions. See also PEAK FLOW METER; SPIROMETER.

cating beverages, alcohol is also a common ingredient in cough syrups. It is thought to be a depressant to the cough center of the brain and may have some muscle-relaxing effect on the bronchial tubes. Two common adverse effects of alcohol (ethanol) are sedation and drying of the mucous membranes of the upper respiratory tract. Alcoholism may eventually result in respiratory arrest and death.

alkalosis, respiratory albuterol (Gen-Salbutamol, Novosalmol, Proventil, Proventil HFA, Proventil Repetabs, Salbutamol, Ventodisk, Ventolin, Ventolin Rotacaps, Volmax) A fast-acting bronchodilating drug used to open constricted airways in the treatment of asthma and in the prevention of exercise-induced asthma, bronchospasm, and the prevention of premature labor. It is in investigational use for hyperkalemia in dialysis patients. Albuterol is contraindicated for patients with severe cardiac disease and hypersensitivity to sympathomimetics. The most widely used of the beta-agonist drugs, its use is rarely limited by minor tremors or palpitations. Possible other side effects include headache, dizziness, restlessness, hallucinations, flushing, irritability, dry or irritated nose and throat, heartburn, nausea, vomiting, muscle cramps, hypotension, and paradoxic bronchospasm. Albuterol also interacts with other aerosol bronchodilators, tricyclic antidepressants, MAO inhibitor antidepressants, and other adrenergics, increasing their action. Other beta-blockers may inhibit the action of albuterol. The therapeutic response is absence of wheezing and difficulty breathing, and improved airway exchange and arterial blood gases (ABGs). Albuterol is available as an aerosolized metereddose inhaler (MDI), as a solution for use with an aerosol nebulizer, or as a tablet or syrup for oral use. For children or other persons who lack the coordination to use an MDI, the product Ventolin is available in a dried powder form dispensed in Rotacaps and inhaled by using a device known as a Rotahaler.

alcohol

A chemical used as a solvent, an antiseptic, an astringent, and a component in intoxi-

Excessive alkalinity (as opposed to acidity) in the body’s fluids because of an acid-base imbalance, either an increase in alkalines or decrease in acid. Altitude alkalosis is caused by decreased oxygen in the air at high altitudes, which then causes respiratory alkalosis. Symptoms include numbness and tingling, carpopedal spasm, tetany, lightheadedness, and paresthesias. Respiratory alkalosis may also be the result of anxiety, fever, hyperventilation due to hypoxia (lack of oxygen), salicylate intoxication, exercise, and excessive assist, such as in the use of a respirator, to breathing. Initial treatment for hyperventilation includes having the person calm down by breathing into a paper bag, thus rebreathing carbon dioxide. Also, the patient may find some relief by breathing with one nostril closed off and the mouth closed. Other treatments depend upon the severity of the patient’s symptoms and his or her medical history, including cardiac and neurologic status, vital signs, and arterial blood gases.

allergen

A particle, substance, or other agent that causes hypersensitivity in certain individuals who come in contact with it. See also AEROALLERGENS.

allergic rhinitis (pollinosis, hay fever) An inflammatory condition of the nasal passages, adjoining sinuses, ears, and/or throat that occurs when an allergic person inhales an allergen to which he or she is sensitive. Allergic rhinitis is an immune response that does not occur in a normal or nonallergic individual. Allergic rhinitis may occur periodically (seasonally) or continuously (perennially).

allergist 9 Cause During the allergic reaction of hay fever, mast cells in the lining of the nose rupture when exposed to an allergen in a susceptible person. The mast cells release chemicals, called mediators, that are responsible for allergic symptoms. Hay fever is an English name given because of symptoms caused by exposure to grass allergens coinciding with the bailing of hay. It usually refers to seasonal allergies, occurring with exposure to the airborne (windblown) pollens of trees, grasses, ragweed, and other weeds and outdoor mold spores. A person may suffer the symptoms during spring, fall, or both seasons. Perennial, or year-round, allergic rhinitis is usually due to exposure to indoor allergens called “inhalants.” Cats, dogs, rodents, house-dust mites, and indoor molds are examples of perennial allergens. Allergic rhinitis is often confused with colds, sinus infections, nasal polyps or other nasal obstructions, and nonallergic, vasomotor rhinitis. Vasomotor rhinitis is nasal congestion that cannot be attributed to another cause, such as allergy. A deviated septum, an abnormality of the cartilage separating the nostrils, is a frequent cause of stuffy noses and can occur in allergic as well as nonallergic individuals. Rarely, more serious conditions such as tumors or nonhealing granulomas may exist. These conditions should be considered in patients who fail to respond promptly to treatment and who have blood-stained nasal mucus. Overuse or abuse of over-the-counter nasal sprays can result in a common and troublesome disorder called rhinitis medicamentosus (rhinitis means an inflamed nose; medicamentosus means caused by medication). This condition is often confused with allergy and may occur in both allergic and nonallergic individuals. Signs and Symptoms These vary in severity from person to person. Symptoms include pruritus (itching), sneezing, rhinorrhea (runny and watery discharge from the nose), postnasal drip, and congestion of the nose, ears, and sinuses. A general state of fatigue and malaise (a feeling of being “unwell”) may exist dur-

ing allergy attacks. Loss of smell or taste occurs in severe cases. Persons with hay fever frequently suffer from allergic conjunctivitis (itchy, watery, and red eyes caused by allergy) and asthma. Physical Appearance Hay fever sufferers often have a characteristic appearance. A horizontal crease across the lower portion of the nose is called the “allergic crease,” caused by the “allergic salute,” a constant pushing up on the tip of the nose by the palm of the hand prompted by the discomfort of nasal stuffiness. Dark circles under the eyes are referred to as “allergic shiners.” These are probably caused by blockage of blood flow to the tiny veins in the area because of swelling. Blood trapped in the area under the eyes has a very low oxygen content, resulting in the dark blue-black discoloration. There will often be swelling and puffiness of the eyelids, redness of the eyes, and watery discharge from the eyes and nose. Individuals with persistent nasal obstruction often breathe through their mouth, which causes facial abnormalities, such as long faces, flattened cheekbones, pinched nostrils, and raised upper lips. Orthodontal problems arise more frequently in allergic persons because of narrower retracted jaws, overbites, and high arched palates. See also ASTHMA; HAY FEVER; POLLINOSIS; POLYP, NASAL; RHINITIS.

allergic salute

See

ALLERGIC RHINITIS.

allergic shiner

See

ALLERGIC RHINITIS.

allergist (allergist-immunologist)

A physician who diagnoses and treats allergic conditions and related disorders. Asthma, hay fever, eczema, and hives are among the illnesses most frequently treated by allergists. Most allergists complete a twoyear fellowship in allergy and immunology following a residency in internal medicine or pediatrics. They are then eligible to become board certified in their specialty by passing a comprehensive examination. See also IMMUNOLOGIST.

10 allergist-immunologist allergist-immunologist

See

ALLERGIST.

allergoids Allergy extracts modified by treatment with the chemical formalin. This modification results in lower incidence of reactions and shorter courses of immunotherapy (allergy shots). While ragweed allergoid has proven to be excellent, no other allergoids are available in the United States. Because most people need multiple extracts for their treatment, use of the singular allergoid may not be practical. allergy

An overreaction by the immune system to a substance called an allergen that does not cause a similar reaction in nonsensitized persons. An allergen is any protein or proteinlike substance recognized by the body as foreign and capable of provoking an allergic response. Austrian pediatrician Clemens P. Pirquet (1874–1929) first used the term allergy, derived from the Greek allos (“altered”) and ergia (“reactivity”), in 1906. He referred both to immunity, which is beneficial, and to harmful hypersensitivity of the immune system as allergy. Today, allergy refers only to the hypersensitivity or injurious effects of the immune system. Causes Most individuals inherit the tendency to be allergic from one or both parents. It is not known why some persons develop allergies and others do not. It is thought by some that exposure to viral infections, smoking, or hormones influence a person’s propensity for allergy. It is also unknown why some individuals will get hay fever and others asthma, or both. Types of Allergy There are four classifications of allergic or hypersensitivity reactions: type I, immediate or immunoglobulin E (IgE) mediated; type II, in which antibodies are directed against cells; type III, in which toxic effects result from antibody and antigen complexes; and type IV, cell-mediated or delayed reactions. Pollens, animal proteins (dander, saliva, urine, feathers), house-dust mites, molds, drugs, foods, and venoms from insects or reptiles are examples

of allergens that can cause immediate, or type I, reactions. After a first exposure, these apparently harmless allergens stimulate the immune system to form IgE antibodies. IgE antibodies are specific to each allergen and attach to the surface of mast cells in the tissues. Upon re-exposure, the recognized allergen combines with its antibodies, rupturing mast cells and releasing biochemical mediators that cause the symptoms of allergy. The most severe form of type I allergic reaction is anaphylaxis. Prevalence The most common allergies include allergic rhinitis (hay fever), asthma, eczema, and urticaria (hives). The National Institute of Allergy and Infectious Diseases estimates that 35 million Americans have allergies and about 10 million have asthma. Approximately 80 to 90 percent of adult allergies are caused by inhaled allergens from animals, pollens, molds, or house dust. Foods are responsible for about 20 percent of children’s allergies but much less so in adults. A small percentage of allergies is caused by contactants or insect stings. Treatment Three main phases of treatment are avoidance of allergen exposure, use of medication, and immunotherapy (or allergy shots). Avoidance of allergy triggers is the management of choice, but it may be difficult or even impossible to achieve. Drugs offer excellent relief from symptoms of allergies and asthma with minimal side effects. Antihistamines, adrenergic agonists or decongestants, beta-agonists and xanthine bronchodilators (theophylline), cromolyn and corticosteroids (derivatives of cortisone) are available in inhaled, oral, and injectable dosage forms. These drugs are among the most widely prescribed of all medicines. Immunotherapy, successfully used to treat allergic rhinitis (hay fever) for many years, is now also recognized as effective treatment for allergic asthmatic patients. Alternative treatments include homeopathy (natrium muriaticum, or other preparation); kinesiology (balancing, stress reduction counseling, bowel cleansing, etc.); aromatherapy (Roman chamomile, helichrysum, melissa, etc.); hyp-

allergy shots 11 notherapy (hypno-healing, neurolinguistic programming, etc.); naturopathy (dietetic management and fasting, applied nutrition, etc.); color therapy (use of blues, greens, and oranges); autogenic training (rebalancing body systems); acupuncture; Ayurvedic medicine (panchakarma and a specialized diet); Chinese and Western herbalism, and auricular therapy (to relieve hay fever symptoms). See also ALLERGEN; ALLERGY SHOTS; ANAPHYLAXIS; IMMUNOGLOBULINE; MAST CELLS.

Allergy and Asthma Network/Mothers of Asthmatics, Inc. A nationwide, community-based, nonprofit health organization dedicated to eliminating morbidity and mortality due to asthma and allergies through education, advocacy, community outreach, and research. The AAN-MA offers membership, publications (Allergy & Asthma Health is the organization’s quarterly magazine; The MA Report is an eight-page newsletter), news and information, job and volunteer opportunities, marketplace, physician roll-call, outreach programs, and other allergy and asthma-related activities. The AAN-MA may be contacted at: Allergy and Asthma Network/Mothers of Asthmatics, Inc. 2751 Prosperity Avenue Suite 150 Fairfax, Virginia 22031 (800) 878-4403 or (703) 641-9595 (703) 573-7794 (Fax) http://www.aanma.org.

allergy shots

Allergy immunization or vaccination. According to a July 29, 1999, report by the American College of Allergy, Asthma and Immunology (ACAAI), allergies affect about 38 percent of all Americans, nearly twice as many as allergy experts had believed, and millions of them suffer unnecessarily or rely on medications they don’t want to take because they are not aware of other effective treatment options, including allergy shots. A representative sample of 1,004 adults was surveyed by the ACAAI about their experiences with allergies. According to ACAAI literature, “Thirty-

eight percent reported having allergies, while 56 percent said they live in a household in which at least one member, including themselves, has allergies. The number of people affected surprised even allergy experts who thought the incidence of allergies was closer to 20 percent of the population. ‘This new data shows us that allergies are almost twice as common as we thought,’ said Ira Finegold, M.D., past-president of the ACAAI. ‘What’s of even greater concern is that the majority of people with allergies don’t know about treatment that can bring them relief. A lot of them are either suffering from the symptoms or from medication sideeffects.’ “Almost two-thirds of respondents who said they have allergies have never tried or considered allergy shots. . . . Allergy shots are a well-established treatment that naturally desensitizes the immune system. Small amounts of purified extracts of the substance causing allergic reactions are periodically injected and gradually increased until immunity is attained. They are effective against allergic diseases including allergic rhinitis (hay fever), insect sting allergy, and asthma. “The treatment has a long track record of effectiveness and safety, with the incidence of adverse reactions less than 2/10 of 1 percent. It can be given to children as young as 4 and is safe for pregnant women as long as treatment was begun before pregnancy. Though not well known, allergy shots are viewed positively by those who are familiar with them, especially by those who have had the treatment, according to the survey. The survey also found that 54 percent of respondents would be willing to try allergy shots if the treatment would free them from medication. “The ACAAI commissioned the national survey as part of a public education campaign to increase understanding of allergy immunization and encourage people who may be helped by this therapy to consider it. The randomized telephone survey was conducted by Opinion Research Corporation (ORC) . . . 502 men and 502 women— 18 years of age and older living in private households in the continental United States. The survey results are projectable to the U.S. population and have a margin of error of plus or minus 2 percent to 4 percent. . . . The only negative perception of

12 altitude sickness allergy shots by a substantial number surveyed was related to cost. More than half answered ‘yes’ when asked if they thought allergy shots are expensive. “The perception seems to be that vaccination is a great treatment for allergies but is not affordable,” Dr. Finegold said. “In fact, allergy shots often are covered by health plans and the treatment can eliminate the need to buy medications. Overall, it’s often less expensive and more effective than relying on medications every day and trying to isolate the allergy-sufferer from the environment. In many cases, the shots eventually can be discontinued, along with allergy medications, and the immunity maintained.” The ACAAI has also created a new consumer education quiz available on its web-site that tests individual knowledge of allergy and treatments, and provides detailed answers. The ACAAI’s free brochure, You Can Have A Life Without Allergies, is available by calling (800) 842-7777. The brochure explains how allergy shots work and fit into the general management of allergy and asthma. See also IMMUNOTHERAPY.

and arterial smooth muscle of the heart. In addition, Altounyan suffered from atopic dermatitis as a child and later from severe asthma. Using himself as the experimental subject, he investigated 670 synthetic compounds, and in 1967 he recognized the effectiveness of cromolyn.

aluminosis A chronic inflammation of the lungs as a result of inhaled alum particles. A strong astringent, alum is a double sulfate of aluminum and potassium and aluminum and ammonia. Aluminosis is seen mostly in alum workers. aluminum chloride

An astringent and antiseptic solution used as an antiperspirant. Aluminum chloride can be irritating and a cause of skin allergy. It also can be toxic if ingested.

Alupent

See

METAPROTERENOL.

alveobronchiolitis Inflammation of the bronchioles and pulmonary alveoli, also known as bronchopneumonia. See also BRONCHOPNEUMONIA.

altitude sickness

Symptoms including headache, euphoria, shortness of breath, malaise, decreased ability to concentrate, lack of judgment, lightheadedness, and fainting that develop when an individual is in an environment of decreased oxygen, such as high on a mountain. Altitude sickness may cause death in some cases. When lack of adequate oxygen causes euphoria, an individual may be unaware of a potentially dangerous problem. Adaptation to high altitudes is possible over a period of time, perhaps months, depending upon the individual.

Altounyan, Roger E. C.

An Armenian-English physician (1922–87), born in Aleppo, Syria. Altounyan developed disodium cromoglycate, or cromolyn, an anti-inflammatory allergy medication. He first experimented with khella, a substance from the dried fruit of an herb, Ammi visnaga, indigenous to Egypt and North Africa, because khella had already been widely used for treating spasms of the intestines, bronchial tubes, uterus,

alveolitis

An inflammation of the air cells, or alveoli, of the lungs. Allergic alveolitis is a lung disease caused by hypersensitivity to organic dusts that are inhaled, especially by individuals whose occupation involves exposure to various dusts or pollutants. See also BAGASSOSIS; FARMER’S LUNG; PNEUMONITIS.

alveolus

The air cell, one of many sacs or small hollows at the end of an alveolar duct in the lungs, where gases are exchanged in respiration.

amantadine (Symmetrel) An antiviral drug that is also used in the treatment of Parkinson’s disease. During “flu” epidemics, amantadine may lessen the severity of, shorten the course of, or prevent type A influenza, but it has no effect on influenza B or other viruses. Individuals at risk for severe complications of influenza, including some asthmatics, may benefit from immunization with influenza vaccine and daily doses of amanta-

American Board of Allergy and Immunology dine for several weeks until the vaccine becomes effective.

Ambu bag The trade name for a bag used to help direct air into the lungs by artificial ventilation. The bag is a reservoir for oxygen attached to a one-way flow valve and a face mask that is placed over the mouth and nose of a patient who is not breathing. This resuscitator, also known as a bag-valve-mask resuscitator, is operated manually. A manikin used in teaching cardiopulmonary resuscitation is called an Ambu simulator. American Academy of Allergy, Asthma and Immunology (AAAAI) A professional organization of allergists and immunologists that promotes the advancement of scientific study of allergy and immunology both academically and in the practice of medicine. It was established in 1943 with the merger of the American Association for the Study of Allergy and the Association for the Study of Asthma and Allied Conditions. The AAAAI publishes the Journal of Allergy and Clinical Immunology. From time to time the academy issues position statements to clarify confusing issues in the fields of allergy or immunology. An emphasis is placed on aiding the public in seeking competent medical care and avoiding unproven or dangerous techniques for the diagnosis or treatment of these disorders. The majority of fellows and members of the AAAAI are board certified in their specialty. Contact telephone number is (800) 822-ASMA.

American Board of Allergy and Immunology (ABAI) A conjoint board of the American Board of Internal Medicine and the American Board of Pediatrics, established in 1971 as a nonprofit organization. It is sponsored jointly by the American Board of Internal Medicine (ABIM), the American Board of Pediatrics (ABP), the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), the American Academy of Pediatrics–Section on Allergy, and the American Medical Association–Section on Allergy. The board consists of an even number of directors. The direc-

tors are nominated by the Sections on Allergy of the American Academy of Pediatrics and the American Medical Association, the AAAAI, ACAAI, and the ABAI itself. The nominees are appointed by the ABIM and the ABP. Each board director is appointed for six years. Purposes of the ABAI The major purposes of this organization are (1) to establish qualifications and examine physician candidates for certification as specialists in allergy and immunology, (2) to serve the public, physicians, hospitals, and medical schools by providing the names of physicians certified as allergists and immunologists, (3) to improve the quality of care in allergy and immunology to the public and increase the availability of specialists to deliver such care, (4) to establish and improve standards for the teaching and practice of allergy and immunology, (5) to establish standards for training programs in allergy and immunology, and (6) to provide increased opportunities for physicians wishing to specialize in allergy and immunology. Certification The ABAI is interested in candidates who have embarked voluntarily on a graduate program of study with the express purpose of excelling in the practice of the specialty of allergy and immunology. In outlining its requirements, the ABAI hopes to help the candidates select superior educational programs that will develop their competency in allergy and immunology. The ABAI believes that all allergists and immunologists should have a fundamental knowledge of the biological science basic to this discipline. Such knowledge is essential to the continued professional progress of any qualified allergist and immunologist. The ABAI anticipates that adequate knowledge in basic science, as applied to this discipline, will be acquired by the candidates during a post–medical school training program. The ABAI wishes to emphasize that time and training are but a means to the end of acquiring a broad knowledge of allergy and immunology. The candidate must demonstrate competency to the ABAI in order to justify certification in this discipline. The responsibility of acquiring the knowledge rests with the candidate. The ABAI is

14 American College of Allergy, Asthma and Immunology responsible for the establishment and maintenance of the standards of knowledge required for certification. Each candidate for certification must satisfy the general and professional qualifications listed below. The candidate must qualify for examination by having passed the certification examination of the ABIM or the ABP. Certification requires three years of postgraduate general training in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), by presentation of evidence acceptable to the board of directors of at least two years of full-time residency/fellowship or other acceptable training in allergy and immunology programs accredited by the ACGME upon the recommendation of the Residency Review Committee for Allergy and Immunology. These programs are listed in the Directory of Graduate Medical Education Programs, published by the American Medical Association, a copy of which may be found in most medical school libraries. Executive Office American Board of Allergy and Immunology, A Conjoint Board of the American Board of Internal Medicine and the American Board of Pediatrics Chairman: Lawrence B. Schwartz, M.D., Ph.D. Co-chair: M. Louise Markert, M.D., Ph.D. Executive Secretary: John W. Yunginger, M.D. Administrative Director: Lynn Des Prez 510 Walnut Street, Suite 1701 Philadelphia, PA 19106-3699 (215) 592-9466

American College of Allergy, Asthma and Immunology (ACAAI) Formerly the American College of Allergy and Immunology (ACAI), a professional medical organization comprised of 4,000 qualified allergists-immunologists and related health care professionals, founded by physicians and scientists to promote and advance the knowledge of allergy and to assure a high quality of care for patients with allergic disorders. Based in Arlington Heights, Illinois, the college is dedicated to the clinical practice of allergy, asthma, and immunology through education and research. The ACAAI publishes the monthly scientific journal Annals of Allergy, Asthma and Immunology,

which is available on-line through December 2000 and thereafter by subscription. Annals on-line contains full-text articles, including figures and tables, and text is searchable by keyword, with hyperlinks to MEDLINE. Archives are being built to include full-text articles of back issues since January 1997. Abstracts will be available from earlier publications. Patient education “Advice From Your Allergist” articles are archived on-line on the following topics: rhinitis, insect sting allergies, urticaria, pregnancy with asthma and allergies, osteoporosis, long-acting bronchodilators, latex hypersensitivity, food allergies, headaches, house-dust allergies, and pet allergies. The website www.annallergy.org provides information about the journal, including instructions to authors, the Editorial Board, and subscription information. The journal received a top rating in a recent readership survey reported by Lippincott Williams & Wilkins and Dataview Research, Inc., scoring its usefulness and comparing it to other medical journals. Additional information on the diagnosis and treatment of asthma and allergic disease is available on the ACAAI public website (http://allergy.mcg.edu).

American Dietetic Association An organization based in Chicago, Illinois, from which nutritional and dietary information important to individuals with allergies or asthma can be obtained. A list of commonly allergenic foods, including cow’s milk, eggs, and wheat, is available. The association may be contacted at: American Dietetic Association 216 West Jackson Boulevard Chicago, IL 60606-6995 (312) 899-0040

aminophenols Chemical derivatives of phenol used in orange, red, and medium-brown hair dyes. Adverse reactions range from mild contact rashes to convulsions from severe absorption or asthma from inhalation. aminophylline

A bronchodilating drug made up of two components, theophylline and ethylenediamine. Available in both tablet and intravenous forms, aminophylline has been a standard treat-

anaphylaxis 15 ment for acute asthma attacks for many years. However, recently, its use has been related to a backup role with the increased use of the beta-agonist bronchodilators. The action of aminophylline is based on the theophylline portion, which is a methylxanthine derivative and has many adverse effects and drug interactions. See also THEOPHYLLINE.

ammonium carbonate

A neutralizing alkaline chemical used as an expectorant in cough syrups, in permanent wave solutions, and in fire extinguishers. It can cause contact rashes.

ammonium iodide

A chemical used as an expectorant in cough syrups. It is also used as a preservative and antiseptic by the cosmetic industry.

analgesia (respiratory implications) Drug therapy used to relieve pain. In the case of respiratory disorders, the use of narcotic painkillers such as codeine, morphine, oxycodone, hydromorphone, nalbuphine, pentazocine, and others is contraindicated in the event of acute bronchial asthma and upper airway obstruction. Side effects that may be caused by these drugs are respiratory depression and respiratory arrest, among other conditions. anaphylactic shock

See

anaphylactoid reaction

ANAPHYLAXIS.

A severe and potentially life-threatening, allergy-like reaction characterized by swelling and constriction of airways caused by the direct release of potent biochemical mediators from cells in the body tissues. As opposed to anaphylaxis, anaphylactoid reaction does not involve immunoglobulin E (IgE) antibodies. Since symptoms of anaphylactoid and true allergic, anaphylactic reactions are indistinguishable, the terms are used synonymously. Immediate anaphylactoid reactions can result from poisoning after eating fish containing large amounts of histamine. Tuna, mackerel, and mahi mahi are the most common sources. Fish inadequately refrigerated or contaminated by Proteus morganii or Klebsiella pneumoniae bacteria may also

contain dangerously high histamine levels. Allergylike symptoms—flushing, erythema, itchy eyes, nausea, diarrhea, and headache—may last up to 24 hours and are self-limiting (they eventually disappear on their own). Swiss cheese may cause a similar reaction. Tuberculosis patients taking the drug isoniazid (INH) are highly susceptible to these food reactions. See also ANAPHYLAXIS.

anaphylaxis (anaphylactic

shock) The most severe or extreme type of allergic reaction, which may be life-threatening, characterized by any or a combination of the following symptoms: itching of the throat or skin, hives, dizziness, tightness and swelling in the throat, difficulty breathing, weakness, sudden drop in blood pressure, or unconsciousness. Anaphylaxis ranges from mild itching to collapse and death and, therefore, constitutes a medical emergency. True anaphylaxis occurs after exposure to an allergen to which a person has been previously sensitized. Prevalence An estimated four deaths per 10 million people from anaphylaxis occur each year. There are insufficient data to determine increased risk for anaphylaxis, such as age, sex, or ethnic criteria. There does not appear to be a predilection to penicillin or insect-sting anaphylaxis in persons known to have other allergies. However, some studies suggest that allergic individuals do have a higher incidence of anaphylaxis. In the early 20th century, before the availability of antibiotics, horse-serum antitoxin was used to treat the often fatal diseases such as diphtheria, scarlet fever, tetanus, and tuberculosis. Prior to the penicillin era, horse serum was the most common cause of anaphylaxis. Penicillin may account for 75 percent of all fatal allergic reactions: an estimated 500 deaths annually in the United States. One fatality occurs for every 7.5 million injections of penicillin; death may also result from oral, inhaled, or topical contact with the drug. Hieroglyphics depict death from an insect sting 4,000 years ago. In 2640 B.C., the Egyptian pharaoh Menes reportedly died suddenly after

16 anaphylaxis being stung by a wasp. Up to 4 percent of the population suffers systemic reactions to stings of bees, wasps, hornets, yellow jackets, and fire ants. Aspirin and the frequently used arthritis drugs called nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, may cause anaphylaxis in as many as 1 percent of individuals. Up to 10 percent of persons with asthma may exhibit anaphylaxis. Cause Despite recognition of fatal allergic reactions dating from biblical times, it was not until 1902 that French professors of medicine Charles Richet (1850–1935) and Paul Portier (1866–1962) linked a case of fatal anaphylaxis to a foreign protein injection that had been previously tolerated by a patient. Anaphylaxis occurs when potent biochemicals such as histamine (also called mediators) are released from mast and other special cells in the body tissues and act in a sequence of events affecting various organs. It is now known that there is more than one mechanism for this reaction. Type I allergy, also called hypersensitivity or IgEantibody–mediated allergic reaction, is the most common and best understood cause of anaphylaxis. Following initial exposure of a foreign protein or hapten, antibodies develop during a latent period. Anaphylaxis occurs upon re-exposure of this same foreign substance. A hapten, of which penicillin is an example, is a low-molecular-weight and nonallergenic substance until it combines with a larger “carrier” molecule to become allergenic. Hundreds of allergens in drugs (especially antibiotics), foods ( the most frequent offenders include eggs, cow’s milk, peanuts, fish and shellfish, and tree nuts), food preservatives (especially sulfites), and foreign proteins (including seminal fluid, insulin, and insect and snake venoms) are capable of inducing anaphylaxis in susceptible individuals. However, other reactions that do not involve antigen-antibody production but stimulate the release of chemical mediators, including histamine, can cause the same symptoms as anaphylaxis. For many years this was referred to as anaphylactoid (anaphylactic-like) reactions. Most allergists feel the term is outdated and refer to all similar reac-

tions as anaphylaxis. Substances capable of inducing these reactions include whole blood, radiocontrast (X ray) media, aspirin, food dyes, and drugs. Trauma, burns, or infections can also induce anaphylactoid reactions. Signs and Symptoms An initial sensation of warmth, itching, or tingling begins in the axilla or groin and gradually spreads throughout the body. Sneezing, intense itching, and constriction in the throat may progress to generalized hives and angioedema, or swelling of the face and tongue. Wheezing, shortness of breath, abdominal pain, nausea, vomiting, and diarrhea may follow. A drop in blood pressure, described by some as a feeling of “impending doom,” may signal collapse (or shock) and death. Any of these signs and symptoms can occur individually or concurrently. The longer the time interval (or latent period) between the initial exposure to an allergen and the onset of symptoms, the less likely it is that death will occur. Treatment Treatment must be initiated at the first signs or symptoms of impending anaphylaxis, since there is no way of anticipating how severe a reaction may become. Epinephrine (adrenaline) given subcutaneously (under the skin) is the drug of choice; if it is given immediately, it may be lifesaving. Antihistamines, bronchodilators, corticosteroids, and oxygen are also administered as needed, but they take much longer to become effective and may not be lifesaving. Arrange transportation of the patient to the nearest emergency room or other medical facility. A delay of even a few minutes can be fatal. A person may experience a recurrence of anaphylaxis as long as 24 hours after the initial reaction and should be monitored for at least 24 hours. Prevention Individuals known to be at risk through a history of a prior severe allergic reaction should carry an adrenaline kit at all times. Identify and avoid a food (rarely more than one) that is thought to be a cause of allergic reaction. Avoidance of a food because another family member has had a serious reaction

anesthesia for the allergic and asthmatic patient to it is not necessary. Skin testing for foods can be hazardous and should be avoided if anaphylaxis has occurred; radioallergosorbent test (RAST) blood food testing is safer but often misleading because of false-positive or -negative results. Specific preventive measures should be taken by persons with cold-induced urticaria (hives), exercise-induced anaphylaxis, and allergy to seminal fluid, venomous insects, drugs, and radiocontrast (X ray) dyes. See also ADVERSE DRUG REACTIONS.

anapnea

Breathing or regaining the breath.

anergy

The inability of certain individuals to react to a test for hypersensitivity to antigens. Normal individuals almost invariably have positive skin tests to mumps, Candida (a common yeast), and tetanus antigens because antibodies to these conditions are present in their blood. However, some skin tests prove negative despite the presence of the antibodies. Several factors influence the possibility of anergy, including the number and type of antigens (bacterial, fungal, or viral) used in the skin test, the characteristics of a positive reaction, and the presence of a mild upper respiratory infection. Anergy was first noticed when patients with measles lost the ability to react to skin-testing for tuberculosis for a short period of time. Anergy also pertains to one whose skin temporarily does not show a reaction to a tuberculin (e.g., Mantoux) test after receiving a live-attenuated measles, mumps, and rubella (MMR) vaccine. If a tuberculin test is required, it should be administered either before or simultaneously with the MMR vaccine or after three months from the date of the vaccination.

anesthesia for the allergic and asthmatic patient Alternatives to general anesthesia should be considered for all surgical candidates with allergies or asthma, because any hypersensitivity may be exacerbated by anesthesia drugs with potentially severe results. (The risk of adverse effects of anesthesia, although small, exists even for nonallergic or nonasthmatic normal individuals.) Spinal, epidural, or

local anesthesias are excellent choices for many surgical procedures. Anesthetics, Local Lotions, creams, ointments, and sprays applied topically in the treatment of local injuries, burns, and insect bites. Other local anesthetics, drugs designed to eliminate sensation only in certain areas of the body, may be injected before minor surgery or repair of skin lacerations, or to numb dental tissues before dental surgery. Snow may have been the first anesthetic agent used and was recognized for its numbing ability by Hippocrates. Cocaine was isolated in 1860 by Niemann from the Erythroxylon coca bush. However, the modern era of a local anesthesia was not entered until 1884, when Sigmund Freud and Karl Koller reported the cocaine’s ability to numb the eye for surgical procedures. Although these agents rarely cause true allergic reactions, they often cause vasovagal syncope (fainting spell brought on by a sudden drop in blood pressure), hyperventilation, palpitations, or anxiety reactions. These are non-immune (nonallergic) adverse reactions resulting from excessive doses or other pharmacologic drug reactions easily confused with allergy. Patients suspected of having a true type I (immediate) allergic reaction to one of these drugs can be tested by injecting them with minute doses, gradually increasing the dose according to standardized protocol. Drugs may cross-react if they belong to the para-aminobenzoic esters group, such as procaine (Novocain) and tetracaine (Pontocaine). Lidocaine (Xylocaine), bupivacaine, and others do not cross-react and can usually be substituted for the drug suspected of a reaction without the need for the tedious process of testing and desensitization. Parabens and other preservatives may be responsible for some adverse reactions rather than the anesthetic drug. Local anesthetics are available in individual, preservative-free dose ampules. Benzocaine, although commonly used topically for temporary relief of the conditions listed above, may cause a sensitivity reaction of its own and worsen rather than improve the condition for which it is employed. Many allergists and dermatologists warn

18 aneurysm against their use on the skin; however, drugs like lidocaine offer temporary relief for ulcers of the mouth, rectal lesions, including hemorrhoids, and painful mucous membranes. Benzocaine, cyclaine, and tetracaine are used to inhibit the cough reflex before invasive diagnostic tests such as bronchoscopy. Another local anesthetic, benzonatate (Tessalon), is available as a prescription cough suppressant. High-pressure dental equipment can cause air infiltration into local oral tissues, resulting in swelling and wheezing that may be confused with an allergic reaction. Local Anesthetic Drugs Ester Type (contain para-aminobenzoic esters and may cross-react): benoxinate (Dorsacaine) benzocaine1 butacaine (Butyn) butethamine (Monocaine) butylaminobenzoate (Butesin) chloroprocaine (Nesacaine)2 cocaine cyclomethycaine (Surfacaine) hexylcaine (Cyclaine)3 procaine (Novocain)4 proparacaine (Ophthaine) tetracaine (Pontocaine)3 Amide Type (do not contain para-aminobenzoic esters and do not cross-react): amethocaine1 amydricaine (Alypin) bupivacaine (Marcaine) dibucaine (Nupercaine)4 dimethisoquin (Quotane) diperodon (Diothene) dyclonine (Dyclone) etidocaine (Duranest) lidocaine (Xylocaine)5 mepivacaine (Carbocaine) oxethazaine (Oxaine) phenacaine (Holocaine) piperocaine (Metycaine) pramoxine (Tronothane) prilocaine (Citanest) pyrrocaine (Endocaine)

More likely to cause contact dermatitis. May be safest because of its short duration of action. 3 More likely to cause true anaphylaxis. 4 More likely to cause anaphylaxis or contact dermatitis. 5 Most widely used and often combined with epinephrine, which may be the cause of adverse effects. 1 2

See also SURGERY, RELATED TO ALLERGIC AND ASTHMATIC PERSONS.

aneurysm From the Greek word aneurysma, meaning a widening, a dilation occurring due to a weakness in the wall of a blood vessel. In the case of an aortic aneurysm, dyspnea, cough, sputum production, congestion, and other symptoms may appear, and there may be pressure on the trachea, esophagus, veins, or nerves. Aneurysms are often the result of trauma or bacterial and mycotic infection. angioedema, hereditary

A rare inherited disorder (genetically known as autosomal dominant) due to the deficiency or malfunction of a substance called C1-esterase inhibitor usually manifesting in late adolescence or early adulthood. Infected persons have less than 15 percent normal-functioning C1 inhibitor (an inhibitor is a chemical that stops enzyme activity), and family history is positive for this disorder in 85 to 90 percent of patients. Lack of C1 inhibitor results in an activation of the complement system (consisting of components related to how antibodies work in the blood) and the release of chemical mediators that produce the symptoms of angioedema. The condition is characterized by recurrent episodes of painful swelling of the skin and mucosa of the upper respiratory and gastrointestinal tracts, and the extremities. Hereditary angioedema can be triggered by minor trauma, sudden changes in temperature, infections, and emotional upset. An estimated 25 percent of untreated individuals die of laryngeal edema after dental or throat surgery. Other symptoms include abdominal pain from swelling of intra-abdominal organs, vomiting, diarrhea, and a drop in blood pressure. Unlike idiopathic, or nonhereditary, angioedema, urticaria (hives) and itching do not occur. Diagnosis is made by measuring C1 inhibitor levels, assays that assess

anthrax 19 functional abnormalities in the presence of normal or near-normal levels of the enzyme, and other complement levels. This life-threatening disease can be treated with synthetic anabolic steroids such as danocrine (Danazol). However, the drug cannot be used in children or adolescents until they have achieved their full growth. Short-term therapy in anticipation of dental or throat surgery includes fresh-frozen plasma given one day prior to surgery. Epsilon-aminocaproic acid and tranexamic acid are drugs sometimes used prior to surgery. Emergency intubation or tracheostomy may be required.

anoxia

Lack of oxygen, such as in high altitude anoxia. Anoxic anoxia is caused by a disorder in the lungs’ ability to fill with oxygen, which in turn may be caused by decreased oxygen supply, a respiratory obstruction, decreased pulmonary function, or insufficient respiratory movements.

antasthmatic

A substance or agent that prevents or relieves the symptoms of asthma.

anthracosilicosis

A type of pneumoconiosis characterized by an accumulation of silica and carbon deposits in the lungs as a result of inhaling coal dust. See also COAL WORKER’S PNEUMOCONIOSIS.

anthracosis

Carbon deposits in the lungs from inhaling smoke or coal dust. See also BLACK LUNG.

anthrax An infectious disease caused by Bacillus anthracis that usually attacks cattle, sheep, horses, and goats, but may also be transmitted to humans through contact with animal hair, hides, or waste materials. The disease may target the lungs or loose connective tissue, which may cause malignant edema, necrosis of mediastinal lymph nodes, and pleural effusion. Shock, coma, and respiratory arrest may also occur. Penicillin, tetracyclines, and erythromycin are among the drugs of choice for the treatment of anthrax. In the fall of 2001 on the heels of the terrorist attacks on the World Trade Center in New York

City, anthrax-tainted mail became a major concern for postal workers and the general population. Considered an act of chemical terrorism (also called bioterrorism) committed by yet unknown perpetrators, anthrax spores in a powdered form were found in envelopes and packages. When inhaled by the recipient, there was a possibility of contracting the disease. The first of several victims of inhalation anthrax was American Media photo editor Bob Stevens, of Florida, who died in September 2001. An initial difficulty in diagnosing the disease involved medical professionals who had rarely, if ever, treated cases of anthrax. Now the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, releases updated knowledge on the diagnosis and treatment of anthrax. Believed to have a survival rate ranging from 1 to 15 percent before the terrorism occurred, inhalation anthrax now presents itself with a 60 percent survival rate. Of the 10 individuals who were reported to have contracted the disease, six survived, most likely due to early recognition of symptoms and prompt antimicrobial administration. Some victims of anthrax, aged 43 to 73, complained of various flu-like symptoms, while others experienced non–flu-like drenching night sweats, nausea and vomiting, abdominal pain, and pleural effusion. Of the three types of anthrax—inhalation, cutaneous, and gastrointestinal—inhalation is the most dangerous and life-threatening, particularly because the symptoms, including fever, malaise, nonproductive cough, chest or abdominal pain, nausea, vomiting, and headache, may suddenly subside (called “the anthrax honeymoon”), and treatment may be delayed. However, untreated symptoms of anthrax may lead to acute dyspnea, a widening of the mediastinum (seen in chest X ray/radiograph), diaphoresis, cyanosis, stridor, shock, and death in up to three days. Some victims of anthrax may also develop meningitis. According to reports, all 10 victims showed abnormal chest X rays with pleural effusion, mediastinal widening, or infiltrates. The incubation period of anthrax may be as brief as two days after contamination to two months. The dearth of information on the incubation period, symptoms, cross-contamination, and methods of infection has prompted the CDC to recom-

20 antibiotic mend the use of ciprofloxacin (Cipro) or doxycycline for initial intravenous therapy plus other antimicrobial drugs until antimicrobial results are specified. Other antibiotics that may be used include ampicillin, chloramphenicol, clarithromycin, clindamycin, imipenem, penicillin, rifampin, and vancomycin, or combinations of various drugs. The use of cephalosporins and trimethoprim-sulfamethoxazole, and the use of penicillin G, ampicillin, or amoxicillin alone, are not recommended by the CDC. For those anthrax sufferers who are allergic or cannot take ciprofloxacin or doxycycline for some other reason, high-dose penicillin, such as amoxicillin or penicillin VK may be substituted, and steroids may be necessary if the patient is experiencing respiratory distress or has meningitis. Treatment for children with anthrax may be even more difficult to diagnose, and the CDC urges pediatric practitioners to be aware of symptoms that may warrant immediate treatment. Prophylactic antibiotics have been recommended for individuals who may have been exposed to aerosolized anthrax spores or to air space shared by a victim of inhalation anthrax. More information is available on the CDC website, www.cdc.gov/ncidod/EID/vol7no6/pdf/jernigan. pdf. See also ANTIBIOTIC; PLEURA; WOOLSORTER’S DISEASE.

antibiotic A natural or synthetic substance or agent that inhibits the growth of or destroys microorganisms. In 1939, the first antibiotic— meaning against life—was gramicidin, used by René Dubos to treat infected cattle. Penicillin’s clinical use came later. A bacteriocidal or bactericidal antibiotic agent kills microorganisms; a bacteriostatic antibiotic inhibits their growth. A broadspectrum antibiotic inhibits or kills a number of microorganisms. Some strains of bacteria were either never affected by antibiotics or have evolved to become resistant to them. This has become a recent problem most likely because the use of antibiotics became so commonplace as to be overprescribed, and because individuals stopped taking the medication sooner than prescribed (therapy usually spans seven to 10 days) when symptoms subsided or disappeared. Completion of antibiotic

therapy is of utmost importance, even after an illness or infection seems to have gone away. Also, many patients demand antibiotics for respiratory or other infections that may in actuality be caused by a virus, not a bacterium, in which case the antibiotic is ineffective and the body develops a tolerance for it that may thwart the effectiveness of an antibiotic prescribed for a future infection. Antibiotics that target certain viruses have been developed. See also PENICILLIN.

antibody A substance produced by B cells (lymphocytes derived from bone marrow) and designed to attack a specific foreign invader called an antigen. For example, a cold virus stimulates a B cell to produce an antibody against that specific virus. The immune process involving antibodies is referred to as humoral immunity. When a B cell encounters its triggering antigen, T cells and other accessory cells collaborate with it to cause the production of large plasma cells. Each plasma cell becomes a factory for producing antibodies. Antibodies are Y-shaped protein molecules known as immunoglobulins. Transported through the circulation to the site of inflammation or infection, antibodies neutralize or combine with and identify antigens for attack by other cells or chemical mediators. antibody deficiency disorder

Acquired or congenital inability to produce all or selective classes of immunoglobulins. Individuals with this disorder have frequent infections or difficulty overcoming them. Examples are X-linked or Bruton’s agammaglobulinemia (lack of gamma globulin antibodies in the blood) and common variable or acquired hypogammaglobulinemia (abnormally low level of gamma globulin in the blood). See also ACQUIRED IMMUNODEFICIENCY SYNDROME; IMMUNOGLOBULIN A; IMMUNOGLOBULIN D; IMMUNOGLOBULIN G; IMMUNOGLOBULIN M.

anticholinergics

Bronchodilating drugs that block the action of nerve reflexes that constrict muscles of the bronchial tubes in the lungs. Anticholinergics take 15 to 20 minutes to become effec-

antihistamine 21 tive, as opposed to faster-acting beta-agonists. Atropine and ipratropium (Atrovent) are examples; only Atrovent is available as a metered-dose inhaler. Adverse effects of anticholinergics, dry mouth and cough, are rarely encountered with ipratropium.

antigen (immunogen) Any substance that, when introduced into the body, is recognized by the immune system and is capable of triggering an immune response. The term immune is derived from the Latin immunis (free from taxes or free from burden). An antigen can be a bacterium, fungus, parasite, virus, or a part or substance produced by these organisms. Tissues or cells from another individual, except an identical twin, are recognized by the immune system as foreign and, therefore, antigenic. See also ALLERGEN; IMMUNE SYSTEM. antigens, cross-reaction among plant families Allergic reactions that occur from exposure to allergens common to more than one plant family. For example, ragweed, a member of the Ambrosiaceae family, has antigens that cross-react with members of the family Compositae. This crossreaction explains why ragweed-sensitive persons may react when drinking chamomile tea, because chamomile is derived from Compositae. Ragweedsensitive persons also may react to pyrethrum, an insecticide made from chrysanthemums, another member of the Compositae. Although hay fever sufferers sometimes experience itching and swelling of the palate after eating melons and bananas during the ragweed season, there is no cross-reactivity between ragweed antigen and the botanical families of melon and banana.

antihistamine Any drug that blocks the effects of histamine, a potent chemical substance produced in the body, and is responsible for the body’s allergic responses. For nearly 50 years, antihistamines have been used to prevent or relieve the symptoms of immediate, type I hypersensitivity, or anaphylactic allergic reactions. Characteristic symptoms include sneezing, rhinorrhea (watery nasal dis-

charge), congestion, itching, wheezing, and swelling of tissues. During an allergic reaction, allergens bind to histamine type 1 receptors on the surface of mast cells and basophils, and cause the cells to rupture and release stored histamine and other substances called chemical mediators. Antihistamines bind to these receptors to prevent allergens from binding, which in turn prevents cell rupture and release of the mediators. Histamine blockade of receptors is competitive, and an inadequate dose or a lapse in timing of a dose of antihistamine may result in poor therapeutic response. Histamine may also be released by other mechanisms during exposure to certain drugs, chemicals, dyes, foods, toxins, alkaloids, venoms, or physical stimuli. Certain foods also contain histamine. Histamine and other released chemical mediators are responsible for the symptoms that occur during anaphylaxis, which may be lifethreatening, and antihistamines alone may be inadequate in this situation. The beneficial effects of antihistamines, as well as any adverse ones, are related to their basic chemical structures. There are five classes of type 1 antihistamines. Some antihistamines such as azatadine have a dual action and also prevent the release of the chemical reactors, thus blocking to varying degrees the cascade of events of allergic reaction. Drugs available in the United States, such as azelastine (Astelin Nasal Spray) and ketotifen (Zaditor Ophthalmic Solution) have traditional receptor blocking abilities, but their greatest antiallergic benefits combat inflammatory late-phase reactions. Since their primary function is against late-phase reaction, azelastine and ketotifen are not really antihistamines by definition. Antihistamines are most effective in seasonal allergic rhinitis or hay fever, slightly less effective for perennial or chronic allergic rhinitis, and least likely to improve symptoms of the nonallergic vasomotor and infectious types of rhinitis. Antihistamines are frequently prescribed with nasal decongestants either separately or combined in one tablet, capsule, or liquid preparation. There is no evidence that antihistamines are of any benefit for the treatment of colds, despite their inclusion in many over-the-counter and prescription cold remedies. But an indirect benefit may be attributed to the sedative side effect of most

22 antihistamine antihistamines, especially when the inducement of drowsiness or sleep is desired. The intense pruritus (itching) that accompanies urticaria (hives) and the allergic skin conditions, eczema and contact dermatitis, are relieved to varying degrees by antihistamines. At night, the added benefit of sedation from the first-generation agents such as hydroxyzine (Atarax) may make them more effective. The nonsedating astemizole (Hismanal) is effective for suppressing hives and can be given in a single-daily dose for convenience. H1 and H2 antihistamines are sometimes combined in resistant cases of hives. Minor allergic reactions to insect stings, drugs, foods, and allergy immunotherapy (allergy shots) often respond to antihistamines. When anaphylaxis is impending or has occurred, epinephrine (Adrenalin Chloride) should be administered promptly. Diphenhydramine (Benadryl) or other antihistamines are useful only as a secondary treatment. Prescription and overthe-counter antihistaminic eyedrops relieve itching associated with seasonal allergic conjunctivitis. Antihistamines are sometimes given prophylactically before a blood transfusion in persons with a history of prior transfusion reaction. While antihistamine may reduce the itching and flushing that can occur during a transfusion, it does not prevent the serious reactions possible from receiving blood from an incompatible donor. Many persons experience adverse reactions to radiocontrast (X-ray dye). Such reactions are complex, and there is a higher incidence in allergic individuals. Antihistamines and corticosteroids should be given to anyone who has had a previous reaction. Sedating properties of antihistamines make them useful as relatively safe, nonprescription hypnotics. One must be warned, however, that overdoses of these drugs may be fatal. Also, tolerance develops quickly, limiting their usefulness for chronic insomnia. Hydroxyzine (Vistaril) and promethazine (Phenergan) are antihistamines often mixed with narcotics such as meperidine (Demerol) to potentiate their effectiveness and also to prevent nausea. Cyclizine (Marezine), meclizine (Antivert, Bonine), and dimenhydrinate (Dramamine) prevent motion sickness and counteract the disabling vertigo of Ménière’s syndrome. Side effects vary by incidence. Intensity corresponds to

the class to which a particular antihistamine belongs. The traditional antihistamines cause drowsiness in many individuals because the drug diffuses into the central nervous system from the general circulating blood. Drowsiness varies greatly among individuals, often improving after several days. Great care must be taken when driving or operating dangerous machinery because of impairment of reflexes. Drowsiness intensifies if other sedative drugs or alcohol are used concurrently. Antihistamines may also disturb coordination and cause dizziness, a feeling of lassitude, fatigue, tinnitus (ringing in the ears), diplopia (double vision), and the inability to concentrate. Instead of sedation from antihistamines, a few individuals, especially infants or toddlers, experience an unexpected excitatory or stimulant effect, at times to the point of insomnia. Seizures, or convulsions, are a potentially serious adverse effect of antihistamines in some individuals predisposed to them, most often children. Sedation is the most frequent side effect of first-generation antihistamines, also referred to as “classic” or traditional antihistamines, such as chlorpheniramine (Chlor-Trimeton) and diphenhydramine (Benadryl). Newer antihistamines such as terfenadine (Seldane), astemizole (Hismanal), and the drugs loratadine (Claritin) and cetirizine are generally nonsedating in most patients. For many years antihistamines were thought to be contraindicated or harmful to patients with asthma. In fact, most over-the-counter and prescription antihistamines come with a warning against their use by these patients. It was thought that their drying effects would aggravate asthma. Not only has this been disproved, but some antihistamines have mild bronchodilating effects and may actually be beneficial to some asthmatics. Rarely will an antihistamine worsen asthma. The topical use of antihistamines available as over-thecounter remedies for the relief of itching from prison ivy, insect stings, and sunburn should be avoided. These products are skin sensitizers in many persons and frequently cause an allergic contact dermatitis worse than the original condition for which they are recommended. Anticholinergic, or atropine-like, side effects range from minor dryness of the mucous mem-

antihistamine 23 branes of the nose, mouth, and throat to constipation, tachycardia (palpitations), excitability, restlessness, nervousness, insomnia, irritability, and tremors. Blurred vision could be a potentially serious problem in a person with untreated or inadequately controlled glaucoma. It is not uncommon for a middle-aged or elderly male to develop a sudden inability to pass urine (acute urinary retention) after taking an antihistamine. Infrequent gastrointestinal disturbances include anorexia (loss of appetite), nausea, vomiting, abdominal pain, constipation, or diarrhea. The most important advance since the availability of these important drugs in the 1940s has been the development of the “second-generation” H1-receptor antihistamines. These newer agents, including terfenadine and astemizole, are nonsedating in up to 99 percent of patients because they do not cross the blood-brain barrier in significant amounts. Some rare side effects of nonsedating antihistamines include increased appetite and weight gain in patients taking astemizole and hair loss in a few patients taking terfenadine. A more serious, but fortunately an extremely rare, problem with both astemizole and terfenadine has been the onset of cardiac arrhythmias (irregularities), including ventricular tachycardia and fibrillation, which can be lifethreatening. Arrythmias follow doses two or three times the recommended dose. Patients at increased risk have been those also taking the drugs ketoconazole (Nizoral), troleandomycin (TAO), or erythromycin, or those with liver diseases such as hepatitis or alcoholic cirrhosis and hypokalemia (a state of low potassium in the blood). Rare cases of blood disorders, such as agranulocytosis (a severe depression of the bone marrow’s production of granulocytic white blood cells), leukopenia (low leukocytic white blood cell count), thrombocytopenia (destruction or decreased production of platelets), and hemolytic anemia (destruction of the red blood cells), are usually reversible when the offending drug is discontinued. Considering the millions of doses of these drugs taken every day, the chances of suffering a serious side effect are slim. Despite antihistamines’ long record of safety, their easy availability makes them popular for suicide attempts. The margin of safety for antihista-

mines is considerably less for children. The first signs of overdose usually occur within two hours of ingestion: drowsiness, dizziness, unsteady gait, flushing, dilated pupils, and fever; however, children will often paradoxically appear hyperactive, with hallucinations, toxic psychosis (bizarre behavior), and tremors. In adults, seizures, respiratory failure, cardiac arrest, and death may result. There is no perfect antidote for antihistamine overdose. Efforts may include eliminating the drug by induced vomiting in a conscious patient or by pumping the stomach in a lethargic or comatose one. Activated charcoal and strong laxatives called cathartics are also given. The drug physostigmine is sometimes used, but not without risk. It should probably be used only in situations when high temperature or delirium does not respond to cooling by hypothermia blankets, fluids, and cold bathing. Antihistamines may mask the early signs of anaphylaxis and should not be used to prevent this reaction when administering immunotherapy (allergy shots). Although the use of drugs during pregnancy, especially during the period of organ development in the first trimester, should be limited, the use of an antihistamine may be unavoidable. Treatment should be based on the same principles for using any drug during pregnancy. Not only must the drug be necessary, but it also should have a long record of use during pregnancy without reported adverse outcomes to the pregnancy and its use must be monitored by a physician experienced in its use during pregnancy. Chlorpheniramine (Chlor-Trimeton) and tripelennamine (Pyribenzamine) are the preferred antihistamines in pregnancy. Antihistamines: Chemical Classification and Generic and Trade Names Amino alkyl ethers (Ethanolamines): clemastine fumarate (Tavist); diphenhydramine hydrochloride (Benadryl) Ethylenediamines: pyrilamine maleate (generic); tripelennamine citrate or hydrochloride (PBZ) Alkylamines (Propylamines): brompheniramine maleate (Dimetane); chlorpheniramine maleate (Chlor-Trimeton, Teldrin); dexchlorpheniramine maleate (Polaramine); tripolidine

24 anti-inflammatory hydrochloride (Actidil) [Other antihistamines of this class not generally used for allergic conditions are not listed.] Phenothiazines: methdilazine (Tacaryl); promethazine hydrochloride (Phenergan); trimeprazine tartrate (Temaril) Piperidines: azatadine maleate (Optamine); cyproheptadine hydrochloride (Periactin) Piperazines: hydroxyzine hydrochloride (Atarax, Vistaril); phenindamine tartrate (Nolahist) Nonsedating: acrivastine (Semprex); astemizole (Hismanal); azelastine (Astelin); cetirizine hydrochloride (Zyrtec); loratadine (Claritin); terfenadine (Seldane). See also

DECONGESTANT; HISTAMINE H2, RECEPTOR

AGONIST.

anti-inflammatory

An agent or substance that prevents or reduces inflammation, the body’s nonspecific immune response to an area that is injured or traumatized. Anti-inflammatory drugs may also relieve pain. Ibuprofen is a popular example of a nonsteroidal anti-inflammatory (trade names include Motrin, Advil, Nuprin, and Rufen). Aspirin (acetylsalicylic acid) is also a nonsteroidal antiinflammatory (also known as NSAIDs) with painkilling and fever-reducing properties. Some NSAIDs have been known to produce asthma in certain individuals, which contraindicates their use. Bronchospasm, nasal polyps, rhinitis, and hypersensitivity to the particular drug are also contraindications.

antimicrobial

An agent or substance that destroys or inhibits the development of microorganisms.

antiseptic An agent or substance that prevents or inhibits the growth of disease-causing microorganisms. antituberculotic Thwarting or stopping tuberculosis in the body. In the treatment of pulmonary tuberculosis, antituberculars are drugs that inhibit RNA or DNA fats and protein synthesis,

which reduces the ability of the tubercle bacillus to replicate.

antitussive

An agent or substance that reduces, relieves, or prevents coughing. A centrally acting antitussive acts on the medullary centers of the brain to suppress the cough reflex.

antiviral An agent or substance that inhibits or destroys viruses. anxiety

Feelings including fear and panic or nervousness that may lead to physiological symptoms or discomfort. Breathing difficulties and disorders may cause anxiety in some individuals. Because anxiety is a response to stress or conflict, a person with a respiratory disorder such as asthma or chronic obstructive pulmonary disease may experience symptoms of anxiety during an exacerbation of the disease or after the discontinuation of a medication. Many individuals, with or without respiratory disease, may experience anxiety as shortness of breath or a feeling of being asphyxiated, faintness, heart palpitations, trembling or shivering, increased sweating, a sensation of choking, fear of losing control or dying, chills, numbness, nausea, diarrhea, pains in the chest, and other manifestations. Very often the family of a person with a respiratory disorder such as asthma may suffer severe anxiety when the person experiences an asthma attack or any situation that causes difficulty breathing. Education, precautions, and strategies prepared ahead of time may decrease the fears of the caregivers. Those with anxiety disorders not usually induced by a medical problem, such as social phobia, obsessive-compulsive disorder, agoraphobia, posttraumatic stress disorder, panic attacks, or panic disorder, should seek treatment if they develop a respiratory or other medical problem, or if they have an anxiety disorder in addition to a respiratory problem. It is also recommended that physicians check for possible adverse effects of a medication if a patient exhibits symptoms of severe anxiety.

apneusis 25 Psychiatric patients with severe respiratory disorders should be monitored carefully so that they can receive the proper medication and comply with proper medical treatment.

apicolysis

A collapse of the apex of the lung induced by surgically creating an opening in the anterior chest wall. This procedure may be performed for a number of reasons based on a physician’s assessment of a patient’s condition. Symptoms of anxiety may require attention and emotional support. Both during and after the procedure, caregivers must monitor the patient carefully for signs of dyspnea, cyanosis, increased pulse and respiratory rate (which may indicate tension pneumothorax), and signs of mediastinal shift, including severe dyspnea, cyanosis, increased pulse and respirations, distended veins in the neck, and severe, uncontrollable cough.

apnea A temporary cessation of breathing, which may be caused by failure of the respiratory center of the brain to discharge breathing impulses. Apnea is a symptom of conditions including arteriosclerosis, meningitis, cardiac and renal diseases, or following trauma to the brain. Apneic oxygenation refers to providing oxygen to the upper airway of patients who are not breathing. Apnea monitoring is recommended especially for infants to prevent sudden infant death syndrome. Infants may be placed on an apnea alarm mattress designed to sound an alarm if the infant stops breathing. Sleep apnea, or a cessation of breathing occurring during sleep, may last approximately 10 seconds and recur 30 or more times in a seven-hour period of sleep. This disorder may be caused by an upper airway obstruction, respiratory muscle activity dysfunction, or a combination of factors. Treatment may include surgical correction of an obstruction, the correction of an underlying disease, weight loss, and the prescription of certain drugs. apneumatosis See also

Congenital atelectasis.

ATELECTASIS.

apneumia A birth defect in which the lungs are absent. Birth defects may result from chromosomal

or genetic abnormalities of one or both parents, and genetic testing may be recommended for those who wish to conceive but may have a family history of genetic problems. Physicians or genetic counselors usually prefer to know the history of at least three generations in a particular family, i.e., causes of death of all parents, siblings, children, aunts, uncles, and grandparents, history of distant relatives if pertinent (such as if they had a genetic disorder), ethnic and racial background, possible intermarriages of relatives, and exposure to drugs that have been known to cause fetal distress or defects. Various testing is also helpful in detecting hereditary disorders. Carrier screening for diseases caused by recessive genes and prenatal diagnosis are among the available methods. Infants born with a physical abnormality such as the absence of lungs are most likely victims of a chromosomal defect or defects in several genes (polygenic). Amniocentesis, ultrasound scanning, and various blood, placental, and fluid tests aid the physician in prenatal diagnosis. Some genetic disorders that are detectable before birth include cystic fibrosis, congenital adrenal hyperplasia, duch*enne’s muscular dystrophy, hemophilia A, alpha- and beta-thalassemia, Huntington’s disease, polycystic kidney disease, sickle cell anemia, and Tay-Sachs disease.

apneusis A respiratory abnormality marked by the difficult and prolonged effort to inhale. The condition is the result of surgical removal of the upper portion of the pons in the brain. This procedure may be treatment for a disorder of certain cranial nerves. The pons is fairly centralized in the brain, just above the medulla and in front of the cerebellum. The pons, which works with the medulla to control breathing, connects the spinal cord with the brain and connects other parts of the brain to each other. Located in some of the pons fibers are nuclei for the trigeminal nerves, which govern impulses for chewing and for sensations of the head and face; the abducens nerves, which regulate some movement of the eyeballs; facial nerves, which carry impulses for the production of saliva, the sense of taste, and facial expressions; and part of the vestibulocochlear nerves that are involved with the sense of balance.

26 apneustic center apneustic center

The area of the brain stem that regulates respiration.

the vagus is the 10th cranial (head) nerve, which has the widest distribution in the body of any of the other cranial nerves.

apple-packer’s epistaxis

Nosebleed caused by contact with dyes used in apple-packing trays. See also EPISTAXIS.

apple-picker’s disease Bronchitis caused by a fungicide used on apples. Bronchitis is an inflammation of the bronchial tubes that causes congestion, pain, and other respiratory symptoms. See also BRONCHITIS. apulmonism A birth defect in which there is an absence of all or portions of a lung. See also APNEUMIA. arch, pulmonary An extension of the fifth aortic arch on the left side of the body into the pulmonary artery. Aretaeus the Cappadocian (ca. A.D. 120–180) A Greek physician who wrote treatises on causes, symptoms, and treatments of acute and chronic diseases and is credited with the first valid description of asthma, Aretaeus noted in his writings that exercise or other physical work may induce difficulty breathing and that a “sense of suffocation” may occur when a patient reclines. (Aretaeus also refers to orthopnea, which in modern medicine means respiratory discomfort that can be relieved when an individual either stands or sits erect, with the help of props such as pillows. A person may experience relief, for example, by what is called “two-pillow orthopnea.”) Also in the writings of Aretaeus are descriptions of heaviness in the chest, occupational hazards, thickened mucus, coughing and hoarseness, a desire for cold air, expectoration of foamy sputum, and other manifestations of asthma. Aristocort

See

AZMACORT; TRIAMCINOLONE.

Arnold’s nerve The auricular branch of the vagus nerve, which, when stimulated, causes coughing. Originating in the medulla oblongata of the brain,

arrest, respiratory

The cessation of normal breathing that results in a dangerously low level of oxygen in the blood or a severe increased level of carbon dioxide in the blood. This condition may stem from a number of conditions: chronic bronchitis; emphysema; bronchiectasis; cystic fibrosis; asthma; bronchiolitis; an airway obstruction, or an inhaled or aspirated foreign body, particle, or object; a chest wound; kyphoscoliosis; a drug reaction; acute respiratory distress syndrome; pulmonary fibrosis; fibrosing alveolitis; tumors; sarcoidosis; radiation; burns; myasthenia gravis; muscular dystrophy; polio; Guillain-Barré syndrome; polymyositis; cerebrovascular accident (stroke); amyotrophic lateral sclerosis (Lou Gehrig’s disease); an injury to the spinal cord; poor breathing ability due to obesity, sleep apnea, or drug intoxication. In the case of respiratory failure or arrest, oxygen administration and alleviating the cause or causes are the treatments of choice.

arrhinia

A birth defect in which there is the lack of a nose. See also APNEUMIA.

arterial blood gases (ABGs) A blood test that determines the body’s acid-base balance and the concentrations of the gases oxygen, carbon dioxide, and bicarbonate in the blood. Blood samples are taken from an artery. An ABG test aids in monitoring respiratory failure, because the heart and lungs work to distribute oxygen from inhalation throughout the body via the bloodstream and expel carbon dioxide by exhalation. The normal acid-base balance, also referred to as the pH, or acidity-alkalinity, is 7.39 to 7.41. Asthma, chronic bronchitis, emphysema, diabetes (specifically diabetic ketoacidosis), aspirin poisoning, chronic obstructive lung disease, and symptoms including repeated vomiting may throw ABGs out of the normal range. See also ASTHMA AND PREGNANCY.

asphyxia 27 artificial pneumothorax

The introduction of air into the pleural cavity by means of the administration of oxygen, nitrogen, or filtered atmospheric air.

the muscles), and is considered a natural antibiotic that, when taken prophylactically, boosts the immune system and fights infection.

aspergillosis, allergic bronchopulmonary (ABPA) artificial

respiration

See

CARDIOPULMONARY

RESUSCITATION.

asbestosis

A lung disease, a variant of pneumoconiosis, resulting from protracted inhalation of asbestos particles (fibrous particles of magnesium and calcium silicate). Asbestosis occurs among workers who mine, mill, or manufacture the substance and construction workers who are exposed to it through building or demolition. Scarring of the lung tissue caused by inhaling asbestos dust may be severely aggravated by smoking, chronic bronchitis, or other pre-existing respiratory disorders. Inhaled asbestos fibers cause fluid to accumulate in the pleural space (between the two layers of the pleura), or, in some cases, cause cancerous, incurable tumors in the pleura, called mesotheliomas. Only workers trained in the proper techniques for the removal of asbestos should attempt such a task. The incidence of asbestosis has decreased significantly from that of four or five decades ago because of new industrial precautions and preventive measures, but people who were exposed back then to any of the four types of asbestos fibers may begin to exhibit respiratory distress (especially those who smoke) or mesothelioma decades later. Treatment for asbestosis inhalation includes removing the victim from the contaminated environment, oxygen therapy, the draining of excess fluid from around the lungs, cessation of smoking, and, in some cases, lung transplantation. See also MESOTHELIOMA.

ascorbic acid

A naturally occurring nutrient, also called vitamin C, in citrus fruits and fresh vegetables. It can be synthesized as well, and is important in the maintenance of the body’s collagen, bone tissue, and dentin production. Vitamin C, an essential vitamin, prevents scurvy (a nutritional deficiency that results in hemorrhaging of gums and mucous membranes and painful indurations of

A pneumonia-like disease caused by an allergic reaction to the mold Aspergillus fumigatus. It usually occurs in adult asthmatics. Signs and Symptoms This disorder usually involves episodes of fever, shortness of breath, wheezing, and coughing up copious quantities of dark brown, and at times blood-streaked, sputum. Diagnosis Because the fungus is ubiquitous (found in healthy persons in small quantities that are harmless), the presence of positive sputum cultures is not sufficient to diagnose this disease. The diagnosis is made in persons meeting the following criteria: (1) episodes of asthma; (2) elevated eosinophils (a type of white blood cell) and total immunoglobulin E (IgE) antibodies in the blood; these values are slightly elevated in most allergic individuals but extremely elevated in persons with this disease; (3) pneumonia-like X-ray findings, which may be temporary; (4) bronchiectasis (destruction of the muscles in the bronchial walls with chronic cough and large amounts of sputum); (5) positive skin tests to the Aspergillus fungus; and (6) positive blood tests for antibodies against the Aspergillus allergen. Treatment Prednisone, a corticosteroid drug, is the treatment of choice. It is used daily, most often for several months, and improvement is usually seen within days. In some cases, recurrences require long-term prednisone use. Prognosis If untreated, aspergillosis will damage lung tissues and can be fatal. See also CORTICOSTEROIDS; PREDNISONE.

asphyxia A life-threatening inability to obtain oxygen, such as in choking, trauma, electric shock, drowning, chest compression, lack of oxygen in the

28 aspiration environment, hemorrhage, pharyngeal and retropharyngeal abscesses, paralysis of respiratory muscles, collapsed lung, child abuse, anesthesia, injury of respiratory nerves or centers, and other conditions. Artificial respiration (cardiopulmonary resuscitation) or other treatments may be indicated. Symptoms include difficulty breathing, cyanosis, rapid pulse, sensual and mental impairment, convulsions, and unconsciousness.

aspiration

The act of drawing air or other substance in or out, such as in suction. When an excess of fluid or air, or a foreign body is aspirated into the nose, throat, or lungs upon breathing in, it may be suctioned, or aspirated, out to relieve the undesirable condition. An aspirator is a device designed to evacuate the affected area.

aspirator

See

ASPIRATION.

aspirin triad A condition consisting of asthma complicated by nasal polyps and aspirin sensitivity. However, there are many people with asthma and nasal polyps who can tolerate aspirin, and others with asthma and aspirin sensitivity who do not have nasal polyps. As a rule, it is usually advisable for any person with asthma to use aspirin and related drugs with caution. Astelin Nasal Spray Brand name for azelastine, the only antihistamine approved for topical use in the United States. See also ANTIHISTAMINE. astemizole (Hismanal) A nonsedating (secondgeneration) antihistamine, prescribed for allergic rhinitis and hives, that may take several days to become effective. Astemizole remains in the body for a prolonged period and may suppress hypersensitivity skin-test results for as long as four weeks. It may not be used simultaneously with the antibiotic erythromycin or in persons with severe liver disease because of the possibility of episodes of cardiac arrhythmias. See also ANTIHISTAMINE.

asthma

A chronic lung disease characterized by recurrent attacks of breathlessness, airways (bronchial tubes) that become hyperactive and constrict when exposed to a variety of stimuli or “triggers,” obstruction of the bronchioles that is reversible (but not completely in some patients) either spontaneously or with treatment, and inflammation of the airways. Asthma derives from the Greek word for “panting.” According to the American Lung Association, more than $3.2 billion are spent annually for in-patient hospital services and a total of $11.3 billion per year: $7.5 billion in direct costs and $3.8 billion in indirect costs. The basic cause of asthma is not yet known. The airways of the asthmatic are hyperactive (twitchy) and overly responsive to environmental changes or stimuli called triggers. Triggers result in wheezing and coughing that some researchers think may be set off by an abnormal reaction to sensory nerves in the lungs. As the attack progresses, chemical mediators are released from cells lining the bronchioles, causing inflammation that leads to contraction of airway muscle, production of mucus, and swelling in the airways. Asthma can be classified as either extrinsic (triggered by outside influences such as allergy) or intrinsic (from within). Each asthmatic reacts to a different set of triggers. Identification of a person’s personal triggers is a major step toward learning to control asthma attacks. Although episodes can sometimes be triggered by strong emotions, asthma is not caused by emotional factors, such as a troubled parent-child relationship. However, researchers at the Children’s National Medical Center in Washington and the National Jewish Center for Immunology and Respiratory Medicine in Denver have found a relationship between family stress and the onset of asthma by age three in genetically predisposed children. Three factors—marital discord, prolonged maternal depression, and parental problems in day-to-day care of the child—significantly increased asthma predisposition in genetically at-risk children from 17 percent (if one or none of these stress factors was present) to 42 percent (if at least two of the risk factors were present). Asthma is a disease, not a psychogenic illness or a sign of emotional instability.

asthma 29 There are great variations in asthma severity from person to person and in the individual asthmatic from time to time. Symptoms range from mild to severe and can become life-threatening. The frequency of episodes ranges from one occurrence in a lifetime to daily attacks. The individual attack may be short-lived, lasting from a few minutes to a few hours, or continuous, with daily symptoms for days or weeks. A severe, constant state of asthma is referred to as “status asthmaticus.” The symptoms of asthma are a major cause of sleep disturbances and time lost from school and work. Although asthma cannot be cured, the symptoms can almost always be controlled with proper treatment. In one study of more than 300 asthma patients, researchers found that only 54 percent accurately estimated the severity of their asthma and 27 percent overestimated the severity. The 20 percent who underestimated the severity of their asthma were considered to be at a greater risk for suffering a life-threatening attack. Experts selected to serve on the National Asthma Education Program have developed guidelines for the treatment of asthma. The four basic steps are: 1. Education of the patient and family 2. Control of the environment 3. A comprehensive drug regimen that may include immunotherapy (allergy shots) 4. Objectively monitoring progress. The goals of therapy are to maintain normal or near-normal activity levels including exercise; maintain normal or near-normal lung function test results; prevent coughing, shortness of breath, waking up at night, and loss of time at school or work; prevent the need for emergency room visits or hospitalizations; and avoid medication side effects. The National Asthma Education Program emphasizes an understanding of asthma by each patient and family members. An educated patient is better able to anticipate and, thus, avoid situations that might trigger or worsen asthma. Other guidelines include identification of triggers at home, school, or work; development of effective and simple drug regimens for the patient

to follow; close monitoring of medication dosage adjustments; monitoring effectiveness of advised environmental control measures; monitoring symptoms objectively with doctor’s office spirometry and home peak flow meters, devices that accurately measure breathing status; identifying high-risk individuals and providing psychological support utilizing mental health and social services personnel; preparation, frequent review, and revision as necessary of a crisis management plan for the patient and his or her family; aggressive, prompt treatment of acute episodes; and primary care coordinated with a specialist in asthma. Recognizing Asthma Asthma may resemble, and can be confused with or might coexist with, other respiratory problems such as emphysema, bronchitis, and lower respiratory tract infection. At times, the only symptom of asthma is a persistent cough, usually at night. In some individuals, coughing and wheezing may occur only with exercise. In infants and children, symptoms suggestive of asthma must be differentiated from many other conditions that cause wheezing. The sudden onset of unremitting wheezing in an infant or small child may point to an obstruction of the large airways by a foreign body lodged in the trachea, bronchus, or esophagus until proven otherwise. Laryngo-tracheobronchomalacia is a congenital disorder involving the softening of cartilage that may be associated with asthma and increased incidence of respiratory infections during a child’s first two years. Croup, caused by a respiratory virus, or acute epiglottitis, a serious bacterial infection that can threaten life, can be confused with asthma because inspiratory wheezing is common to both. Cystic fibrosis (CF) may coexist with asthma and should be suspected in any infant with failure to thrive (poor growth) and recurrent respiratory infections. In older children and adolescents, CF should be suspected in asthmatic patients who have had recurrent pneumonia. Mitral valve prolapse, which occurs commonly in slender adolescents (females more than males) and causes chest pain during strenuous exercise, may be confused with exercise-induced asthma. It

30 asthma is characterized by a systolic click heard in the mitral area with a stethoscope; diagnosis is confirmed by an echocardiogram. Hyperventilation syndrome may be misdiagnosed or coexist with asthma, especially in adolescents. The patient typically appears anxious and breathless but without wheezing. A complaint of tingling of the fingers and toes is common. Treatment consists of reassurance and having the patient rebreathe into a paper bag to elevate carbon dioxide levels. Recurrences may require psychological counseling and, possibly, antianxiety drugs. In adults, asthma is often confused with the other common lung diseases, emphysema and chronic bronchitis, which to some degree act like asthma. The hallmark of the three lung diseases is airway obstruction. The principal difference in the conditions is the degree of reversibility of the airway obstruction. A patient with asthma should have normal airflow between attacks. Chronic bronchitis is characterized by obstruction to varying degrees but usually is not completely reversible with treatment. The obstruction found in patients with emphysema is irreversible by definition. However, most patients fall between these strict limits. Asthma may be hard to diagnose and is greatly underdiagnosed. To distinguish asthma from other lung diseases, doctors rely on a combination of the patient’s medical history (the patient’s recount of his or her symptoms and past disorders), a thorough physical examination, and certain tests: measurement of airflow into and out of the lungs, chest X rays, blood tests, and skin tests. Sometimes, challenges with methacholine (a drug that constricts the bronchi in persons with asthma) are indicated.

Asthma Screening The American College of Allergies, Asthma and Immunology’s (ACAAI’s) Nationwide Asthma Screening Program is an assessment tool used to identify individuals who may be at risk for asthma and its complications. Now in its fourth year, the program has screened more than 20,000 people and referred more than half of them to professionals for diagnosis. The screenings are conducted by allergists, physicians who are asthma specialists, free of charge at shopping malls, civic centers, health fairs, and other accessible locations throughout the country. During a screening, adults who are experiencing breathing problems complete a 20-question Life Quality Test developed by the ACAAI. A special test is available for the parents of children up to age eight, called the Kids’ Asthma Check. In addition, participants in the screenings take a special lung function test that involves blowing into a tube and meet with a physician to determine if they should seek a thorough examination and diagnosis. People who already know they have asthma may also speak with a specialist at the screenings. The following Kids’ Asthma Check questions for children ages one through eight require a yes or no answer: Symptoms and Signs of an Asthma Attack It is unusual to have a sudden life-threatening attack of asthma without warning signs. Usually the signs of an impending asthma attack manifest hours or even days before a full-blown attack develops. Every asthma patient should have an emergency strategy preplanned with his or her physician. The

QUESTIONNAIRE FOR ASTHMA IN CHILDREN 1. When walking or playing hard with friends, my child has trouble breathing or coughs. 2. When walking up hills or stairs, my child has trouble breathing or coughs. 3. When running or playing sports, my child has trouble breathing or coughs. 4. Sometimes my child wakes up at night with coughing or trouble breathing. 5. Sometimes my child has trouble taking a deep breath. 6. Sometimes my child makes wheezing sounds. 7. Sometimes my child complains of pain or tightness in the chest. 8. Sometimes my child coughs a lot. 9. Being outdoors or around dust or pets makes my child’s breathing worse. 10. It’s hard for my child to breathe in cold weather. 11. It’s hard for my child to breathe when people smoke or there are strong odors. 12. Colds make my child cough or wheeze.

YES

asthma 31 National Asthma Education Program recommends the use of peak flow meters to follow the progress of an asthma attack. There are inexpensive portable devices to measure the peak flow (airflow in the bronchial tubes). Use of a peak flow meter can be a valuable guide with which to follow a person’s progress. Worsening of asthma can usually be detected in time to take corrective measures. Because individuals vary, patients should know their own signs of an impending attack. The initial sign may be itching of the face or throat, a feeling of tightness in the chest, and mild wheezing. This is the time to act to prevent progressive or sudden worsening of the attack. Early intervention is the key to preventing the need for emergency treatment and asthma fatalities. Extrinsic asthma is a form of asthma caused by allergens found in the environment, such as seasonal or perennial allergens such as house-dust mites, but can be triggered by a perennial allergen. A greater percentage of children (up to 85 percent) than adults (about 50 percent) suffer from extrinsic asthma. Extrinsic asthmatics usually have positive skin or radioallergosorbent tests (RAST), but not every asthma patient suffers from allergies. Foods may be blamed as a cause of asthma. Foods were cited for allergic reactions by patients almost four times as often as allergic rhinitis. However, most experts feel the true incidence of foodinduced asthma is much less frequent. In double-blind food challenges (tests in which a suspected allergenic food or placebo is given to a patient and monitored for reaction), symptoms of asthma could be confirmed only in 25 to 33 percent of the children. Most cases of food hypersensitivity stem from milk allergy in early infancy. Many adverse food reactions are probably caused by food additives or preservatives such as sulfites, bisulfites, and metabisulfites. Intrinsic asthma may be caused by factors other than allergy. Intrinsic asthma occurs in less than 50 percent of adults and in about 15 percent of children with asthma. Some children from infancy experience wheezing triggered only by viral respiratory infections. Other children and adults suffer asthma triggered by irritants, emotional factors, and other nonallergenic stimuli. Many of those

with intrinsic asthma have nasal polyps and sensitivity to aspirin. Skin tests for allergy are usually negative in these persons, but it is possible to have both intrinsic and extrinsic asthma. Nocturnal Asthma Nocturnal asthma refers to the occurrence of symptoms of asthma during the night. Nearly 40 percent of asthmatics experience nightly symptoms; approximately 64 percent have episodes three nights a week, and about 75 percent at least one night per week. Asthma attacks seem to occur most often between 10 P.M. and 7 A.M., peaking at about 4 A.M. When several things simultaneously trigger asthma, results can be severe. The most devastating asthma attacks that lead to respiratory arrest and possibly death most often occur between midnight and 6 A.M. During sleep, mucus secretions accumulate in the bronchial tubes, and the backup, or reflux, of stomach acid may spill over into the lungs, causing irritation and inflammation of lung tissue. The circadian fall in the body’s production of cortisone and adrenaline and the rise of other chemicals, such as histamine, further worsen the situation during the night. In addition, the cell counts of neutrophils and eosinophils (cells that release mediators of inflammation) are higher in patients with nocturnal symptoms. Timing medications to coincide with peak effectiveness and times of greatest need can greatly reduce symptoms and allow patients to sleep through the night. Medications for Asthma Medications are prescribed when the symptoms of asthma cannot be prevented by controlling the environment or other triggers such as a viral respiratory infection. The medicines used depend on the frequency and severity of symptoms and may be therapeutic or preventive, or both. Bronchodilators are chosen for their ability to prevent or reverse airway obstruction. They include beta-adrenergic agonists such as albuterol, metaproterenol, and pirbuterol; methylxanthines such as theophylline; and the anticholinergics atropine and ipratropium. Anti-inflammatory agents interrupt the development of bronchial inflammation and also act to

32 asthma prevent asthma attacks. These drugs include corticosteroids (cortisone-like drugs), cromolyn, and others that are still investigational. Beta-agonists alone may be all the therapy necessary for mild, episodic asthma. Metered-dose inhalers (MDIs) on an as-needed, or “PRN,” basis are the first line of therapy. These drugs are also taken before exercise or sports to prevent symptoms. Their prolonged use at regular four- to sixhour intervals has been associated with some diminished occurrences of asthma, and the recommended three to four doses a day should rarely be exceeded. Overuse of beta-agonists has been associated with increased risk of death from asthma. Oral dosage forms of beta-agonists are also available as short-acting (six to eight hours duration of action) or sustained-release (lasting up to 12 hours) tablets. When both dosage forms of betaagonists are taken simultaneously, the MDI is reserved for acute episodes or prior to exercise. Theophylline is the most widely used methylxanthine. It is available in tablet, capsule, and liquid forms, which are short- or long-acting, and for many years was the prime drug for the treatment of asthma. A related drug, aminophylline, is available for intravenous use but is rarely used orally. Theophylline and aminophylline have come under scrutiny because of the frequency of adverse effects, especially in infants. The 1991 asthma expert panel report from the National Institutes of Health (see the 1997 report below) relegates the methylxanthine drugs to a secondary or tertiary role behind beta-agonists and the anti-inflammatory medications. The methylxanthines are thought to inhibit phosphodiesterases, enzymes implicated as a cause of asthma. These drugs dilate constricted bronchioles. Longacting forms are most useful in preventing nighttime awakening from asthma. In addition, they reduce respiratory muscle fatigue and have a mild degree of anti-inflammatory activity. Close monitoring of blood levels can usually avoid the most serious complications of these drugs. The inhaled anticholinergic ipratropium, an atropine-like drug, is a weak bronchodilator that also blocks reflex bronchoconstriction by inhaled irritants. Although it is less effective than other

bronchodilators, ipratropium lacks side effects and is useful in the few individuals who cannot tolerate other drugs. Corticosteroids are the most effective antiinflammatory drugs for the treatment of asthma. They can be given orally as tablets or liquids, by injection, or topically as aerosol MDIs. Despite the fear of adverse effects, systemic corticosteroids, when used appropriately early in an asthma attack, prevent progression and lessen the need for emergency room visits and hospitalizations, and they may be lifesaving. In severe asthmatics, they may be required daily or on alternate days. Inhaled corticosteroids are safe and effective as preventive therapy and are first-line therapy for anyone with frequent symptoms of asthma. In recommended doses, side effects are usually limited to local irritation of the pharynx, though this can be prevented by rinsing the mouth after each use or by using a spacer device. Spacers allow active medication to be inhaled, while irritating larger particles settle in the chamber of the spacer. In addition to reducing adverse effects, they allow poorly coordinated persons, often including young children, to use MDIs effectively. Cromolyn sodium is a preventive, anti-inflammatory drug causing no serious side effects, administered by MDI or nebulizer. It is most effective in children. Prevalence According to a March 1999 report by the U.S. Centers for Disease Control and Prevention, asthma now affects more than 14 million Americans, approximately double the rate of 20 years ago. The asthma rate for children age four and younger has increased 160 percent between 1980 and 1994. The incidence of asthma seems to be equally distributed among males and females, but blacks have a 4.4 percent rate of asthma, while whites have a 4.0 percent rate. Increases have been reported in all ages, races, and in both sexes. Individuals with asthma require more than 100 million days of restricted activity per year. African Americans are three times as likely to die from asthma as are whites of all ages; however, this incidence increases five times in individuals ages 15 to 44. The asthma death rate doubled for children ages five to 14.

asthma 33 According to the American Academy of Allergy, Asthma and Immunology, nearly one in 10 American children have asthma, and the reason for that is still unknown. One theory for the increase is the result of spending more time indoors where we are exposed to more potent allergens. Studies are now being conducted to better understand the inflammatory response to allergens and the fundamental regulators of the entire process. The studies are focused on identifying the basic abnormality that causes asthma and the genes that direct the allergic process, developing more advanced patient-education, medicine, and treatments, including asthma self-management techniques, and refining emergency measures for asthma attacks. In the December 1999 issue of the Annals of Allergy, Asthma and Immunology, asthma “far exceeds other causes of occupational pulmonary disease, with an estimated 5 percent of all adult asthma cases workplace-related, and some 250 causative agents implicated.” The American Lung Association says the rate of asthma in the United States will likely double by the year 2020. The association supports the findings and recommendations of the report released by the Pew Environmental Health Commission at the Johns Hopkins School of Public Health entitled “Attack Asthma: Why America Needs a Public Health Defense System to Battle Environmental Threats.” The report calls for the creation of a national asthma tracking system within five years, development of an action plan to coordinate the efforts of federal agencies responsible for responding to the nation’s asthma problem, expanded investment in asthma prevention research, and implementation of a comprehensive public education campaign for the public and health care providers. John M. Corruthers, Jr., president of the American Lung Association, said the association “will continue to work with the 17 million Americans who have asthma and establish a foundation for significantly reducing the number of people who develop asthma in the future.” Asthma-Related Death In the United States, minorities from inner-city neighborhoods have a much higher proportion of

deaths as a result of asthma than do urban whites. In Chicago in a five-year period, 90 percent of all asthma deaths were persons in minority groups, although minorities accounted for only 40 percent of the total population. In the past decade, the greatest increase in deaths occurred in those older than 65 years of age. Nonwhites are almost three times as likely to die from asthma as whites. However, despite recently increased asthma deaths, the number of such deaths in the United States—approximately 14 people per day (more than 5,000 per year), according to the Statistical Abstracts of the United States—is one of the lowest numbers of asthma deaths in the world. Factors that increase risk for a fatal attack of asthma include age over 65, ethnicity (nonwhite race), previous life-threatening asthma attack(s), hospital admission for asthma within the last year, psychological and psychosocial problems, lack of access to medical care, and abuse of asthma drugs. In the past decade (1990–2000), the greatest increase in asthma deaths is seen in older age groups. There has also been a significant trend in deaths among those from five to 34 years of age during the same period. African Americans have almost three times the rate of asthma deaths as Caucasians for all ages. However, in age group 15 to 44, the rate increases to five times the rate for Caucasians. Persons who have required intubation and a respirator for respiratory failure, or who have suffered respiratory acidosis in the past, are at increased risk to die from a similar episode. Persons hospitalized within the previous year for asthma were more likely to die from asthma, as well as those with more than two hospitalizations for severe asthma and patients on oral corticosteroid therapy. There is an association between children dying suddenly from asthma and prior expressions of hopelessness, despair, and a wish to die. Unemployment, alcohol abuse, recent family loss, recognizable depression, and schizophrenia increase the risk of sudden and unexpected death from asthma for adults. Many poor families in urban neighborhoods lack a regular family doctor or asthma specialist. Treatment is often delayed until the patient’s

34 Asthma and Allergy Poster Child diagnosis is status asthmaticus (severe unrelenting asthma). Patients usually seek emergency room medical care only during a crisis. In rural areas, a similar situation can arise because of the great distance to a medical facility or lack of a specialist. Lack of prevention and knowledge of asthma may prevail in any environment. A Canadian study, based on health insurance records of 12,300 asthma patients between 1978 and 1987, demonstrated twice the risk of a fatal or near-fatal asthma attack in patients overusing certain medications. The use of twice the maximum recommended dose of a beta2-agonist MDI was considered the causative factor in this increased risk. Risk Factors for Asthma-Related Death • Past history of sudden severe exacerbations. • Prior intubation for asthma. • Prior admission for asthma to an intensive care unit. • Two or more hospitalizations for asthma in the past year. • Three or more emergency care visits for asthma in the past year.

accessory muscles, paradoxical breathing, cyanosis, and a respiratory rate of greater than 60 are key signs of serious distress. • Objective measurements such as oxygen saturation of higher than 91 percent also indicate serious distress. • Response to beta2-agonist therapy can be variable and may not be a reliable predictor of satisfactory outcome. However, because infants are at greater risk for respiratory failure, a lack of response noted by either physical examination or objective measurements should be an indication for hospitalization. • Use of oral corticosteroids early in the episode is essential but should not substitute for careful assessment by a physician. • Most acute wheezing episodes result from viral infections and may be accompanied by fever. Antibiotics are generally not required. Sources: Kallebnach et al., 1993; Rodrigo and Rodrigo, 1993; Suissa et al. 1994; Greenberger et al., 1993; O’Hollaren et al., 1991.

See also ACIDOSIS, RESPIRATORY; APPENDIX I; ARTERIAL BLOOD GASES; ASTHMA AND PREGNANCY; ASTHMA CAMPS; BETA-ADRENERGIC AGONISTS; BRONCHITIS,

• Hospitalization or an emergency care visit for asthma within the past month.

CHRONIC;

• Use of more than 2 canisters per month of inhaled short-acting beta2-agonist.

EXERCISE-INDUCED ASTHMA; IMMUNOTHERAPY; IPRA-

• Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids. • Difficulty perceiving airflow obstruction or its severity. • Comorbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease. • Serious psychiatric disease or psychological problems. • Low socioeconomic status and urban residence. • Illicit drug use. • Sensitivity to Alternaria. Special Considerations for Infants • Assessment depends on physical examination rather than objective measurements. Use of

CORTICOSTEROIDS;

CROMOLYN

SODIUM;

CROUP; CYSTIC FIBROSIS; EMPHYSEMA; EPIGLOTTITIS; TROPIUM; OCCUPATIONAL ASTHMA; PEAK FLOW METER; SPIROMETER; TRIGGER, ASTHMA; THEOPHYLLINE.

Asthma and Allergy Poster Child

From 1983 to 1993, the Asthma and Allergy Foundation of America (AAFA) sponsored a national, annual contest in which a child with a documented history of asthma and allergies, as well as other certain qualities, was selected to represent all children who wish to overcome their illness. Poster children were judged to be outgoing and articulate, and would participate in AAFA-sponsored events. Past national poster children are: Lanny Bert Powell (Greenville, S.C.), 1983; Reggie Smith (Baltimore, Md.), 1984; Ann Cordrey (Cincinnati, Ohio), 1985; Jamie Noland (Ft. Collins, Colo.), 1986; Scott Halverson (Omaha, Nebr.), 1987–88; Chele Williams (Newport News, Va.), 1989; Jennifer Carol Price (Midland, Tex.),

asthma and pregnancy 35 1990; Chris Dulman (Michigan), 1991–92; and Amanda Johnston (Portland, Oreg.), 1993. The AAFA may be contacted at: Asthma and Allergy Foundation of America 1125 15th Street NW, Suite 502 Washington, DC 20005 (800) 7-ASTHMA

asthma and pregnancy Asthma is present in at least 4 percent of all pregnancies and may occur in as many as 10 percent. Asthma may occur for the first time during pregnancy. Preexisting asthma may worsen or improve during pregnancy. About one-third of pregnant women with asthma worsen during pregnancy, one-third continue unchanged, and one-third improve. General Treatment Principles of Asthma During Pregnancy • Asthma is a chronic condition with acute exacerbation or attacks; close monitoring by both patient and doctor is necessary to detect subtle changes throughout pregnancy. • Prevention of attacks is of utmost importance. Identify and avoid triggers, and optimize measures to reduce the presence of indoor allergens, such as furry pets, dust mites, and molds. Especially avoid tobacco smoke. Use air-conditioning during pollen seasons to reduce exposure. Use preventive drugs daily exactly as prescribed. • Anticipate or intervene early during an attack. Use a peak flow meter to detect subtle changes in breathing and have a plan to act before attacks become severe or catastrophic. • Although using as few medications as possible is generally desirable during pregnancy, normal breathing and oxygen levels must be maintained in the mother to assure normal oxygen supply to the fetus. Inhaled drugs are preferred, but if they are not totally effective, systemic drugs should be used to achieve normal lung function. • Disorders that aggravate asthma, such as sinus infections, nasal allergies, and heartburn, should be treated promptly so they will not trigger asthma.

Adverse Effects Whether a pregnant woman’s asthma worsens, remains the same, or improves, uncontrolled asthma can produce serious complications for mother and fetus. Maternal complications from asthma include preeclampsia (a toxemia of pregnancy), gestational hypertension, hyperemesis gravidarum (severe nausea and vomiting during pregnancy), vagin*l hemorrhage, toxemia, and induced and complicated labor. Fetal complications include increased risk of fetal death, diminished growth, prematurity, low birth weight, and neonatal hypoxia. The more severe the asthma, the greater the risk, but even mildly uncontrolled asthma is a risk. When asthma is well controlled, even if medications are required, the outcome of pregnancy should be the same as those experienced by a nonasthmatic mother. PREFERRED DRUGS FOR THE TREATMENT OF ASTHMA DURING PREGNANCY Drug Type

Specific Drug

anti-inflammatory

beclomethasone (Beclovent, Vanceril) cromolyn sodium (Intal) prednisone

bronchodilator

inhaled beta2-agonist: albuterol (Proventil, Ventolin), metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire) theophylline (Constant-T, Quibron, SloBid, Slo-Phyllin, Theo-Dur, Theo-24, Theolair, Theovent, Uniphyl; serum levels must be monitored to avoid toxicity)

Effect on Fetal Oxygen Supply During pregnancy, changes occur in the mother’s body, unrelated to asthma, that cause a mild sensation of shortness of breath in many normal women. However, these “normal” changes affect neither the supply of oxygen to the fetus nor the results of breathing tests that are used to measure the severity of asthma in the mother. During an asthma attack, the mother’s body utilizes available oxygen, reducing the amount supplied through the placenta to the fetus. A small fall in oxygen concentration that would result in only

36 asthma and pregnancy minimal to moderate distress to the mother can be catastrophic to the baby. Goals of Therapy and Treatment Traditionally, asthma was viewed as an intermittent acute illness. Symptoms were due to constriction of the bronchioles, and the goal of drugs was to reverse this spasm. Since scientists have determined the importance of lung inflammation in asthma, the goal of treatment is not only to improve symptoms during an attack but also to prevent symptoms from recurring. Treatment of asthma during pregnancy follows the same principles as for the nonpregnant individual. Avoidance of asthma triggers may reduce the need for drugs. When drugs are needed, the preventive anti-inflammatory cromolyn and corticosteroid inhalers are especially useful, safe, and effective. Monitoring Mother’s Breathing Status For pregnant patients with asthma, objective measurement of lung function is essential. This can be done in the doctor’s office with spirometry or a peak flow meter. Inexpensive hand-held peak flow monitors can be used at home or in the workplace to detect changes that may indicate the onset of an asthma attack. The peak flow meter may detect changes before symptoms are apparent. Fetal Monitoring For pregnant women with asthma, fetal evaluation is based on objective measurements such as sonography (ultrasound), electronic fetal heart rate monitoring, and by subjective means, such as the mother’s assessment of fetal kicks (“kick count”). Sonography from 12 to 20 weeks provides a guide to fetal growth and should be followed frequently in cases where asthma is moderate or severe to detect growth retardation. Effects of Asthma Drugs In considering the possible effects of drugs and disease on pregnancy, it is important to keep in mind the incidence of adverse pregnancy outcomes in the general population. Congenital anomalies (birth defects) occur in 3–8 percent of all newborns, and of these only 1 percent or fewer are attributable to drug exposures.

Both animal and human data are studied to evaluate the safety of drugs. If studies in animals, where huge doses are used during testing, are reassuring, the potential for effects in humans is low. However, animal data do not always give complete information. It may not be possible to know whether the effects of a drug on the newborn were caused by the use of excessive doses by the mother, the disease process itself, or other multiple factors. Human studies rarely include large numbers of patients exposed to a particular drug. Therefore, drugs that have been used for many years without a significant number of reported adverse effects are considered most reliable. Immunotherapy Immunotherapy (allergy shots) may prevent asthma symptoms triggered by allergies, therefore reducing the need for drugs. Desensitization by injecting minute amounts of allergy extracts for cat dander, dust mites, molds, and pollens is generally safe and effective. The principal concern for giving immunotherapy during pregnancy is the same as in nonpregnant individuals, to avoid anaphylaxis (the most severe form of allergic reactions). Because a severe reaction may threaten the lives of both mother and fetus, injections of allergy extracts must be given cautiously and doses are usually not increased or sometimes slightly decreased during pregnancy. It is generally recommended that allergy immunotherapy not be initiated during pregnancy, because it takes several months for any benefit to be evident and doses must be given in increasing amounts during the early stages of treatment. Influenza (“Flu”) Vaccine Annual flu vaccine is recommended for all patients with moderate or severe asthma. Influenza vaccine is based on a killed virus, and there is no evidence of risk to mother or fetus. Physical Activity Physical activity should be encouraged and no different from that of a nonasthmatic pregnant woman. If necessary, pretreatment with a betaagonist metered-dose inhaler such as albuterol or cromolyn five to 60 minutes before exercise should be used.

asthma camps 37 PREFERRED DRUGS FOR THE TREATMENT OF ALLERGY OR RESPIRATORY INFECTIONS COMPLICATING ASTHMA DURING PREGNANCY Drug Type

Specific Drug

antibiotics

amoxicillin

antihistamine

chlorpheniramine (Chlor-Trimeton) tripelennamine (Pyribenzamine)

anti-inflammatory

cromolyn sodium (Nasalcrom nasal spray) beclomethasone (Beconase, Vanceril)

cough

dextromethorphan, guaifenesin (Robitussin)

decongestant

oxymetazoline (Afrin) nasal

spray or drops

pseudoephedrine (Sudafed) (must be used sparingly to avoid rebound worsening of nasal congestion)

Summary Pregnant women with asthma need specific treatment. Nondrug measures are preferred such as improving the environment to avoid known trigger-allergens or irritants such as tobacco smoke. Drugs with many years of safe use are the best choice. A panel of experts from the National Institutes of Health strongly recommends that asthma be as aggressively treated in pregnant women as in nonpregnant women. See also EXERCISE-INDUCED ASTHMA; PEAK FLOW; PEAK FLOW METER; RHINITIS MEDICAMENTOSA; SPIROMETER. [Adapted from the National Asthma Education Program’s report Management of Asthma During Pregnancy (NIH Publication No. 93-3279A, October 1992).]

asthma camps

These recreational facilities provide a safe, medically supervised, and enjoyable experience for children with asthma who would otherwise be unable to attend camps. According to the American Lung Association, there are currently more than 130 children’s asthma camps in the nation and the number is growing. The Consortium on Children’s Asthma Camps (CCAC) has established parameters for the operation of asthma camps. The Consortium was established in 1988 to coordinate camp activities of national organizations

involved in the care of children with asthma. According to CCAC, the purpose of the Consortium is to promote the quality of medical care delivered at existing asthma camps; to provide parameters for educational goals; to promote the development of new asthma camps, and to develop initiatives to target high-risk children and give them the opportunity to attend asthma camp. The Consortium is composed of representatives from the American Academy of Allergy, Asthma and Immunology, the American Lung Association, the American Thoracic Society, the American Academy of Pediatrics, and the Asthma and Allergy Foundation of America. The current chairman is Sherwin Gillman, a practicing allergist in Orange County, California.

The key objectives of asthma camps include: 1. improving a child’s ability to self-manage asthma through a creative yet systematic approach to asthma education; 2. introducing children with asthma to a full camp/outdoors experience; 3. gathering valuable information on the effectiveness of various means of asthma education; 4. teaching asthma management in a fun and engaging way, leading to improved patient compliance; 5. providing health care volunteers with an opportunity to utilize and hone their professional skills in a fun, unusual environment; 6. providing a forum for all relevant audiences for teaching and learning optimum asthma management practices. The Inner City Asthma Camp Initiative In 1993, the national Consortium on Children’s Asthma Camps launched Phase I of the Inner City Asthma Camp Initiative: to meet the growing needs of inner-city children with asthma. The goals of this phase of the initiative were to develop and implement educational programs to take place both before and after asthma camp, and to involve not only camp attendees but their families as well; to identify and recruit for these programs disadvantaged children, ages 9–12, who have asthma and live in

38 asthma-friendly schools urban areas, and to increase knowledge of, change attitudes about, and gain more control over asthma among inner-city children who have the disease and their parents, guardians, or adult caregivers. Five asthma camps participated independently in Phase I, which included a study to evaluate the effectiveness of asthma camps in teaching innercity children and their families about the disease and how to manage it better.

Results of the study determined that, after participating in camp and pre- and post-camp activities, children reported fewer symptoms of asthma, and their ability to manage asthma increased. They also indicated that the camp experience expanded their knowledge of asthma and improved family communication. Most of the children in the study said they enjoyed the camp experience and found it helpful. (A complete copy of the study Effectiveness of Asthma Camps for Inner City Families by Stephen C. Weisberg, M.D., David H. Olson, Ph.D., and Richard J. Sveum, M.D., is available from the Consortium.) Asthma Roadways, Phase II, of the initiative (July 1995–November 1999) elected the following goals: to reduce asthma-related hospitalizations; to reduce asthma-related emergency room visits; to decrease symptom days, and to improve the quality of life, related to asthma, in the target population. Asthma Roadways was designed to encourage children with asthma and their families to interact effectively, which, it is hoped, will help them gain control over asthma by setting individual and family goals; learn more about asthma and environmental controls; reduce family stress related to asthma; improve family communication about asthma and increase overall satisfaction of individuals within families. In 1999, the Consortium sought to create comprehensive and consistent national guidelines and standards for the set-up, operation, and evaluation of resident and day asthma camps. In March 1999 a website was launched with links to all sponsors. In addition to a database of all asthma camps in the country, the Parameters for Medical Policies and Procedures for Children with Asthma was published in 1996, and the book for children I’m Going to Asthma Camp was published in 1997. For more informa-

tion, visit http://www.lungusa.org/asthmacamps/ about.htm. Camp Broncho Junction Camp Broncho Junction, formerly in Red House, West Virginia, was a pioneering, 16-year effort. The founders, the late Dr. Merle S. Scherr and his late wife, Lois, conducted psychological evaluations of the campers in the areas of behavioral and sociopsychological adjustment and provided a sharp profile not only of the individual patients but also of the group as a whole. Clinical psychologists and psychiatrists, testing with the California Test of Personality, and counselors’ ratings implemented psychological evaluation through personal interviews. The results point toward a more realistic and positive integration of the children’s physical problems into their total lifestyle. When the children were separated into two groups, those with severe asthma and those with the least severe asthma, improvement was especially striking in the most severe group. Group therapy sessions with children and families and weekend therapy sessions also contributed to patient improvement.

asthma-friendly schools

The National Heart, Lung, and Blood Institute, the National Asthma Education and Prevention Program, and the School Asthma Education Subcommittee developed the following questions to determine what constitutes asthma-friendly schools. Children with asthma need proper support at school to keep their asthma under control and be fully active. Use the questions below to find out how well your school assists children with asthma: 1. Is your school free of tobacco smoke all of the time, including during school-sponsored events? 2. Does the school maintain good indoor air quality? Does it reduce or eliminate allergens and irritants that can make asthma worse? Allergens and irritants include pets with fur or feathers, mold, dust mites (for example, in carpets and upholstery), co*ckroaches, and strong odors or fumes from such products as pesticides, paint, perfumes, and cleaning chemicals.

Ayerza’s syndrome 39 3. Is there a school nurse in your school all day, every day? If not, is a nurse regularly available to the school to help write plans and give guidance for students with asthma about medicines, physical education, and field trips? 4. Can children take medicines at school as recommended by their doctor and parents? May children carry their own asthma medicines? 5. Does your school have an emergency plan for taking care of a child with a severe asthma episode (attack)? Is it made clear what to do? Who to call? When to call? 6. Does someone teach school staff about asthma, asthma management plans, and asthma medicines? Does someone teach all students about asthma and how to help a classmate who has it? 7. Do students have good options for fully and safely participating in physical education class and recess? (For example, do students have access to their medicine before exercise? Can they choose modified or alternative activities when medically necessary?)

sion of the bronchus by enlarged lymph nodes, tumors, or aneurysms. Atelectasis in varying degrees is present during asthma attacks, particularly in children. Symptoms range from none to breathlessness. The X-ray appearance of atelectasis may be confused with the markings, or infiltrates, in the lungs associated with pneumonia. See also PNEUMOTHORAX.

If the answer to any question is no, students may be facing obstacles to asthma control. Asthma that is out of control can hinder a student’s attendance, participation, and progress in school. School staff, health care professionals, and parents can work together to remove obstacles and to promote students’ health and education. Contact asthma organizations for information about asthma and helpful ideas for making school policies and practices more asthma-friendly. Federal and state laws are there to help children with asthma. Asthma can be controlled; expect nothing less.

Aufrecht’s sign

asthmatic bronchitis

autoimmune disease

See

ASTHMA.

atmiatrics (atmotherapy) with medicated vapors. atmotherapy

See

atomizer

NEBULIZER.

See

Therapeutic treatment

ATMIATRICS.

atresia, pulmonary A congenital condition in which the pulmonary valve between the pulmonary artery and the right ventricle of the heart is closed. Named for the German physician, Emanuel Aufrecht (1844–1933), who first defined it, a diminished breathing sound heard through a stethoscope that indicates stenosis (constriction) of the trachea or windpipe.

auscultation

The act of listening to bodily sounds, usually through a stethoscope in order to determine any abnormalities. Chest sounds are heard both anteriorly and posteriorly, and patients are typically requested to take deep breaths in and out, and cough. See ACQUIRED IMMUNE DEFI-

CIENCY SYNDROME.

Atarax The trade name for the antihistamine hydroxyzine hydrochloride, also known as Vistaril Parenteral. See also ANTIHISTAMINE.

autotuberculin Tuberculin, or the soluble cell substance prepared from the tubercle bacillus that causes tuberculosis, made by taking cultures of an individual’s own sputum.

atelectasis

A partial or total collapse of the lung that may be caused by mucous plugs, excessive secretions, foreign-body obstruction, or compres-

Ayerza’s syndrome Named for the Brazilian physician, Abel Ayerza (1861–1918), a condition of

40 Ayurvedic medicine pulmonary insufficiency marked by difficulty breathing, chronic cyanosis (blue coloration of skin and mucous membranes), erythrocytosis, spleen and liver enlargement, and bone marrow hyperplasia.

Ayurvedic medicine

The ancient Hindu medical system, named from the Sanskrit words ayu (lifespan) and veda (knowledge). Through yoga, herbal remedies, massage therapy, pulse diagnosis, and other factors, Ayurveda medicine

seeks to integrate mind and body for optimal wellness.

Azmacort Metered-dose asthma inhaler containing the cortisone-like anti-inflammatory drug triamcinolone. This unique inhaler comes with a white barrel-shaped device called a spacer. Spacers assure that even individuals with less than perfect coordination receive an adequate dose of the drug. See also CORTICOSTEROIDS; INHALED MEDICATIONS; INHALER; SPINHALER.

B Bacillus anthracis

See

Bacteria generally have flagella, or whiplike tails, for motility, and most form colonies that can flourish in soil, water, organic matter, humans, animals, and plants. In humans, undesirable bacteria usually succumb to antibiotic treatment. See also ANTIBIOTIC.

ANTHRAX.

bacteria Living microscopic organisms composed of a single cell and lacking chlorophyll. Structurally, a bacterium bears some resemblance to the human cell. Parts of one bacterium include the nuclear region (or chromosomes), or “central intelligence” in which DNA dictates the characteristics of the cell; ribosomes, which carry RNA and units of protein in the cell’s cytoplasm; and the cell membrane and the cell wall, which carry proteins, fats, and sugars. Bacterial infections, especially those affecting the respiratory and integumentary systems, may trigger or intensify conditions of allergy and asthma, or be mistaken for them. The three major categories of bacteria are spherical or ovoid, such as micrococci, diplococci, staphylococci, streptococci, and sarcinae; rod shaped, or bacilli, such as coccobacilli and streptobacilli; and spiral, or spirilla, such as spirochetes and vibrios. Because bacteria have no chlorophyll and do not photosynthesize the way plants do, they derive their nutrients from organic material, parasites, soil, or nonliving organic matter. Bacteria are considered pathogenic if they are capable of causing disease in their host, but many bacteria are nonpathogenic and perform beneficial functions in the human body and the environment, especially in the nitrogen cycle of the soil. Aerobes are bacteria that thrive on atmospheric oxygen; anaerobes can live without oxygen. Most bacteria reproduce asexually by binary fission, or splitting into two parts. Certain species of rod-shaped bacteria form spores, which are encapsulated bacterium cells in a resting or dormant stage. While in this stage, spores resist heat, cold, dehydration, disinfectants, and other attempts to destroy them.

bagassosis A form of hypersensitivity pneumonitis. This allergic pneumonia-like disease is caused by the inhalation of bagasse dust, the dusty fibrous waste of sugarcane after the sugar-containing sap has been removed. See also HYPERSENSITIVITY PNEUMONITIS. bag-valve-mask resuscitator

See

ARTIFICIAL RES-

PIRATION.

baker’s asthma An occupational lung disease caused by repeated exposure to flour, especially wheat, an airborne allergen. There is usually no related allergy to ingested bakery products. In one study, 10 percent of exposed bakers selected randomly developed asthma. The bakers were exposed an average of 17.4 years before symptoms developed. Immunotherapy (allergy shots) may be effective treatment for the inhaled food allergen causing baker’s asthma. This type of therapy is not recommended when the food allergen exposure is from oral ingestion. Baker’s rhinitis is an allergic condition of the upper respiratory tract caused by repeated exposure to flour, usually airborne wheat allergen. bambuterol A beta-agonist (bronchodilating) drug chemically related to terbutaline. Bambuterol has a direct action in lung tissue; little of the active

42 barosinusitis drug is absorbed into the bloodstream, therefore minimizing the possibility of side effects. It also has the advantage of requiring only one daily dose. See also BETA-ADRENERGIC AGONISTS.

barosinusitis A condition characterized by pain and inflammation in one or more of the nasal sinuses when they have ascended or descended in response to a change in environment, such as being in an airplane when a sinus outlet is blocked. barrel chest Enlarged chest diameter attributable to conditions including chronic obstructive pulmonary disease (COPD), chronic bronchitis, and emphysema. basic life support Part of cardiopulmonary resuscitation (CPR) and emergency cardiac care that attempts to prevent respiratory or circulatory arrest and provides means for external support of those functions. See also CARDIOPULMONARY RESUSCITATION; BAGMASK-VALVE RESUSCITATOR. beclomethasone (Beconase, Beconase AQ, Vancenase, Vancenase AQ, Beclovent, Vanceril) A corticosteroid drug used as a nasal spray for the prevention of allergic rhinitis and as a metereddose inhaler for the prevention of asthma. Beclomethasone’s anti-inflammatory action, considered safe for use during pregnancy, is also prescribed for the treatment of nonallergic nasal polyps and rhinitis medicamentosus. However, the drug is typically more effective for allergic rather than nonallergic disorders. Some authorities recommend cautious use in persons with active tuberculosis, bacterial, systemic fungal, or viral infections, recent nasal injury or surgery, nasal infection, or ocular herpes simplex. For hay fever, beclomethasone may take a week or more before reaching full effectiveness; in nonallergic conditions, it may take three weeks to prove either effective or noneffective. Severe asthma should be stabilized by using oral corticosteroids before a beclomethasone inhalant can elicit preventive, anti-inflammatory benefits. Most asthma authorities now advocate the use of

this and other anti-inflammatory metered-dose inhalers as first-line maintenance therapy in persons with mild to moderate asthma. See also AEROSOL; CORTICOSTEROIDS; CORTICOSTEROID NASAL SPRAYS.

Beclovent

See

BECLOMETHASONE.

bends Bubbles of nitrogen that get into the blood and tissues in the event of a rapid decrease in air pressure. The condition (common among deep-sea divers) causes pain in the limbs and abdomen. It occurs also when a person ascends too fast after a period of exposure to increased air pressure while under water. The treatment is to restore normal air pressure via a hyperbaric chamber so the patient may slowly regain normal pressure. See also CAISSON DISEASE; DECOMPRESSION ILLNESS. benign pneumoconiosis

Conditions such as siderosis (from the inhalation of iron oxide), baritosis (inhalation of barium), and stannosis (inhalation of tin particles) that show up in a chest X ray but actually do not cause symptoms or dysfunction of the lungs.

berylliosis

Poisoning typically affecting the lungs, caused by beryllium particles (beryllium is a metallic element) that may be inhaled or contracted under the skin. The particles result in fibrosis and granulomata. Beryllium is used today mainly in the aerospace industry, but it used to be mined for use in the electronics and chemical industries, particularly in the manufacture of fluorescent light bulbs. The lung inflammation from beryllium fumes or dust is different from other occupational lung diseases because it seems to affect only those with a hypersensitivity to beryllium, although symptoms may not appear for one or two decades after even a brief exposure to the substance. It has been reported, too, that people living near beryllium refineries have also developed berylliosis. Potentially fatal, acute berylliosis may manifest suddenly with coughing, dyspnea, weight loss, and eye and skin irritation. Chronic berylliosis is characterized

beta-adrenergic agonists 43 by abnormal tissue forming in the lungs and enlarged lymph nodes, and involves the individual’s history of exposure to beryllium and subsequent events in his or her medical history, such as changes in the chest X ray. The disease may be mistaken for other lung diseases, such as sarcoidosis, and may require other diagnostic testing. Treatment consists of corticosteroid medications and ventilator support, and proper and prompt treatment may lead to recovery in a week to 10 days. If lungs have been severely damaged over a long period of time or over the course of many flareups of the chronic form of the disease, there may be concurrent cardiac problems, including heart failure.

beta-adrenergic agonists

Drugs, also known as beta-agonists, that act as bronchodilators to relieve spasms of the bronchi during an asthma attack. These potent drugs act by stimulating the beta2receptors on smooth muscle in the bronchial tree. Alpha-adrenergic receptor stimulation causes a constriction of blood vessels and may raise blood pressure and heart rate. Beta-adrenergic stimulation primarily affects the airways or air passages. There are two types of receptors, beta1 and beta2. Drugs that act only on beta2-receptors have fewer side effects and are the most frequently used in treating patients with asthma. More than 5,000 years ago, the ancient Chinese treated asthma with ma huang, an herbal remedy that contains the beta-agonist ephedrine. Epinephrine (adrenaline) is a hormone that affects both alpha and beta receptors, and because of its rapid onset of action, it is a useful emergency drug. Within minutes after being injected into the subcutaneous tissues, it induces relief of severe bronchoconstriction and can usually prevent or reverse anaphylaxis if given promptly. Thus, epinephrine can be a truly lifesaving drug. Because of its alphaadrenergic properties, however, it tends to cause a jittery feeling and heart palpitations in many individuals. Albuterol, an example of a selective beta2 drug, with sufficiently rapid onset of action for all but the most extreme situations, has relatively few adverse stimulatory effects and is available in a wide variety of dosage forms.

A Canadian study of more than 12,000 patients over a 1-year period through 1977 raised some questions about the safety of beta-agonists. The Canadian data suggest that merely taking twice the usual dose of beta2 from an inhaler more than doubles the risk of death from an asthma attack. The drug fenoterol (Berotec) is twice as potent as any beta2 drug available in the United States. Asthma Medication Safe When Taken as Directed (Palatine, Illinois, Aug. 9, 1991) Drugs known as beta2-agonists are safe and effective for the treatment of asthma, and patients taking the medication should continue despite recent reports of potentially fatal side effects associated with overuse of the drugs, according to a national professional organization of physicians specializing in the treatment of asthma. The American College of Allergy, Asthma and Immunology said beta2-agonists are the drugs of choice for the treatment of acute, intermittent, and exercise-induced asthma and are safe if taken as prescribed. Beta2-agonists belong to a class of drugs called bronchodilators and are often administered through an inhaler. “We have been successfully and safely using beta2-agonists to treat asthma for more than 10 years,” said Dr. Edward O’Connell, president of the college. “As with any drug, there can be side effects if the patient exceeds the prescribed dosage, and we caution patients not to do this.” O’Connell also cautioned against discontinuing medication and said patients should discuss concerns about recent reports with their physicians. About 10 million Americans suffer from asthma, a disease that causes wheezing, coughing, and difficulty in breathing, and claims about 4,600 lives each year. Beta2-agonists relieve the symptoms of asthma attacks by relaxing and expanding the lung airways.

The FDA is considering a review of beta2-agonists because of reports that taking twice the prescribed dose might be fatal. “The danger for asthmatics is that if the prescribed dose of beta2agonists does not bring relief, the patient may try taking more of the drug,” O’Connell said. “Patients who are not getting relief from the prescribed dose of medication should never increase

44 beta-adrenergic receptors the dosage on their own,” O’Connell said. “They should talk with their doctors about supplementing with other drugs or switching to a different treatment plan. The essential thing is to develop a treatment plan only under the direction of the doctor.” The 3,600-member American College of Allergy, Asthma and Immunology is a national organization of physicians who specialize in the treatment of asthma and other allergic diseases. Board-certified allergists complete a three-year residency in either pediatrics or internal medicine and a twoyear fellowship study in allergy and immunology. —Press release from the American College of Allergy, Asthma and Immunology issued in August 1991. BETA-AGONISTS AVAILABLE IN THE UNITED STATES Dosage Forms Available

albuterol (Proventil, Ventolin) bitolterol (Tornalate) epinephrine (Adrenalin, Primatene) isoetharine (Bronkometer Bronkosol) isoproterenol (Isuprel)1 metaproterenol (Alupent, Metaprel) pirbuterol (Maxair) terbutaline2 (Brethaire, Brethine, Bricanyl)

1, 3, 4 3 2, 3, 4 3, 4 1, 2, 3, 4 1, 3, 4 3 1, 2, 3

orally=1; injectable=2; metered-dose inhaler (MDI)=3; nebulizer solution=4 (Not all brands are available in all dosage forms.) 1 Rarely used for the treatment of asthma because of adverse effects. 2 Terbutaline ampules for injection may be used as a nebulizer solution.

beta-adrenergic receptors

See

BETA-ADRENERGIC

AGONISTS.

beta-blocking agents

Drugs used to treat heart problems, high blood pressure, migraine headaches, and glaucoma. The most serious side effect of beta-blockers is constriction of the bronchial tubes, which can cause or worsen an asthma attack in an allergic or asthmatic person. Epinephrine (adrenalin chloride), the drug of choice for the treatment of severe allergic reactions or anaphylaxis, may be ineffective in persons taking beta-blocking drugs. Beta-blockers should be avoided by those with asthma or severe allergies.

WARNING: BETA-BLOCKING AGENTS MUST NEVER BE USED IN ANY PATIENT RECEIVING ALLERGY IMMUNOTHERAPY OR ALLERGY SHOTS and must be used very cautiously, if at all, in any allergic or asthmatic patient. Examples of beta-blocker medications (capsules, tablets, or eyedrops) are (brand names in parentheses): acebutolol (Sectral) atenolol (Tenormin) atenolol + chlorthalidone (Tenoretic) betaxolol hydrochloride (Betoptic) eyedrops carteolol (Cartrol) labetalol (Normodyne or Trandate) labetalol + hydrochlorothiazide (Nonnozide or Trandate HCT) levobunolol (Betagan) eyedrops metoprolol (Lopressor) metoprolol + hydrochlorothiazide (Lopressor HCT) nadolol (Corgard) nadolol + bendroflumethiazide (Corzide) penbutolol (Levatol) pindolol (Visken) propranolol (Inderal) propranolol + hydrochlorothiazide (Inderide) timolol (Blocadren) timolol (Timoptic) eyedrops timolol + hydrochlorothiazide (Timolide)

beta-receptors

See

BETA-ADRENERGIC AGONISTS.

biopsy The removal of a tiny portion of live tissue for medical analysis leading to a diagnosis. Tissue may be obtained by aspiration through a needle or other methods. bioterrorism

The use of toxic substances, particularly biological agents classified by the Centers for Disease Control and Prevention (CDC) that may be deliberately aerosolized and inhaled, constituting an act of war. Among the highest risks to national security according to transmissibility and threat to life are smallpox, anthrax, Yersinia pestis (which causes bubonic, septicemic, and pneumonic plague), botulism, tularemia, and viral hemorrhagic fevers. Other somewhat lower

Bostock, John 45 risks include Q fever, brucellosis, glanders (Burkholderia mallei), castor bean toxin (ricin toxin), Staphylococcus enterotoxin B, Nipah virus, and hantaviruses. Bioterrorism, with “weapons” including bacteria, viruses, and poisons, has an extensive history that dates back to the 12th century. According to a Nursing Spectrum article (December 17, 2001, Vol. 13, No. 25 NY/NJ) on biological weapons by Richard Stilp, R.N., M.A., C.H.S.P., corporate director of safety for Orlando Regional Healthcare, “In 1346, the Tatar army hurled the corpses of those soldiers who died of the plague over the Kaffa City walls, infecting residents who were defending the city. Some of those who left Kaffa may have started the Black Death pandemic that spread throughout Europe. Russian troops used this same tactic against Sweden in 1710. Biological warfare also occurred during the French and Indian War (1754–63) when an Englishman, Sir Jeffrey Amherst, gave smallpoxladen blankets to Native Americans who were loyal to the French. The Native Americans sustained epidemic casualties as a result.” The most recent instances of bioterrorism occurred concurrently with the terrorist attacks on the United States on September 11, 2001, with the destruction of the World Trade Center in New York City and damage to the Pentagon in Washington, D.C. As the news media reported the details of these events, letters containing powdery anthrax spores were sent through the mail to media and political offices. Stilp wrote that at least 17 countries have developed an anthrax weapon program in the knowledge that the spores can sustain their viability for more than 40 years. “In 1970, the World Health Organization (WHO) concluded that the release of 50 kilograms of aerosolized anthrax upwind of a population of 5 million could lead to an estimated 250,000 casualties and 100,000 deaths,” he explained. Preventive measures include the prophylactic administration of appropriate antibiotics if infection is suspected, the development of immunizations, and education of health care professionals as well as the lay public on the prevention, detection, and treatment of diseases transmitted through terrorism. See also ANTHRAX; BOTULISM; TULAREMIA.

bird breeder’s lung An adverse reaction in certain individuals caused by contact with birds, particularly their excrement, including pigeons and parakeets. Symptoms—chills, fever, shortness of breath, and coughing—may be acute or delayed and subside when contact is no longer occurring. black death black lung

See See

BUBONIC PLAGUE.

COAL WORKER’S PNEUMOCONIOSIS.

blast injury

An injury attributable to a sudden, severe change in air pressure. See also ALTITUDE SICKNESS.

block, air

Air that leaks from one of the passageways of the respiratory system and collects in connective lung tissue. This causes an obstruction of the normal air flow.

blowing exercise

Blowing into a tube attached to a bottle of water, which is attached to another bottle so the air pressure from one projects the water into the other. This exercise is designed to increase intrabronchial pressure and help expand the lung.

blue baby A newborn whose blood is not properly oxygenated, thus causing cyanosis, or bluish coloration of the skin and mucous membranes. In some cases, this condition may be a congenital anomaly in which the blood travels directly from the right to the left side of the heart without reaching the lungs. Bostock, John

British physician (1773–1846) credited with coining the term hay fever, which he believed was “produced by the effluvium from new hay.” In his writings “Case of a Periodical Affection of the Eyes and Chest” and “Of the Catarrhus Aestivus, or Summer Catarrh,” Bostock described in accurate detail common symptoms of hay fever as heat, fullness, redness, and itching in the eyes, sneezing with the discharge of mucus, difficulty in breathing, a quickened pulse, restlessness, perspiration, and loss of appetite.

46 botulism botulism

A life-threatening condition caused by a neurotoxin called botulinum, caused by the spore-forming bacillus Clostridium botulinum, that is usually associated with ingestion of improperly canned and, thus, contaminated food. However, botulinum may be intentionally aerosolized, which would pose a serious threat to the public. Symptoms include paralysis of respiratory muscles and upper and lower extremities, diplopia, dysphonia, dysphagia, and dysarthria. The Centers for Disease Control and Prevention (CDC) maintains a supply of an antitoxin to fight cases of botulism, and if detected early, most individuals afflicted with the toxin recover. See also BIOTERRORISM.

Bouchut’s respiration Exhalation longer than inhalation in children with asthma or bronchopneumonia, named for French physician Jean A. E. Bouchut (1818–91). Bovet, Daniele Swiss-born Italian scientist (1907–92), who discovered antibacterial sulfanomides and, with Ernest Fourneau in 1933, succeeded in synthesizing the first series of antihistamines. Bovet won the Nobel Prize in physiology or medicine in 1957. bradykinin

A potent chemical mediator whose vasodilating action plays a role in asthma, pulmonary edema, and anaphylaxis. This slow-moving kinin, a term for a group of polypeptides, influences contraction of smooth muscle, promotes hypotension, increases blood flow in small blood capillaries, and sparks the pain reflex.

bradypnea

Excessively slow respirations.

brass founder’s ague

Tremors resulting from the inhalation of toxic fumes or from zinc or brass poisoning. See also BRASS POISONING.

brass poisoning The adverse effect of inhaling the fumes of zinc and zinc oxide. Although rarely fatal, brass poisoning damages tissue in the respira-

tory system and may result in dryness and burning in the respiratory tract, cough, headache, and chills. Inhaling humidified air often relieves the symptoms.

breath, bad

Malodorous air expelled from the mouth. Also called halitosis, bad breath is usually caused by the ingestion of foods containing potent oils, such as onions and garlic, strong-smelling beverages, and other liquid substances, or the fermentation of food particles lodged between teeth. Proper toothbrushing, flossing, and regular dental hygiene prevent bad breath in most cases. Deodorant mouthwashes, gargles, sprays, mints, lozenges, and gum are available. Although not the cause of intestinal disorders, halitosis may indicate a systemic disease. For example, renal failure causes the breath to take on the characteristic smell of urine. An abscess on the lung creates bad breath. Liver disease may cause the breath to smell mousy. Severe diabetes may cause an acetone (nail polish remover) breath odor. People who think their breath smells bad when it does not may be suffering from psychogenic halitosis. Schizophrenics or people with paranoid or obsessive feelings of being dirty or smelly or the sense of “rotting inside” may believe they have offensive breath.

Breath Enhancer

A device to facilitate the use of aerosol metered-dose inhalers for poorly coordinated persons with asthma.

breath-holding attacks

Arrested breathing, cyanosis (turning blue), rigidity and extension of the arms and legs, and possible loss of consciousness that starts with a child’s crying and, subsequently, the child’s body goes limp, he or she resumes breathing and becomes alert. Breathholding attacks cease of their own accord before the child reaches school age. Voluntary or involuntary breath-holding on the part of a child may be part of a tantrum or tactic used to get parents’ attention and an attempt to manipulate their behavior and responses. Psychological counseling may be recommended for both the child and parents.

bronchial crises 47 breathing

The process of respiration, that is, the taking in (inhaling) of oxygen into the lungs and the expelling (exhaling) of carbon dioxide. The normal exchange of these gases is essential to life. Certain breathing patterns characterize a variety of conditions, including asthmatic breathing, or prolonged wheezing heard throughout the chest cavity; bronchial breathing, or harsh breathing sounds accompanied by a high-pitched expiration; CheyneStokes breathing, or periods of apnea followed by increased depth and frequency of respirations; cogwheel breathing, or a respiratory murmur often associated with bronchitis and incipient tuberculosis; continuous positive-pressure breathing, or a method of artificially assisting respiration; intermittent positive-pressure breathing, or a mechanism that administers air or oxygen for assisting respiration; Kussmaul breathing, or very deep, gasping seen in cases of severe diabetic acidosis and coma; and shallow breathing, which occurs in cases of acute lung disease when chest walls are thickened, when ribs are fractured thus inhibiting deep breathing, in pleurisy, emphysema, and other respiratory disorders. See also RESPIRATORY SYSTEM.

breathing exercises

A series of deep breathing techniques to build up lung capacity and to help an individual with respiratory disorders to relax and breathe as normally as possible. The Eastern practice of yoga includes breath control and rhythmic, deep breathing, which are geared to overall physical and mental improvement. Asthmatic children often respond to relaxation breathing techniques when they feel an asthma attack coming on, and in some cases, the fullblown attack can be avoided. Essentially, one is advised to inhale through the nose, filling the belly and then the chest with air, and to exhale through the mouth and contract the muscles in the abdomen. Breathing exercises may also be done with a spirometer, a plastic tube containing plastic balls. As one blows air into the mouthpiece of the tube, the balls rise. This encourages deep breathing, which helps clear the lungs and oxygenate the entire body. Physicians prescribe spirometry for patients with bronchitis, pneumonia, and other, especially chronic, lung diseases.

Brethaire

See

TERBUTALINE SULFATE.

Brethine

See

TERBUTALINE SULFATE.

Bricanyl

See

TERBUTALINE SULFATE.

Bromfed

See

BROMPHENIRAMINE.

brompheniramine (Bromfed, Dimetane, Dimetapp) A mildly sedating, commonly used antihistamine of the alkylamine class. Brompheniramine is available alone or in combination with a decongestant in prescription and over-the-counter allergy preparations. See also ANTIHISTAMINE.

bronchadenitis

Inflammation

bronchial

glands.

bronchi

The two large branches extending from the trachea, or windpipe, into the lungs, forming what is commonly known as the “bronchial tree.” Because each bronchus is an airway, a buildup of mucus, an infection, physical and chemical irritants, swelling of the bronchial mucosal lining, excess calculi, or a foreign body or obstruction can cause choking, bronchitis, bronchoedema, lung abscess, and pneumonia. A bronchoscope is an instrument through which the bronchi can be examined. Bronchopulmonary disorders are those that involve both bronchi and lungs, such as bronchial pneumonia. See also BRONCHIOLES; RALE.

bronchial asthma See also

A common term for asthma.

ASTHMA.

bronchial breathing Harsh breathing associated with high-pitched expiration (tubular breathing). bronchial challenge See also

A diagnostic breathing test.

SPIROMETER.

bronchial crises motor ataxia.

Paroxysms of coughing in loco-

48 bronchial glands bronchial glands Mucous or mixed glands in the bronchi or bronchioles. bronchial tree

See

BRONCHI.

bronchial washing Cleansing of one or both bronchi, or the process of irrigating the bronchi for the collection of cells for diagnostic testing. bronchiarctia

A narrowing or constriction of a

bronchial tube.

bronchiectasis

Dilation or irreversible widening of a bronchus or bronchi, usually chronic and involving a secondary infection, such as bronchopneumonia, chronic bronchitis, tuberculosis, and whooping cough or other damage to the bronchial wall. The bronchial wall has several varying layers corresponding to each segment of airway and is lined by an inner mucosa and submucosa that serve to protect airways from harmful particles and substances. Structural layers provide elastic, cartilage, and muscle fiber, while blood vessels and lymphoid tissue nourish and maintain the bronchial wall. When parts of the wall are inflamed or destroyed in bronchiectasis, mucus production increases and promotes bacterial growth, and the general protective structure breaks down. The damage may extend to the alveoli of the lungs and result in bronchopneumonia, scarring, and dysfunctional lung tissue. Inflammation and an increase in blood vessels in the bronchial wall may also result in coughing up blood and airway blockage that inhibits oxygen distribution. Bronchiectasis may be acquired or congenital, and on one or both sides of the chest. An underlying disease, such as allergic bronchopulmonary aspergillosis, may also be the cause. Frequent occurrences of pneumonia may be a sign of bronchiectasis. The most common cause is chronic or recurring infection; other conditions, including abnormal immune response, birth defects of the airways, and a predisposing factor such as bronchial obstruction, may lead to bronchiectasis as well. Symptoms include coughing, difficulty breathing, the production of foul secretion and sputum that

separates into three layers, the bottom layer containing pus cells, a greenish middle layer, and a layer of froth on top. Treatment includes antibiotics, postural drainage, and bronchodilating aerosols. Saccular bronchiectasis refers to dilated bronchi that are irregularly shaped or shaped somewhat like a sac. Varicose bronchiectasis refers to dilated bronchi that look like varicose, or herniated, veins, and an irregular dilation also found in cystic fibrosis. Preventive measures reduce the incidence of bronchiectasis: immunizations against measles and whooping cough; influenza and pneumococcal vaccines; early use of antibiotics in the case of pneumonia or tuberculosis; appropriate use of corticosteroid and other anti-inflammatory drugs if allergic bronchopulmonary aspergillosis and other disorders are present; avoidance of noxious fume, gas, dusts, and smoke; avoidance (in infants and children) of aspiration of foreign objects; avoidance of oversedation that leads to respiratory depression; prompt medical attention to neurological symptoms, including coughing or vomiting after eating, difficulty swallowing, and impaired consciousness; avoidance of using mouth or nose drops such as mineral oil at bedtime, and diagnosis by bronchoscopy and treatment of any obstruction in the bronchus before an extreme condition arises.

bronchiloquy

Strange vocal sounds as a result of a bronchus covered with consolidated lung tissue.

bronchiocele

A dilatation, swelling, or tumor located in a bronchus, one of the two large branches of the trachea or windpipe. This may indicate a number of bronchial disorders, including chronic bronchiectasis. See also BRONCHIECTASIS.

bronchiolectasis See also

Dilation of the bronchioles.

BRONCHIECTASIS.

bronchioles

The smaller subdivisions of the bronchial tree in the thorax, so named because the bronchi and bronchioles resemble a tree trunk and

bronchitis, chronic 49 its roots. The bronchioles bring air from the trachea, the upper part of the windpipe, to the lungs and participate in the exchange of gases (oxygen and carbon dioxide) in the breathing process. Bronchial glands are mucus-producing organs in the bronchi and bronchioles. (The Greek word for windpipe is bronchus.) Among disorders of the bronchioles are bronchitis, bronchiolitis, and bronchopneumonia. See also BRONCHIOLITIS; BRONCHITIS.

bronchiolitis An acute inflammatory disease of the bronchioles, or small airways, in infants in which excessive mucus production results in airway obstruction. This obstruction leads to tachypnea (rapid shallow breathing), with a respiratory rate of 50 to as high as 80 breaths per minute, hypoxemia (reduced oxygen content of the blood), and hyperinflation (overinflated lungs). Bronchiolitis occurs more often in winter and spring months, usually during the first six months of life. It predominantly affects males and may occur in epidemics. During outbreaks, respiratory syncytial virus and parainfluenza are most often the cause, but the bacterium Mycobacterium pneumoniae can cause bronchiolitis in older children and bronchioles may be contused with asthma. X rays, blood gas studies, and physical examination findings are virtually identical. Both illnesses are often caused by viral respiratory infections in infants, although allergy testing in the older child may help to confirm the diagnosis. Congestive heart failure can also be mistaken for both bronchiolitis and asthma in the infant. Treatment of acute bronchiolitis is based on improving hypoxemia, preventing dehydration, and administering bronchodilating drugs and corticosteroids. Antibiotics are probably of no value unless there is suspicion of a secondary bacterial infection. Recovery usually occurs within two weeks, but bronchiolitis can be fatal. Some believe that infants with bronchiolitis have a greater chance of developing asthma later on in life. However, it may be difficult to determine if the original diagnosis of bronchiolitis was correct or if the infant was actually having an initial attack of asthma. See also RESPIRATORY SYNCYTIAL VIRUS.

bronchiospasm

See

bronchiostenosis

BRONCHOSPASM.

Constriction or narrowing of a

bronchial tube.

bronchitis An infection or inflammatory disease in the bronchi and bronchioles caused by viral or bacterial germs, allergy, or irritating dust and fumes. It may be an acute infection or a chronic process. Typical symptoms may include coughing, wheezing, shortness of breath, chills, fever, fatigue, and excessive sputum. Infectious bronchitis, which occurs most often in winter months, may be caused by microorganisms such as Mycoplasma pneumoniae and Chlamydia, and recurring infections stemming from chronic sinusitis, bronchiectasis, allergies, and in children, enlarged tonsils and adenoids. Irritative bronchitis involves inhalation or exposure to various chemical dusts and fumes such as ammonia and strong organic solvents, air pollution such as ozone and nitrogen dioxide, or cigarette and other smoke. Treatment includes drinking adequate fluids, taking aspirin or acetaminophen to reduce fever, and, in certain cases in which a bacterial infection is evident, antibiotics, including tetracycline, ampicillin, trimethoprim-sulfamethoxazole, erythromycin (when Mycoplasma pneumoniae is suspected), and amoxicillin (for children). Sputum tests provide the information for proper diagnosis in the event of severe bronchitis. Chest X ray may be necessary to rule out the development from bronchitis to pneumonia. In mild cases, patients recover fully, although bronchitis may be life-threatening to the elderly and individuals with chronic heart or lung disease. See also BRONCHITIS, CHRONIC. bronchitis, chronic

A disorder characterized by excessive mucus production in the bronchial tree with a persistent productive cough. By definition it lasts at least three months of the year for at least two consecutive years. Chronic bronchitis may or may not be related to asthma. Persons with chronic asthmatic bronchitis have a long history of cough and mucus production and develop wheezing as the disease progresses.

50 bronchoalveolar lavage Chronic asthma with obstruction is characterized by a prolonged course of wheezing and late onset of a chronic productive cough. Chronic bronchitis is often confused with emphysema, an expansion of the air spaces in the lungs resulting in destruction of the alveoli, or air sacs. In chronic obstructive lung, or pulmonary, disease (COLD, COPD), the flow of air in and out of the lungs is blocked as a result of chronic bronchitis or emphysema, or both. In asthma without chronic obstruction, the blockage is present only during an attack. However, in chronic obstructive lung disease, some obstruction exists at all times. Approximately 20 percent of adult males have chronic bronchitis, although only a small number become disabled because of it. Chronic bronchitis is less common in females. Individuals who smoke, have allergies, or are frequently exposed to irritants or pollution in the environment may also suffer the disease. See also BRONCHITIS; EMPHYSEMA.

bronchoalveolar lavage The use of sterile saline solution to “wash” the lungs of secretions, cells, and protein from the lower respiratory tract. A fiberoptic bronchoscope introduces the fluid into the lung, and this treatment may be for diagnostic purposes or to treat patients with cystic fibrosis, pulmonary alveolar proteinosis, and severe asthma with bronchial obstruction due to a mucus plug. bronchoblennorrhea Chronic bronchitis characterized by large amounts of thin sputum. bronchocele

A dilation or swelling of a part of a

bronchus.

bronchoconstriction

See

bronchodilating drugs

BRONCHOSPASM.

Also known as bronchodilators, first-line medications that block the constriction of bronchial tubes during an asthma attack. Bronchodilators include beta-agonists, such as albuterol, and xanthine derivatives, such as theophylline. The exact mechanism by which these

drugs exert their beneficial effects is unknown. These drugs are available as metered-dose inhalers, solutions for injection or inhalation, or as oral tablets, capsules, and syrups. See also BETA-ADRENERGIC AGONISTS; THEOPHYLLINE.

bronchodilator

See

BRONCHODILATING DRUGS.

bronchoedema

Swelling of the mucosa of the bronchial tubes that constricts the airways and makes breathing difficult.

bronchofiberscope An instrument also known as a fiberoptic endoscope used to examine the bronchi. bronchography The introduction of a radiopaque substance into the trachea or bronchial tree for the diagnostic purposes of x-raying the lung or a portion of the lung. A bronchogram, or X ray of the lung, may be obtained during a bronchography. broncholithiasis

Calculi (stones) developed in the bronchi causing an obstruction or inflammation.

bronchomycosis An infection in the bronchi or bronchial tubes caused by a fungus, typically of the genus Candida. bronchopathy

Any disease involving the bronchi

or bronchioles.

bronchoplegia Muscle paralysis of the walls of the bronchial tubes. bronchopneumonia

Lung inflammation (pneumonia) complicated by the concurrent inflammation of the terminal bronchioles and alveoli. Caused by various pneumococci, Group A hemolytic streptococci, varieties of staphylococci, Klebsiella pneumoniae, Francisella tularensis, and various forms of other bacteria, viruses, rickettsiae, and fungi, bronchopneumonia is characterized by pro-

bronchospasm 51 ductive coughing (i.e., cough with expectoration of sputum), short and shallow respirations (50 to 75 breaths per minute), and sometimes cyanosis (blue coloration of the mucous membranes due to lack of oxygen). In children, the temperature may reach to 105 degrees Fahrenheit, and the fever may last two to three weeks. In the elderly, the fever (if any) may be 100 to 101 degrees Fahrenheit with only a slight cough and a small amount of sputum, but weakness, chest pain, chills, and sore throat may be evident. The treatment of choice includes antibiotic therapy, bed rest, increased fluids, a soft diet, painkilling medication, oxygen (for cyanosis), and treatment of shock symptoms if they present. Complications of bronchopneumonia include lung abscess, empyema, pericarditis, paralytic ileus, and atelectasis. See also PNEUMONIA.

bronchopulmonary aspergillosis, allergic (ABPA) Pneumonia-like disease caused by an allergic reaction to the mold Aspergillus fumigatus. It usually occurs in adult asthmatics. Signs and Symptoms This disorder usually involves episodes of fever, shortness of breath and wheezing, and coughing up copious quantities of dark brown, and at times blood-streaked, sputum. Diagnosis Because the fungus is ubiquitous (found in healthy persons in small quantities that are harmless), the presence of positive sputum cultures is not sufficient to diagnose this disease. The diagnosis is made in persons meeting the following criteria: (1) episodes of asthma; (2) elevated eosinophils (a type of white blood cell) and total immunoglobulin E (IgE) antibodies in the blood; these values are slightly elevated in most allergic individuals but extremely elevated in persons with this disease; (3) pneumonia-like X-ray findings, which may be temporary; (4) bronchiectasis (destruction of the muscles in the bronchial walls with chronic cough and large amounts of sputum); (5) positive skin tests to the Aspergillus fungus; and

(6) positive blood tests for antibodies against the Aspergillus allergen. Treatment Prednisone, a corticosteroid drug, is the treatment of choice. It is used daily, most often for several months, and improvement is usually seen within days. In some cases, recurrences require long-term prednisone use. Prognosis If untreated, aspergillosis will damage lung tissues and can be fatal.

bronchopulmonary dysplasia A chronic lung disease of premature infants that develops after a period of intensive respiratory therapy. Dysplasia refers to abnormal formation of tissue. bronchopulmonary lavage Irrigation of the bronchi and bronchioles to remove abnormal or excessive secretions. bronchorrhagia Hemorrhage (profuse bleeding) in the bronchial tube. bronchorrhea An abnormal secretion, which may be offensive to others, from the mucous membrane in the bronchi. bronchorrhoncus From the Greek word rhonchos, meaning “snore,” a rale heard in the bronchial passageway. bronchoscopy An examination of the bronchi through a device called a bronchoscope. The instrument is inserted into the trachea and down to the bronchi so the physician can diagnose a bronchial abnormality. bronchosinusitis

The simultaneous inflammation and infection of the bronchi and sinuses.

bronchospasm

Also called bronchiospasm, sudden narrowing or constriction of the bronchial tubes during an asthma attack or in persons with

52 bronchospirochetosis bronchitis. Bronchospasm is also referred to as bronchoconstriction. See also ASTHMA; BRONCHITIS.

bronchospirochetosis

A type of bronchitis caused by spirochetes, or microorganism of the order Spirochaetales. Bronchopulmonary spirochetosis is also known as hemorrhagic bronchitis.

bronchostaxis Profuse bleeding, or hemorrhage, from a bronchial wall. bronchostomy

From the Greek word stoma, or mouth, the surgical creation of an opening into a bronchus.

bronchotomy A surgical incision made into a bronchus, the larynx, or trachea, usually in order to open an airway. Bronkaid Mist

The trade name for epinephrine,

USP.

Bronkephrine The trade name for ethylnorepinephrine hydrochloride, USP. Bronkodyl

See

Bronkometer Bronkosol

THEOPHYLLINE.

See

ISOETHARINE.

bubonic plague (black death)

Named from the Greek word for gland, bubo, and the Latin plaga, meaning stroke or wound, bubonic plague is most famous for its epidemic proportions in Europe during the Middle Ages, hence the term “black death.” Plague is an acute, extremely contagious disease caused by Yersinia pestis, a microorganism found in infected rats, mice, squirrels, and prairie dogs. It is mainly transmitted to humans by way of a rat flea bite, and results in enlarged lymphatic glands, adenitis or pneumonia, and symptoms of severe poisoning. Symptoms include high fever, a staggering gait, restlessness, delirium or confusion, shock,

and coma. Even though it may be fatal, a mild form of plague is known as ambulatory; pneumonic plague refers to extensive lung involvement. In hemorrhagic plague, one of the severe forms of the disease, there is bleeding into the skin. Bubonic is the most common form of plague characterized by the formation of buboes, or swollen lymph nodes. Untreated bubonic plague causes death between the third and fifth day from the onset of symptoms in 60 percent of its victims. (Tuberculosis, caused by a Mycobacterium, is sometimes called “white plague.”) Plague infections occur most frequently in the United States in the Southwest, including Arizona, California, Colorado, and New Mexico. Recent outbreaks have been limited to an individual case or small clusters of people. In addition to infected flea bites, plague may be transmitted by the droplets of an infected person’s cough or sneeze. Pneumonic plague occurs when the lungs are infected by the plague bacteria. Symptoms High fever, chills, rapid heartbeat are signs of the plague, and in most cases, a severe headache, with a cough developing within a day or so from the time of exposure to the bacteria. The sputum becomes bloody and eventually turns uniformly foamy, resembling raspberry syrup. If untreated, a victim may die within two days of the onset of symptoms. Prevention Rodent control and use of insect repellent are key, especially to travelers to areas in which there are reported incidences of plague infection. Prompt treatment, i.e., within 24 hours, is also important when plague infection is suspected. Treatment includes streptomycin, tetracyclines, and chloramphenicol, and individuals with pneumonic plague must be isolated to prevent spreading the disease. A plague vaccine is available and is made by adding the preservative chemical formaldehyde to kill specific plague bacilli.

budesonide (Rhinocort,

Pulmocort) Corticosteroid available in the United States as a nasal spray for allergic rhinitis and in other countries as

byssinosis 53 a metered-dose inhaler for asthma. Budesonide has a greater potency than many similar drugs. See also CORTICOSTEROID METERED-DOSE INHALERS; CORTICOSTEROID NASAL SPRAYS.

butane

See

byssinosis

INHALANT ABUSE.

An allergic lung disease caused by occupational exposure to an unknown allergen in the dust from the processing of cotton, flax, hemp, or sisal. Symptoms of shortness of breath and wheezing gradually intensify upon increased expo-

sure and may lead to respiratory failure. Smoking increases the risk of permanent lung damage. Byssinosis is largely preventable by wearing a face mask and treating raw textiles before manufacturing. Because these measures are ignored in developing countries, the incidence of this disease is greater there than in the United States. Government compensation is available in the United States for those afflicted with byssinosis. Bronchodilating drugs, either aerosol inhalers or tablets, and removal of exposure to the harmful dusts are the treatment of choice. See also OCCUPATIONAL ASTHMA.

C cachexia The condition of being in bad health, malnourished and wasting that may occur in the course of chronic catastrophic disease, including advanced pulmonary tuberculosis. In addition to prescribed medical therapy, treatment consists of rest, good hygiene and nutrition, prevention of skin breakdown, pain, and fractures, maintenance of elimination, and emotional support.

cancer, lung A form of disease characterized by the uncontrolled growth of cells (derived from normal cells) and subsequent malignancy that is capable of killing the host by spreading from the original site to other parts of the body. Cancer is named from the Greek word karkinos, meaning crab. It is estimated that 200 different types of cancers exist, most of which, like the crab’s slow movement, have an insidious onset. See also LUNG CANCER.

caisson disease Pain in the joints, skin irritation, a burning sensation in the lungs, coughing, and various neurological disturbances caused by a sudden or rapid reduction in environmental air pressure. Caisson disease—named from the French word caisse, meaning “box”—is frequently seen in aviators and deep-sea divers. Also known as the bends or decompression illness, caisson disease is characterized by nitrogen bubbles forming in the tissue space and small blood vessels when a diver comes to the surface of the water after being 30 or more feet below in an environment of compressed air, or a pilot ascends rapidly from sea level to an elevation of 18,000 feet or higher. Treatment includes use of a hyperbaric chamber for recompression and then a gradual decompression. See also BENDS.

candidiasis An infection by the yeastlike fungus of the species Candida albicans affecting various parts of the skin or mucous membranes, including the bronchi and lungs. Oral nystatin, ketoconazole, or clotrimazole may be prescribed for localized infections, and systemic infections may be treated with amphotericin B and other medications. cannabis

The hemp plant, Cannabis sativa, from which the dried flowering tops are processed into a preparation that, when inhaled or ingested, may cause euphoria and, according to some reports, pain relief, antiemesis (particularly the important constituent called delta-9-tetrahydrocannabinol, or THC, in the treatment of cancer), and alleviation of the symptoms of glaucoma. Cannabis is also known as marijuana, which can be smoked. In addition to possibly exacerbating psychoses, such as schizophrenia, marijuana is a “gateway” drug known to cause psychological dependence, and the inducement of toxic delirium, among other ill effects. Cannabis that is smoked may lead to respiratory disorders. Although it has not been proven that heavy and chronic marijuana use causes lung cancer and other serious pulmonary impairments, marijuana contains some of the same harmful

canal, pharyngeal The tubular opening from the sphenoid bone to the palatine bone that contains the sphenopalatine vessels. canal of Lambert

The connecting points between bronchioles and alveoli in the lungs, which may help prevent collapse of the lung. See also ATELECTASIS.

carbon monoxide poisoning 55 components as tobacco smoke. Smoking marijuana is often concurrent with cigarette smoking, which increases the risk of respiratory disease. See also HASHISH; TOBACCO.

cannula, nasal Flexible tubing inserted into the nostrils that provides oxygen at 1 to 6 liters per minute. The tubes that go approximately 1 centimeter into each nostril are connected to a common tube and an oxygen source. capacity, vital The volume of air that can be forcibly exhaled from the lungs after a full inhalation. Caplan’s syndrome

Named for British physician Anthony Caplan (1907–76), a type of rheumatoid arthritis with severe fibrosis of the lung, found in coal miners and others with forms of pneumoconiosis. The syndrome is a rare disorder in which scar nodules develop in the coal miner’s lung as well as in the lungs of people who have been exposed to coal dust even if they do not suffer from black lung. See also COAL WORKER’S PNEUMOCONIOSIS.

capnography The record made of the level of carbon dioxide in the exhaled air of patients connected to a ventilating device. capreomycin sulfate (Capastat). See also

A tuberculostatic drug

TUBERCULOSIS.

carbinoxamine An antihistaminic drug, commonly combined with a decongestant, used to treat allergic rhinitis (hay fever) conditions. It is available in oral formulations as Rondec (Abbott) or as a generic brand. Carbinoxamine may cause drowsiness. See also ANTIHISTAMINE. carbon dioxide [CO2] A colorless, odorless gas exhaled during respiration that is the result of carbon oxidation that takes place in the tissues. Blood

levels of CO2 increase during hyperventilation, characterized by shortness of breath, tingling of extremities, and, at times, vomiting, elevated blood pressure, and disorientation. See also ARTERIAL BLOOD GASES; CARBON DIOXIDE INHALATION; CARBON DIOXIDE POISONING; HYPERVENTILATION.

carbon dioxide inhalation A 5 to 7.5 percent level of carbon dioxide and oxygen used for patients to inhale as a way to stimulate respiration (particularly in individuals with pulmonary disease) and as part of or sequel to the administration of artificial respiration. See also CARBON DIOXIDE. carbon dioxide poisoning The intake of excessively high levels of carbon dioxide, characterized by extremely deep breathing, a feeling of pressure in the head, acid taste in the mouth, ringing in the ears, a slight burning sensation in the nose, and possibly near respiratory arrest and unconsciousness. The treatment is administration of oxygen. See also CARBON DIOXIDE. carbon monoxide Known as CO, a colorless, tasteless, odorless, and insidiously poisonous gas produced as a result of imperfect combustion and oxidation. Engine exhaust gas is a common source of CO, and it is also found in coal mines (from the incomplete combustion of coal), sewers, cellars, and gasoline motors. Smoking tobacco, which impedes the level of oxygen in the bloodstream, increases the blood’s level of CO. In turn, night vision may be affected. Carbon monoxide detectors, similar to smoke detectors, have been developed for household use to prevent poisoning. See also CARBON MONOXIDE POISONING. carbon monoxide poisoning

The intake of excessively high levels of carbon monoxide in a brief period of time or the effect of inhaling small amounts over an extended period of time may cause poisoning. Inhaling fumes while in a closed car with the motor running, or using a gasoline

56 carbon tetrachloride poisoning motor in an enclosed area may cause the CO to combine with the hemoglobin and thereby cut off the body’s oxygen supply. Poisoning symptoms vary and may include a “cherry red” skin color, weakness of muscles, pounding heart, headache and throbbing in the temples, nausea, dilated pupils, ringing in the ears, and rapid pulse. Treatment of choice is the administration of 100 percent oxygen. Complications that may arise include cerebral edema, muscular spasms, blindness, paralysis, and other neurological disturbances. See also CARBON MONOXIDE.

carbon tetrachloride poisoning

The result of inhaling excessive levels of carbon tetrachloride (CCl4), a clear liquid with an odor similar to that of ether. Inhaling even a small quantity may cause death by damaging the liver and kidneys. Symptoms include eye, nose, and throat irritation, headache, nausea, visual disturbance, confusion, ventricular fibrillation, and depression of the central nervous system. Treatment includes the administration of oxygen, lavage with saline solution, and the removal of clothing contaminated with the chemical.

carcinogen

Any chemical or substance that induces the risk of developing cancer in animals or humans. Carcinogenesis refers to the origin of cancer.

carcinoma, alveolar cell

A malignant tumor that develops in the lung. A carcinoma specifically occurs in epithelial tissue and they frequently metastasize through the bloodstream or the lymph system. See also CANCER, LUNG.

carcinoma, bronchogenic A bronchogenic carcinoma is malignant and develops in the bronchi. See also CANCER, LUNG. carcinoma, oat cell A tumor that develops in the bronchus and contains tiny cells shaped like oats. See also CANCER, LUNG.

Cardarelli’s sign

Named for Italian physician Antonio Cardarelli (1831–1926), a throbbing movement of the trachea, or windpipe, to one side, which may accompany an aortic aneurysm.

cardiac asthma

Severe shortness of breath caused by fluid in the lungs that produces bronchospasm and wheezing. This condition results from an inability of the left chambers of the heart to pump adequately, that is, congestive heart failure. Cardiac asthma is accompanied by hyperventilation, a state of rapid breathing, and the person appears to be having an asthma attack. Primary treatment involves heart drugs such as diuretics, digitalis, and ACE inhibitors. Bronchodilators are sometimes helpful.

cardiopneumograph A device that records the motions of the heart and lungs for diagnostic purposes. cardiopulmonary arrest The sudden cessation of breathing and blood circulation, indicating the need for cardiopulmonary resuscitation and/or other methods that may revive the victim. See also CARDIOPULMONARY RESUSCITATION. cardiopulmonary resuscitation Commonly referred to as CPR, a method to try to restore breathing and heart function, i.e., to provide oxygen as quickly as possible to all the vital organs of a breathless victim. A CPR assessment is the first step to determine the victim’s state of consciousness; in three to five seconds, a caregiver must lift the jaw and remove any liquid or solid material in the mouth to make sure the airway is open. It is also best to remove the victim’s dentures at this time. (If the victim has sustained trauma of the head and neck, care must be taken not to move the victim unless it is absolutely necessary.) Next, the caregiver should observe the chest for breathing movements and listen for breaths. If there is no rise and fall of the chest or evidence of breathing, CPR may be started. To begin CPR, the caregiver kneels over the victim at the shoulder, tilts back the head and lifts the chin (unless spinal injury is suspected, in which case, one simply brings the jaw forward). Once the

cavity, pleural 57 airway is open, the caregiver gently pinches the victim’s nostrils closed, takes a deep breath and places the lips to form a seal over the victim’s mouth. (If the victim is an infant, the caregiver creates a seal over the nose and mouth.) The caregiver then gives two full breaths lasting one to one-anda-half seconds, watching carefully that the victim’s chest rises with each ventilation. A bag-valve-mask or other device may also be used to prevent the spread of disease between caregiver and recipient of CPR. The caregiver must also assess the victim’s circulation by taking the carotid-artery pulse (between the groove of the trachea and the strap muscles in the neck). If there is a pulse but no sign of breathing, continue mouth-to-mouth resuscitation by administering one breath every five seconds, or 12 breaths per minute. If there is still no pulse, the victim is suffering cardiac arrest and chest compressions over the lower part of the sternum (breastbone) should be started. With fingers either interlocked or extended and using the heel of the hands placed over the notch where the ribs meet the sternum in the middle of the chest, the caregiver should compress straight down on the sternum approximately an inch-anda-half to two inches on an adult victim, an inch to an inch-and-a-half on a child, and half an inch to an inch on an infant. After each rhythmic compression, the chest should return to its natural position. Eighty to 100 compressions per minute (at least 100 per minute for an infant) should be applied. CPR should not be interrupted for more than seven seconds. IT IS IMPORTANT FOR SOMEONE TO CALL 911 OR A LOCAL EMERGENCY NUMBER WHILE CPR IS BEING GIVEN SO EMERGENCY MEDICAL PERSONNEL CAN REACH THE VICTIM AND TAKE HIM OR HER TO THE HOSPITAL. When the victim begins to breathe on his own, stop chest compressions. Check with community health facilities and organizations for complete CPR instructions and emergency measures. Everyone capable of learning CPR should be certified.

carrier A person, animal, insect, substance, or other agent capable of spreading a disease organism without showing signs of having the disease itself. See also INFECTION CARRIERS.

case-control study A method of examining disease and disease processes by way of two groups, one of those who have a disease—referred to as cases—and one of those who do not—referred to as controls. Information is obtained from each group and analyzed. The method is useful in epidemiology. The first case-control study involved English chimney sweeps who developed cancer of the scrotum. Researchers hypothesized that the nature of their work had something to do with the incidence of scrotal cancer among their group as opposed to the rate of scrotal cancer in the general public. Epidemiologists also use the case-control study to determine other characteristics of disease processes, such as frequency of occurrence, risk factors, circ*mstances of exposure, and the differences between the cases and the controls. cast, bronchial

Hardened segments of bronchial secretions that accumulate and take on the shape of the bronchial tubes. Bronchial casts may be seen in the sputum of asthma or bronchitis patients. Cast material consists of substances thrown off during the course of pathological conditions (the products of effusion). The substances may also mold themselves to nasal, tracheal, esophageal, renal, urethral, intestinal, and vagin*l passages.

catarrh

Inflammation of mucous membranes characterized by a dry cough and severe coughing spells with little or no expectoration, especially in the aged with emphysema or asthma.

catheter, pulmonary artery

A tube that is passed into the pulmonary artery for the purpose of measuring pressures in the artery, wedge pressure in the pulmonary capillaries, and heart function.

cavernous rale

Hollow spaces in the respiratory tract that produce a bubbling sound. Cavernous respiration refers to a hollow sound heard when there is a lung cavity. See also RALE.

cavity, pleural

The space between the parietal pleura, serous membranes that extend from the

58 cell-mediated immunity roots of the lungs and cover the pericardium to the chest wall and backward to the spinal cord, and the visceral pleura, which invests the lungs and enters the interlobar fissures. The pleura pulmonalis refers to the membranes investing the lungs and fissures between the lobes. Pleurae secrete a lubricating substance that decreases friction between the structures of the lungs during respiratory movements. Pleural effusion refers to fluid escaping into the chest cavity between the visceral and the parietal pleura and may be seen in a chest X ray if the fluid measures more than 300 milliliters. Pleural fibrosis, which occurs with pulmonary tuberculosis, means the pleura thickens and obliterates the pleural cavity, making respiratory movements difficult. Pleuralgia is the medical term for pain occurring in the pleura or in the side. See also PLEURISY.

generation, cephalosporins are sometimes ineffective against some bacteria that produce a defensive enzyme, beta-lactamase, which inactivates the antibiotic before it can kill the bacteria. The newer second- and third-generation drugs in this group are more effective against these infections, including sinusitis and bronchitis. Trade names include Keflex, Duricef, Velosef, Ceclor, Ceftin, and Suprax. Many other cephalosporins are available in injectable forms for serious infections.

cerebral anoxia

A condition in which there is a severe lack of oxygen supply to the brain usually caused by cardiopulmonary arrest. Irreversible brain damage may result within a few minutes if the anoxia remains untreated. See also CARDIOPULMONARY RESUSCITATION.

chalcosis Poisoning caused by copper deposits in the lungs and tissues.

cell-mediated immunity

Immune protection provided by the direct action of immune cells such as macrophages. This differs from humoral (bodily fluids) immunity, which chiefly involves B cells and antibodies. The macrophage ingests the antigen, digests it, and then displays antigenic fragments on its own surface. The macrophage then binds to a group of genes called a major histocompatibility complex (MHC). This combined structure attracts a T cell’s attention. A T cell whose receptor fits this antigen-MHC complex binds to it and stimulates the macrophage to secrete interleukin-1. Interleukin-1 in turn activates other T cells and starts a series of biochemical processes that may result in certain subsets of T cells becoming cytotoxic, or killer, cells. The T killer cells track down viral-infected body cells. When the infection has been eradicated, suppressor T cells shut down the immune response.

chalicosis

A form of pneumoconiosis, or silicosis, a respiratory tract disorder associated with the inhalation of dust from stonecutting. See also PNEUMOCONIOSIS.

Charcot-Leyden crystals Six-sided, doublepointed crystals (solid formations made by salts, water, and other substances of the body) found on microscopic examination of sputum from asthma and bronchitis patients. The crystals are also found in the feces of patients with certain inflammatory conditions of the bowels, including ambiasis. Named for French neurologist Jean M. Charcot (1825–93) and German physician Ernst V. von Leyden (1832–1910), these colorless and sometimes needlelike protein crystals are produced by eosinophil cells. chemical warfare

cephalosporin

A group of antibiotics called cephalosporin C, derived from the fungus Cephalosporium, which are used to treat a wide range of infections that may be resistant to the penicillins. Cephalosporins kill bacteria by interfering with the development of the bacterial cell wall and production of proteins by the organism. Older, or first-

Another term for biological warfare referring to the tactics of combatants that include the release of toxic chemicals. The substances—gases, defoliants, herbicides, etc.—are capable of producing lung, nerve, skin, and eye irritation, blindness, paralysis, hallucinations, and deafness. See also BIOTERRORISM.

chloroformism 59 chest (thorax) The area between the frontal base of the neck and the diaphragm, named from the Greek word thorax, which means chest. The anterior surface of the chest is located above and over the clavicles, or collarbones, over and above the sternum, or breastbone, over the breast, or mammary, area, between the third and sixth ribs on either side, and the area above the lower border of the 12th rib on either side. The posterior (rear) surface includes the entire area of the scapulae, or shoulder blades, and the side regions include above the sixth rib and under the arms. In patients with advanced pulmonary emphysema, the chest becomes rounded out like a barrel and is called a barrel-shaped thorax. The bony thorax refers to the skeletal structure including the thoracic vertebrae, 12 pairs of ribs and the breastbone. In individuals with large pleural effusions, the chest becomes an obliquely oval shape and is known as Peyrot’s thorax. The long, flat chest of patients with constitutional visceroptosis (a dropped or downward displacement of one of the organs enveloped in a body cavity such as the thorax) is known as thorax paralyticus. The chest houses the lungs, heart, pleural cavity, pulmonary artery and veins, the thoracic aorta, vena cava, thymus gland, lymph nodes, trachea, bronchi, mediastinum, thoracic duct, and esophagus. chest expansion, normal The upward movement of the chest as air is taken into the lungs.

chiropractic A widely acclaimed discipline eschewing drugs and surgery and favoring handson manipulations, referred to as adjustments, of the spinal cord. Modern chiropractic follows tenets expressed in 1895 by Daniel David Palmer, of Iowa, based on the teachings of Hippocrates, who believed all illnesses had their sources in the spine. According to chiropractic, when vertebrae are subluxated, or dislocated or misaligned, the person experiences any number of ailments, including allergy, headaches, and back pain. Although there is a great deal of anecdotal testimony to their effectiveness, chiropractic techniques and theories have not been scientifically proven. Since symptoms of allergy and asthma often wax and wane, improvement following spinal manipulation may be falsely attributed to chiropractic. Because emotional stress triggers asthma (although it is not its cause), a placebo effect may result from chiropractic treatments. However, chiropractic as a system of health care thrives on the premise that the relationship between the spinal column and the nervous system is significant, and that normal transmission and expression of nerve energy are key elements in the healing and maintenance of the body. The main approach is that vertebral subluxation causes stress, which when removed will lead to the body’s capacity of setting intrinsic healing mechanisms in motion. The American Chiropractic Association is the major organization for chiropractic physicians. Chlamydia psittaci

Cheyne-Stokes respiration

See

BREATHING.

chill Shivers, coldness, pallor, body tremors, and chattering of teeth associated with infections or diseases, including pneumococcal pneumonia and malaria. Chills may be caused by a disturbance in the temperature-regulating center of the hypothalamus, the part of the brain that controls certain metabolic activities, such as water balance, sugar and fat metabolism, and inhibiting and releasing hormones. chin-lift airway technique MONARY RESUSCITATION.

See

CARDIOPUL-

A microorganism that causes a disease in birds and lower mammals that may be transmissible to humans. In an accidental human host, the illness takes on an influenza-like form or may be a severe type of pneumonia. See also PSITTACOSIS.

chloral hydrate poisoning

An adverse effect of excessive amounts of chloral hydrate, a sedative and hypnotic drug, that causes respiratory depression that may require assisted respiration.

chloroformism The potentially lethal inhalation of chloroform, an antiseptic and local anesthetic, as recreational drug abuse. A clear liquid with an etherlike odor, chloroform was used in the early

60 choana days of medicine as anesthesia by having the patient inhale it, usually by placing a piece of cloth or gauze soaked in the chemical over the person’s nose and mouth, a practice that is now obsolete. Developed in 1838, chloroform was chemically referred to as CHCl3 and was also used as a solvent and a veterinary antiseptic. Chloroform as a singular substance is not readily available today. Other substances, including nail polish remover, rubber cement, nitrite room deodorizers, gasoline, and paint thinner, are among the numerous abused inhalants in popular use today, particularly by teenagers. See also HUFFING; INHALANT ABUSE.

choana

From the Greek word meaning funnel, a funnel-shaped opening at the back of the nostrils (posterior nares) leading to the pharynx.

choke, choking The condition of impaired breathing and circulation of air to the brain attributable to a compression or obstruction in the trachea or larynx. A spasm in the larynx as a result of inhaling an irritating gas or anything that constricts the neck may also cause interference in the airway. If a person is choking on food or an object, the Heimlich maneuver may relieve complete airway obstruction. Signs of true choking include panic, inability to speak or make noise, cyanosis, and fainting. If the forced air pressure of the Heimlich maneuver does not work, a surgical intervention may be necessary to restore breathing. See also HEIMLICH MANEUVER. cholesterohydrothorax A pleural effusion in which the fluid contains cholesterol. See also CAVITY, PLEURAL. cholohemothorax

Abnormal presence of bile and blood in the thoracic cavity.

chorditis Inflammation of the vocal cord (also called the spermatic cord). Chorditis nordosa refers to tiny white nodules that form on one or both vocal cords and accompanying hoarseness. Usually this is a condition in singers or others who overuse

their voice. Resting the voice is the treatment of choice, but surgery to remove the nodules may be necessary in severe cases.

chronic obstructive pulmonary disease Known commonly by its acronym COPD, or COLD (chronic obstructive lung disease), a condition in which there is persistent blockage of airflow into or out of the lungs because of chronic bronchitis or emphysema or both, or chronic asthma or chronic bronchiolitis. In all forms of COPD, air gets trapped in the lungs, which then leads to a decrease in the number of capillaries in alveoli walls and the impairment of the exchange of oxygen and carbon dioxide between the alveoli and the bloodstream. Eventually carbon dioxide becomes elevated, and the oxygen level is dramatically reduced. A history of persistent dyspnea (difficulty breathing) on exertion, with or without a chronic cough, and less than one-half the normal breathing capacity are the main diagnostic criteria for COPD. In the United States, approximately 14 million people suffer from COPD, according to the Merck Manual of Medical Information, September 2000, and it is “secondary only to heart disease as a cause of disability that makes people stop working, and the fourth most common cause of death. More than 95 percent of all deaths from chronic obstructive pulmonary disease occur in people over age 55. It affects men more frequently than women and is more often fatal in men. It’s also fatal more often in whites than in nonwhites and in blue-collar workers than in white-collar workers.” Merck also says COPD may be an inherited tendency, and that smoking or working in an environment where there are chemical fumes or nonhazardous dust may increase the risk of COPD. Also, approximately 10 to 15 percent of smokers develop COPD. As they age, their lung function decreases more rapidly than that of nonsmokers. Symptoms of COPD include a “smoker’s cough,” bringing up mucus, common colds that frequently become chest colds (during which sputum may turn yellow or green because of pus), wheezing, and, as the disease progresses, shortness of breath when carrying out normal activities of daily living, possible severe weight loss, and swelling of the legs.

chylopneumothorax 61 In mild asthma, inflammation that thickens the bronchial walls, constriction of the muscles in the bronchial tubes, or obstruction by excessive mucus is present only during an attack. However, in the case of severe asthma, there is usually a degree of chronic obstruction that is reversible to varying degrees with treatment. Chronic bronchitis is often confused with emphysema, an expansion of the air spaces resulting in destruction of the alveoli, or air sacs in the lungs. Approximately 20 percent of adult males have chronic bronchitis, although only a small number are disabled because of it. It is less common in females and most common in smokers, but allergies and other irritants, pollution from the environment, and occupational exposure can be causes. Pure emphysema is rare and is not reversible with treatment. The degree of obstruction found in chronic bronchitis is often greater than that found in most asthmatics but less than that in emphysemics. In rare cases, a deficiency of the protein alpha1antitrypsin, produced naturally by the body and which prevents neutrophil elastase (an enzyme) from injuring the lung’s air sacs, or alveoli, may also be the cause of emphysema. Individuals who inherit the deficiency develop emphysema by early middle age, particularly in smokers. Young people who develop emphysema are tested for the deficiency by way of a blood test. The main treatment is cessation of smoking, use of bronchodilating drugs, avoiding exposure to airborne irritants, and avoiding dehydration. Antibiotics may be used in the presence of bacterial infection, and oxygen therapy and exercise programs may improve the quality of life for COPD patients. For those with the alpha1-antitrypsin deficiency, intravenous infusions of the protein may be required. Lung transplantation may also be an option in certain patients. People with COPD have an increased risk of developing lung cancer. See also BRONCHITIS; BRONCHODILATORS; CANCER, LUNG; EMPHYSEMA.

cases of severe asthma. Patients have fever, extremely elevated eosinophil counts in their blood, and vasculitis. In addition, they generally have a long history of allergies, usually allergic rhinitis (hay fever) that progresses to asthma. A vasculitis, an inflammatory condition of blood vessels, evolves that may affect almost any organ but most often targets the heart, lungs, skin, central nervous system, muscles and bones, kidneys, or gastrointestinal tract. The person may develop nasal polyps, which cause obstruction of the nasal passages and sinusitis. The most serious complications result from vasculitis. About one-third of patients have abnormal chest X rays that resemble those seen in cases of pneumonia. If the skin is involved, rashes, hives, bumplike lesions called nodules, or large areas of bruising may occur. Abdominal obstructions and perforations cause pain and diarrhea. Myocardial infarctions (heart attacks) or inflammation of the heart muscle can result in heart failure. Brain and nerve involvement often leads to strokes and is a major cause of serious disability or death. Kidney impairment leads to hypertension (high blood pressure). Symptoms of arthritis and muscle cramping may be present. Churg-Strauss syndrome may begin with a feeling of malaise but may progress quickly with severe weight loss. The American College of Rheumatology lists six criteria for diagnosing this condition:

Churg-Strauss syndrome (allergic angiitis and granulomatosis) A combination of symptoms first reported in 1951 in association with a cluster of 13

chylopneumothorax The condition of chyle and air in the pleural space. Chyle is a milky alkaline fluid, found in the intestine, consisting of absorbed

(1) asthma; (2) eosinophil count increasing to 10% of white blood cells; (3) a mononeuropathy or polyneuropathy (singular or multiple degeneration of nerves resulting in weakness); (4) pneumonialike fluid accumulation seen in chest X rays; (5) abnormality of the sinuses; and (6) characteristic blood vessel biopsy. The presence of four or more of these criteria highly suggests Churg-Strauss.

Cortisone is the treatment of choice, but other immunosuppressive drugs are sometimes used. Five-year survival was greater than 60 percent in 1977, the last year data are available.

62 chylothorax fats and the products of the digestive process. Chylothorax refers to chyle present in the pleural cavities.

chylothorax

See

CHYLOPNEUMOTHORAX.

cigarette smoke Fumes from a burning cigarette, which are not in themselves allergenic, although tobacco smoke is an irritant to persons with asthma and nasal or eye allergy. In the past some practitioners have skin-tested and given immunotherapy (allergy shots) to patients believed to be allergic to tobacco smoke, but there is no scientific rationale for this treatment. See also LUNG CANCER; PASSIVE SMOKING; TOBACCO. circulation, pulmonary Blood from the veins entering the right atrium of the heart that then passes through the tricuspid valve and into the heart’s right ventricle to the pulmonary artery. Each of the artery’s two branches then goes into a lung and its capillaries, where, by way of hemoglobin in the red corpuscles, the venous blood takes up oxygen from inspired air. The red arterial blood then goes back to the heart through the four pulmonary veins, two from each lung going into the heart’s left atrium. When the blood enters the atrium, it is fully oxygenated. Citelli’s syndrome

Named for Salvatore Citelli, an Italian laryngologist (1875–1947), a condition characterized by insomnia or drowsiness seen accompanying infected adenoids or sphenoid sinusitis in children.

clapping Also called cupping or tapping, percussion of the chest using a cupped hand as a method of loosening secretions in patients with respiratory disorders such as tuberculosis involving excessive mucus and congestion. Clara cells

Named for Max Clara, the Austrian anatomist born in 1899 who identified them, the cells in the epithelium of the bronchioles that provide secretions for the respiratory tract.

clean room

A room or environment in which the air—its temperature, pressure, humidity, and purity—is controlled. A filter may be used to remove 99.97 percent of all particles 0.3 microns (1 micron = 1/25,000 inch) and larger. Clean rooms are used in research and for individuals suffering from severe allergy or chronic infection due to immune system deficiency.

cleft palate A congenital anomaly in which there is a fissure, or elongated opening, in the roof of the mouth (palate) that creates a passageway between the mouth and the internal portions of the nose. clubbing Enlargement of the tips of the fingers or toes and loss of the normal angle at the nail bed, frequently caused by lung or other diseases or a hereditary factor. coal

worker’s pneumoconiosis Commonly known as black lung, a lung disease caused by the inhalation and accumulation of coal dust in the lungs. After the coal dust collects around the bronchioles, it spreads to other parts of the lung and eventually causes spots that may be detected on a chest X ray. A more serious form of the disease may occur in 1 to 2 percent of individuals who have simple black lung. Even long after exposure to coal dust has ended, lung tissue and blood vessels may suffer the effects of progressive massive fibrosis, or severe scarring. The scars measure at least a half-inch in diameter, and the fibrosis then causes coughing and debilitating shortness of breath, especially in coal miners who have been exposed to coal dust for more than 10 years. There is no cure for black lung, but drugs that help keep airways patent and free of secretions may be of help. Prevention is the key: adequate suppression of coal dust at the worksite; chest X ray every four to five years; transfer of workers at risk for progressive massive fibrosis to an area where coal dust levels are minimal; cessation of cigarette smoking; and avoidance of toxic exposure to industrial pollutants.

concha, nasal 63 cocaine hydrochloride poisoning, acute

The toxic effect of applying or inhaling cocaine hydrochloride, a topical anesthetic derived from the shrub Erythroxylon coca of Bolivia and Peru. Street names for the drug include crack, snow, gold dust, toot, co*ke, and lady. Symptoms after an initial stimulating effect are irregular respirations, tachycardia, hallucinations, vomiting, muscle spasms, chills or fever, restlessness, incoherence, dilation of pupils, seizures, coma, and death from respiratory arrest. Treatment includes intravenous diazepam (Valium), an emetic (or gastric lavage if the drug was ingested), succinylcholine chloride if convulsions interfere with breathing, oxygen, and artificial respiration. If a victim survives for three hours after the onset of symptoms, he or she is likely to recover.

coccidioidomycosis Also known as granuloma, valley fever, desert rheumatism, and coccidioidal, a disease affecting the respiratory organs in its acute (primary) form, caused by the fungus Coccidioides immitis. The progressive form of the disease may involve any part of the body and is considered grave and often fatal. The primary type does not require treatment. For patients with pulmonary disease, ketoconazole may be prescribed to inhibit the infection and suppress symptoms. However, amphotericin B is the only drug that is effective against the progressive form. See also GRANULOMATOSIS, WEGENER’S. codeine poisoning

An overdose of codeine, an alkaloid obtained from opium, that causes serious and potentially fatal depression of respiration and heart rate.

cogwheel respiration

See

BREATHING.

coin test

A diagnostic test for pneumothorax, or collapsed lung. A coin is placed on the chest over a suspected area of the lung and struck by another coin. If a metallic ringing sound is heard, a cavity containing air is underneath. Physicians now order X rays to confirm the diagnosis.

COLD disease.

The acronym for chronic obstructive lung

See also

CHRONIC

OBSTRUCTIVE

PULMONARY

DISEASE.

cold, common

A respiratory infection caused by a virus including sneezing, nasal discharge and congestion, sore throat, and coughing, all of which are often confused with or coexist with allergy symptoms. Viral colds can also trigger asthma; shortness of breath and wheezing may persist for a prolonged period following resolution of the viral infection. Some patients have asthma symptoms only when they “catch” a cold.

cold-induced rhinorrhea

A runny nose that occurs upon exposure to cold air. It is not an allergy and does not respond to antihistamines, but it may be prevented by using a mixture of atropine sulfate and saline solution as a nasal spray.

columna nasi tum. See also

Another term for the nasal sep-

NOSE.

coma

From the Greek koma, meaning deep sleep, an abnormal stupor from which the victim cannot be aroused. Occurring as a result of illness, acute infection or bacterial intoxication, inhalation of gases or fumes, or injury, coma may require basic life support as treatment. A patient’s airway must be kept patent, and all vital signs and bodily functions must be monitored. Adequate ventilation and oxygenation are also among the top priorities for a patient in a coma. There are several types of coma, including diabetic, hepatic, uremic, vigil, apoplectic, alcoholic, hypoglycemic, Kussmaul’s, and irreversible (brain death).

communicable disease

Any infection or malady that is transmissible from one body to another.

concha, nasal

Part of the anatomical structure of the nose, one of three bones shaped like scrolls, hence the name from the Greek word meaning shell, that project from the lateral wall of the nasal cavity. The superior, middle, and inferior conchae all protrude over an opening, or meatus.

64 congestion, pulmonary congestion, pulmonary An abnormal amount of blood in the pulmonary vascular bed, usually associated with heart failure. coniofibrosis Pneumoconiosis caused by the inhalation of asbestos, silica, or other dust, which produces fibrosis in the lung. coniosis Any illness, ailment, or anomaly caused by the inhalation of dust. coniosporosis

Asthma and pneumonitis caused by inhaling the spores of the fungus Cryptostroma corticale or Coniosporium corticale. Essentially a hypersensitivity reaction, coniosporosis occurs in workers who strip the bark of trees under which the fungi grow.

cor pulmonale

A dysfunction of the heart’s right ventricle caused by lung disease or disorders of the pulmonary vessels or chest wall. Long periods of time spent at high altitudes may also result in cor pulmonale.

corticosteroid metered-dose inhalers

Various asthma inhalers containing cortisone derivatives possessing anti-inflammatory properties useful in the prevention of asthma symptoms. See also CORTICOSTEROIDS.

corticosteroid nasal sprays (beclomethasone, budesonide, dexamethasone, flunisolide, fluticasone, mometasone furoate, triamcinolone) Derivatives of the hormone cortisone that relieve symptoms of nasal congestion and excessive discharge from allergic rhinitis (hay fever). They may also give relief for vasomotor rhinitis (nonallergic nasal congestion) and may have a beneficial effect on small nasal polyps. Also called “steroid” nasal sprays, these medications may take one to two weeks to become effective and may be prematurely discarded by uninformed patients as ineffective. These are considered maintenance medications, and since their effectiveness does not accumulate, they must be used continuously. Because only a minimal quan-

tity of the active drug is absorbed from the nasal passages into the bloodstream, there is little chance for side effects. Use in children, however, must be closely monitored. See also CORTICOSTEROIDS.

corticosteroids

Naturally occurring (or synthetically manufactured) hormones produced by the adrenal glands, located next to the kidneys. Although corticosteroids do not initiate cellular or enzymatic activity, they are essential for many functions necessary for life, including the regulation of carbohydrate, protein, and fat metabolism, and salt and water balance. Natural and synthetic corticosteroids play a vital role in fighting allergic and inflammatory reactions. Although these drugs can be lifesaving, they also may produce very deleterious effects with large doses or prolonged therapy. Corticosteroids differ from dangerous anabolic steroids, which are often used illegally by athletes to enhance bodybuilding.

Antiallergy Effects The cortisone-like drugs have the ability to interfere with allergic antigen-antibody reactions. This most likely occurs by blocking the inflammatory tissue injury that results from the release of chemical mediators from mast and basophilic cells. Prostaglandin production is also suppressed by these drugs. In addition, these drugs suppress all types of delayed hypersensitivity or cell-mediated immune reactions. This is especially useful for preventing tissue transplant rejections from occurring. Metabolic Effects Hydrocortisone removes glycogen stores in the liver and raises blood sugar levels. In corticosteroid-treated patients, diabetes mellitus usually develops only in those with a latent diabetic tendency and rarely raises glucose to dangerous levels in normal patients. Hydrocortisone in physiologic or normal quantities is essential for normal muscle contraction. However, large doses or prolonged therapy causes a negative nitrogen balance by increasing amino acid production from protein, with depletion of body protein. This in turn causes severe muscle

corticosteroids 65 wasting, or atrophy, and weakness. A similar effect on bone results in osteoporosis with decreased bone matrix and removal of bone calcium. This process also interferes with normal growth in children. Aseptic necrosis is another serious adverse

effect of high-dose corticosteroid therapy. Hydrocortisone in high doses also causes a redistribution of the body’s fat stores with thinning of the extremities and increased disposition in the face and trunk. Thinning of subcutaneous tissue may occur

66 corticosteroids

corticosteroids 67 with resulting red or purple striae and ecchymosis, or bruises. Sodium and water retention also occurs, but potassium is lost. Blood pressure elevation may occur with high-dose therapy. Hormonal Changes When used for a prolonged time, corticosteroids may suppress the production of the pituitary hormone corticotropin (ACTH). ACTH secretion stimulates the adrenal glands for the natural production of cortisone. If the adrenal glands atrophy, they may fail to respond adequately to a crisis such as an acute illness, like an asthma attack or the stress of surgery, and if an extra dose of the drug is not administered, the patient may die. Some women develop hirsutism (excessive hair production), and acne is more common as a result of breakdown products of androgens, or male hormones, from prolonged use of corticosteroids, but rarely do these drugs affect menstrual function. Anti-inflammatory Effects One of the beneficial roles of anti-inflammatory drugs is to assuage reactions in asthma and arthritis; this same ability to suppress inflammation may have a deleterious effect on wounds by interfering with the healing process. The ability to suppress inflammation may be so great that the warning signs and symptoms of a major complication may be missed until there are serious consequences, such as a bleeding peptic ulcer or a severe infection. There may be an increased incidence of gastric or duodenal ulcers in corticosteroid-treated patients. Central Nervous System and Behavioral Changes Hydrocortisone stimulates the central nervous system and may cause seizures, especially in children with a seizure disorder. High-dose therapy may induce psychotic behavior, including hallucinations and delusions. Depression or alternately euphoria, insomnia, and agitation may result. Effects cannot be predicted by prior personality qualities. Rarely, increased intracranial pressure develops, resulting in a condition called “pseudotumor cerebri.”

Effects on the Eyes Topical corticosteroid eyedrops are frequently prescribed to treat allergic eye conditions, but they can cause a dangerous increase in intraocular pressure and other serious adverse effects that may lead to blindness. They should be prescribed only after evaluation by a physician well trained in their use. Uses Corticosteroids are mainstays for allergy and asthma treatment and are often lifesaving. In addition, they are effective therapy for arthritis, eye diseases, skin diseases, and many other diseases. Corticosteroids are available by injection, orally, and topically as creams, gels, ointments, lotions, solutions, aerosolized metered-dose inhalers, skin sprays, and nasal sprays. The potential for adverse effects is great with prolonged systematic use. Use of alternate-day dosing can greatly lessen this potential, but not completely. When allergy patients have been stabilized, they are usually candidates for aerosol corticosteroid therapy to prevent attacks by keeping inflammation under control. Corticosteroid nasal sprays play a similar preventive role for nasal allergies. Contraindications to the Use of Corticosteroids In early 1992, the Food and Drug Administration (FDA) warned about the use of corticosteroids in patients not immune to chicken pox (varicella) or other reduced-immunity illnesses. Several deaths have occurred in otherwise normal, asthmatic children who contracted chicken pox while being treated with corticosteroids. These drugs should be used only if no alternative exists. Corticosteroids absolutely must be avoided in the presence of herpes simplex infection of the eyes. They must be used cautiously in patients with coexisting diseases, including diabetes mellitus, hypertension, peptic ulcer disease, osteoporosis, diverticulitis, psychotic conditions, renal insufficiency, and congestive heart failure (except in certain inflammatory conditions such as rheumatic heart disease), and following some recent surgical intestinal procedures. Some references recommend against the use of corticosteroids during pregnancy; however, the use of prednisone should not be

68 coryza spasmodica withheld in patients with asthma and other serious diseases. Use of these drugs in patients with tuberculosis was once considered an absolute contraindication. However, in life-threatening situations they can be used in combination with antituberculosis drugs. WARNING: The risk of using corticosteroids must always be weighed against the risk of not using them.

coryza spasmodica CO2 therapy cough

See

HAY FEVER.

CARBON DIOXIDE INHALATION.

A reaction, or reflex, of the upper respiratory tract to correct an irritation or blockage of the airways. Dust or other particles, fumes, smoke, gases, and viral and bacterial infections cause the sudden, expulsive rumble characterizing a cough. Some coughs, such as whooping cough, create high-pitched sounds, whereas the inflammation of the upper respiratory tract, especially when children have croup, creates a narrowing of the airways and a barking cough. When an object becomes lodged in the larynx, or voice box, the cough mechanism is triggered to help expel the object and stop a person from choking. Coughing is also the body’s way of expelling mucus, phlegm, or other irritant, in which case it is called a productive cough. A dry, or unproductive, cough, which does not result in expulsion of a substance, may be caused by bronchospasm (a sudden narrowing of the bronchi), featured in asthma, allergic reactions, or infection. Causes of chronic coughing include smoking and/or lung disease, a foreign object trapped in a bronchus, and anxiety or nervousness. Other causes of cough include upper airway obstruction or irritation; infections; irritation or structural abnormalities; or other disorders of the epiglottis and larynx such as vocal cord paralysis, polyp, or tumor; tracheomalacia; external compression by lymph nodes, tumor, or vascular ring; intraluminal obstruction by foreign body, mucus plugs, inflammation or tumor; bronchospasm of asthma, chronic bronchitis, or emphysema; cysts; congenital malfor-

mation; inflammation from allergic diseases such as hypersensitivity pneumonitis; interstitial lung diseases; congenital heart disease; congestive heart failure; gastroesophageal reflux; hiatus hernia; edema; hysteria; paralysis; adverse effects of drugs such as the ACE inhibitor antihypertensives (benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, and ramipril) or drug toxicity; smoke from tobacco or fires; noxious fumes or gases; organic dusts containing allergens such as dust mites, animal allergens, industrial allergens, scents in perfumes and household or commercial cleaning agents; aerosol products; cold; humidity; and dryness. Types of coughs include 1) aneurysmal, described as brassy and clanging, as in individuals with an aneurysm; 2) asthmatic, i.e., more closely resembling difficulty breathing; 3) brassy, such as the cough in individuals who have pressure on the left recurrent laryngeal nerve; 4) bronchial, such as that which occurs in individuals with bronchiectasis or bronchitis and is accompanied by the production of sputum; 5) diphtherial, i.e., a brassy cough and labored breathing as a result of laryngeal diphtheria; 6) dry, in which there is no accompanying moisture; 7) effective or productive, which refers to the expectoration of exudates; 8) hacking, such as repeated coughing associated with pulmonary tuberculosis; 9) harsh, referring to the metallicsounding cough heard in patients with laryngitis; 10) moist, or a loose cough that produces mucus or exudates; 11) paroxysmal, i.e., in whooping cough and bronchiectasis patients; 12) pulmonary, i.e., hard, painful coughing such as patients with pneumonia experience; 13) reflex, which refers to a cough that is a result of irritation of Arnold’s nerve, the middle ear, pharynx, stomach, or intestine; 14) uterine, i.e., a reflex cough caused by an irritation of the uterus or other female organ; and 15) whooping, also known as pertussis, described as a paroxysmal cough with a whooping sound made upon inspiration. An antitussive refers to a drug that inhibits or suppresses a cough. See also COUGH, EAR; WHOOPING COUGH.

cough, ear A reflex cough resulting from an ear infection, irritation, or foreign body lodged against the tympanic membrane (eardrum).

cyclosporin 69 cracked pot sound The sound, similar to that of striking a cracked pot, during percussion to diagnose a pulmonary cavity. crackles

Rales or abnormal lung sounds including coarse crackles, which are longer, louder, and low-pitched, and fine crackles, which are soft, short, and high-pitched. See also RALE.

crepitation

A crackling sound, such as a rale heard in pneumonia patients, or the grating sound caused when the ends of broken bones rub against another bone or surface. See also RALE.

crepitus redux A rale or any abnormal sound heard through a stethoscope placed on the chest, that signals the recovery stage in pneumonia patients. See also RALE. cromolyn sodium (disodium cromoglycate, Intal, Nasalcrom, Opticrom) A drug that prevents the release of histamine and other chemical substances from mast cells in the eye, nose, and lungs, therefore preventing allergy symptoms and asthma. This drug is often discarded by patients who underestimate its benefit because it is very slow-acting and requires up to two months to exert its full effectiveness. However, cromolyn is a first-line treatment for respiratory allergies and asthma. It also has almost no side effects and is safe to use during pregnancy.

crossed finger airway technique A technique for removing debris or foreign material from the mouth of a person about to receive cardiopulmonary resuscitation. See also CARDIOPULMONARY RESUSCITATION. croup

A disease characterized by a metallic cough, often described as a “seal-like” bark, with hoarseness that occurs when breathing in. It is accompanied by thick mucus in the nose and throat, dyspnea, laryngeal spasm, and, at times, by

the formation of a membrane. Catarrhal croup refers to acute catarrhal laryngitis. Croup is most commonly caused by a viral infection during infancy or early childhood, and is generally a benign condition. However, when accompanied by high fever, it may be caused by a dangerous bacteria, Haemophilus influenzae. Unless antibiotics are started early, the bacterial form of croup may lead to the life-threatening complication known as acute epiglottis. The less severe forms of croup can be treated by breathing warm, humid air in a steamed-up shower or small bathroom.

crowing A harsh, crow-like sound produced when air is taken into the lungs. Curschmann’s spirals Named for German physician Heinrich Curschmann (1846–1910), coiled spirals of mucus seen frequently in the sputum of asthma patients. cyanosis Blue coloration of the mucous membranes caused by lack of oxygen supply. See also BLUE BABY. cyclic adenosine 3’, 5’-monophosphate (camp, cyclic AMP) A substance whose presence is essential for stabilization of mast cells in body tissues, which along with basophils are responsible for the symptoms of allergy. It is also deficient in asthmatics. Drugs such as epinephrine and theophylline increase camp-inhibiting mast cell degranulation and are useful for the treatment of asthma. cyclosporin An immunosuppressant drug used to prevent or suppress organ transplant rejection. Researchers at the National Heart and Lung Institute in the United States and the Royal Brompton Hospital in London are investigating cyclosporin as an alternative to dangerously high levels of corticosteroids required by the most severe asthma patients. Although some individuals in one study group had a significant improvement in lung function and less frequent acute episodes of asthma, cyclosporin can cause serious

70 cyst, alveolar kidney problems and is still considered experimental therapy.

cyst, alveolar

An air cyst or sac, formed when alveoli (air sacs) in the lungs dilate and rupture.

cystic fibrosis (CF) Among the most common fatal inherited diseases, an autosomal recessive genetic disorder. CF affects the exocrine secretory glands of the respiratory and digestive systems. Often called “sixty-five roses” by children afflicted with the disease, CF’s excessive production of thick, sticky mucus causes a chronic cough, wheezing, and plugging of the bronchial tubes. Trapped bacteria cause recurrent respiratory infections. Mucus also blocks the pancreatic secretion of digestive enzymes, causing malabsorption of nutrients and foul bulky stools, with failure to gain weight and thrive, a common finding in young children. This disorder is often confused with asthma, pneumonia, or other respiratory diseases when symptoms first appear, usually in infancy. Mild cases may escape recognition until adulthood. Gastrointestinal symptoms may be confused with

celiac disease or other disorders. Diagnosis is confirmed by a positive sweat chloride test. Since CF was first recognized as a disease in 1938, it has been estimated to occur in one in 2,000 to one in 1,600 live white births in the United States, but only one in 17,000 blacks. About one in every 20 persons carries the CF recessive gene. Genetic counseling is advisable when a previous pregnancy resulted in CF. Prenatal diagnosis and carrier state of parents can be established by DNA genetic markers. Until recently the prognosis for CF patients was poor, with very few patients surviving childhood. However, newer antibiotics and aggressive physical therapy to help drain the mucus from the airways by a technique called postural drainage, and the use of pancreatic enzymes and nutritional supplements, can greatly improve the outlook. Males generally outlive female patients, with half of patients living past age 21. Respiratory failure is the leading cause of death. The discovery of the CF gene on the long arm of chromosome 7 gives hope for the possibility of a cure for this disease utilizing gene therapy within a few years.

D Chronic Moderate Asthma In this category, asthma symptoms are not controlled by the occasional use of a beta2-agonist. There may also be a frequent need for beta2agonists, possibly more than twice a week. Symptoms in this group may be most apparent at night or, as in mild asthma, may be triggered by the environment or exercise. The lungs function at 60 to 80 percent of the predicted range for a person’s age, sex, and height, indicating a compromise in airway flow. The National Asthma Education Program’s Guidelines for the Diagnosis and Management of Asthma recommends the use of an anti-inflammatory agent in any person with moderate or severe asthma. Anti-inflammatory drugs include inhaled cromolyn sodium or inhaled corticosteroids. These safe and effective medications reduce the frequency and severity of asthma attacks and the need for oral corticosteroids. Nighttime awakening may necessitate the addition of long-acting bronchodilating drugs such as theophylline or albuterol. Occasional short bursts of oral corticosteroids are needed, but not on a daily or frequent basis. Individuals rarely require urgent emergency room visits.

death rattle

A rattling sound, or rale, produced in the throats of patients who are dying. The sound is caused by excess mucus and the absence of the cough reflex.

decompression illness

See

BENDS.

decongestant

A class of drug or other agent that acts against nasal or bronchial congestion. Also known as alpha-adrenergic agonists, decongestants may be used topically as nasal spray or drops, and orally in capsules, tablets, or syrups.

decortication, pulmonary The surgical removal of a segment of surface lung tissue or a pleura. Decortication is used as a treatment, though rarely, for severe pleural effusion when there is difficulty accomplishing the drainage of pus from the area. degree of asthma severity

The ranges or the levels of asthma from asymptomatic to fatal, with the majority of cases described as mild to moderate.

Chronic Mild Asthma Persons with chronic mild asthma have no abnormalities in baseline pulmonary lung tests, or spirometry, between asthma attacks. During attacks, airflow rates fall 20 percent below their predicted normal values. Asthma symptoms are usually triggered by exercise; exposure to irritants or allergens such as pollens, animals, or house-dust mites; or respiratory infections. Treatment prior to exposure is usually effective in preventing symptoms. Inhaled beta2-agonists are usually the only therapy necessary to control attacks, and they are used on an as-needed (PRN) basis only.

Chronic Severe Asthma Individuals whose asthma is not controlled by maximal drug doses and who may be at risk for life-threatening asthma attacks show a pulmonary function less than 60 percent of baseline. Airflow varies widely during attacks. These persons may require long-term use of daily or every-other-day oral corticosteroids. See also ASTHMA; CORTICOSTEROIDS.

demand valve manually cycled resuscitator

A type of resuscitator (trade names include Rober-

72 depressant, respiratory shaw valve and Elder valve) that uses high-low oxygen that is cycled by pushing a button and watching the chest of the patient rise.

depressant, respiratory

dexchlorpheniramine (Polaramine)

An antihistaminic drug used in the treatment of allergic disorders. This drug is moderately sedating and has few side effects.

A drug that lessens the frequency and depth of breathing.

dextromethorphan

depression A neurotic or psychotic disorder characterized by lethargy, loss of interest in socializing, sex, work and other activities of daily living, weeping and/or pervasive sadness, insomnia, inability to concentrate, and other symptoms. When asthma and depression occur simultaneously, both conditions can intensify, according to Nancy J. Rubin, Psy.D., of the University of Alabama School of Medicine in Tuscaloosa. Rubin reported in the American Medical Association’s Archives of Family Medicine that people with depressive disorders or symptoms tend to have physical, social, and role-functioning difficulties comparable to the difficulties of those who suffer from one or more of the eight major chronic illnesses, including lung disease. One association involves the effect of depression on the respiratory system. A depressed person enters a psychological state of nonaction, associated with decreased energy expenditure, decreased ventilation, low oxygen consumption, and skeletal relaxation. These conditions further complicate asthma, a disorder already characterized by compromised ventilation and borderline blood gas values. Another theory involves dysfunctional brain mechanisms associated with depression. One group of researchers speculates that neurotransmitter imbalances found in asthma and depression may combine to worsen both conditions. However, the correlation of brain dysfunctions and asthma is not fully understood. Formal assessment by a mental health professional of the patient with severe asthma is recommended as part of the standard medical assessment.

diaphragm From the Greek word diaphragma, or partition, the musculomembranous structure that separates the abdomen from the thoracic cavity. When a breath is taken in, the diaphragm contracts and moves downward to make room for the lungs to expand. Upon exhalation, it rises to its normal inverted-basin shape. Originating at the sixth ribs (anterior intercostals) and the 11th and 12th ribs posteriorly, the diaphragm is the major inspiratory muscle that helps draw air into the lungs, aids in defecation and childbirth by its capacity to increase intra-abdominal pressure during exhalation with the glottis closed, and its spasmodic activity during hiccoughs or sneezing.

dexamethasone (Decadron) tory derivative of cortisone. See also CORTICOSTEROIDS.

Non-narcotic synthetic derivative of levorphanol similar in structure and effectiveness to codeine as a cough suppressant. Dextromethorphan is found combined with antihistamines, decongestants, and expectorants in many prescription and over-the-counter allergy and cold remedies, including Benylin DM, Delsym, Mediquell, Pertussin, and Robitussin DM. This antitussive (cough-suppressing) drug is the safest available. It rarely causes minor adverse effects, such as mild nausea or dizziness, and is the cough suppressant of choice during pregnancy.

diffusion

The action of gaseous, liquid, or solid molecules of a substance to travel from an area of high concentration to an area of lower concentration.

Dilor

See

DYPHILLINE.

Dimetane

See

BROMPHENIRAMINE.

Dimetapp

See

BROMPHENIRAMINE.

An anti-inflamma-

diphenhydramine (Benadryl)

An antihistaminic drug used to treat the symptoms of allergic rhinitis

disinfectant 73 (hay fever) and urticaria (hives), including sneezing, runny rose, nasal congestion, itchy eyes and pruritus (itching). It is given by injection as a secondary treatment for severe allergic anaphylactic reactions (epinephrine, or adrenaline, must be used as the primary drug in this severe, shock-like, life-threatening condition), which may occur in persons allergic to bee stings or certain foods. Diphenhydramine is also useful as a cough suppressant, for the prevention and treatment of motion sickness, and for parkinsonism. It is widely available topically in creams or lotions for the relief of itching. However, many allergists and dermatologists advise against this use because of frequent adverse effects. The principal side effect is sedation, and it is often prescribed as a nonhabituating hypnotic in the treatment of insomnia.

diphtheria A contagious and sometimes lifethreatening infection by the bacterium Corynebacterium diptheriae spread by moist droplets coughed into the air by an infected person. The microorganism multiplies and causes inflammation in the mucous membranes of the mouth and throat, and certain types of the bacterium produce a toxin that may damage the heart and brain. Because of the effectiveness of the diphtheria-tetanus-pertussis (DTP) vaccine, diphtheria is rare in the United States and other developed countries, with fewer than five cases since 1980. Current instances of the disease have been reported in countries of the former Soviet Union, including Russia. Although anyone may be affected, the disease is mostly seen in children younger than 10. The Schick test, developed by the Hungarianborn pediatrician Bela Schick (1877–1967), determines the degree of an individual’s immunity to diphtheria. The test involves an intradermal injection of 0.1 milliliters of dilute diphtheria toxin, which is one-fiftieth of the minimum lethal dose (MLD) that would kill a small guinea pig within four days. A red, inflamed spot at the site of injection appearing after three or four days indicates a positive test. Little or no reaction to the injection constitutes a negative result and therefore an immunity. Symptoms include a mild sore throat and pain with swallowing, nausea, vomiting, chills, head-

ache, low-grade fever, swollen lymph nodes in the neck, runny nose, laryngitis, difficulty breathing, rapid heart rate, and prostration. In nasal diphtheria, a higher fever is usually present. Also, there may be inflamed adenoids, a blood-tinged discharge from the nose, and bad breath. Named from the Greek diphthera, or membrane, the disease is characterized by the false membrane on a mucous surface and at times affecting the skin. The pseudomembrane appears yellowish-white or gray and adheres to the tonsils or pharyngeal walls. If a child develops mild diphtheria, a pseudomembrane may never appear. Also, diphtheria carriers are able to spread the disease but manifest no symptoms themselves. Treatment involves hospitalization, usually in the intensive care unit (ICU) in order to monitor breathing and heart function, and the intravenous administration of the diphtheria antitoxin, which is made from horse serum. A patient may be allergic to the antitoxin, in which case he or she must be desensitized before receiving the drug. Penicillin, ampicillin, and erythromycin are also used to fight the bacterium. Three consecutive negative cultures after the completion of antibiotic therapy indicate that the bacterium has been eliminated. When the larynx is severely affected and an airway becomes obstructed, intubation or surgery (tracheotomy) may be necessary. Nerve damage may result if the condition is not treated promptly. Diphtheria victims may also develop skin lesions, especially where crowded conditions and poor hygiene prevail, myocarditis (inflammation of the heart muscle) and rarely, disturbances of the eye. Recovery from diphtheria may take many weeks.

diphtheria-pertussis-tetanus toxoid vaccine

See

DIPHTHERIA.

disinfectant

Any chemical that kills bacteria, especially vegetative microorganisms. Examples are chlorine, fluorine, iodine, silver nitrate, sulfurous acids, alkalies, formaldehyde, 70 percent alcohol, salts of heavy metals, cresols, phenol (carbolic acid), benzoic and salicylic acids and their sodium salts, thymol, potassium permanganate, boric acid, chloride of lime, and iodoform.

74 disodium cromoglycate disodium cromoglycate Dittrich’s plugs

which some individuals are predisposed through adverse reaction to routine immunizations and the removal of tonsils, and other nose and throat operations. Bronchopneumonia has been known to develop in rare cases of severe poliomyelitis.

diver’s paralysis

drip, postnasal A discharge flowing from the postnasal region (behind the nose) to the throat, caused by allergic or vasomotor (nonallergic) rhinitis or chronic sinusitis.

See

CROMOLYN SODIUM.

Small particles, named for German pathologist Franz Dittrich (1815–59), made of pus, detritus, bacteria, and fat globules in fetid sputum. See

BENDS.

doxapram hydrochloride (Dopram)

A drug that

stimulates respiration.

drainage, negative pressure

In the treatment of pneumothorax (collapsed lung), the use of a tube promoting negative air pressure (suction) so that excessive or abnormal fluids, blood, pus, or secretions may be drained. A drainage tube is a device that allows those substances to flow out of a wound or abscess.

droplet infection

The result of inhaling infected microorganisms, usually spread by an infected person’s cough or sneeze into the air. The common cold is typically transmitted by droplets.

drops, nose

Any medication or solution sprayed or dropped into the nostrils and nasal cavity.

drowning drainage, postural

The use of gravity to help remove secretions from the nose, bronchi, sinuses, and lungs by placing the patient in a position in which his head is lower than his feet. Tapping or cupping on the patient’s back may also aid in the procedure.

drainage tube

A hollow cylindrical device that may be inserted into the body in order to draw pus, blood, serum, or other fluid out of an area of a wound or infection in which fluid has accumulated. When drainage is required in the chest cavity, the tube is attached to a suctioning device. Typically, chest drainage may also involve the suctioning of air from the pleural space while preventing air from being sucked back in. Chest tubes are inserted into the pleural space for this procedure.

Drinker respirator

The apparatus, commonly known as the “iron lung,” that presses upon a patient’s thoracic area in order to produce alternating positive and negative air, as in the normal breathing process. The device was invented by Philip Drinker, born in 1894, an American engineer in industrial hygiene. The iron lung became widely used for the treatment of poliomyelitis, to

The cessation of breathing and heart function as a result of immersion in water or a spasm in the glottis that stops air or water from getting into the lungs (dry drowning). Near-drowning refers to recovery from severe oxygen deprivation and subsequent lung damage after being underwater for a long time. An individual who is submerged in cold water may survive because of the “diving reflex” such as that discovered in seagoing mammals. Very cold water slows the heart rate and redirects the blood from the extremities and intestines back to the heart and brain. It also cools the body tissues, which then do not require as much oxygen as warm ones do. Victims of near-drowning may, however, experience impaired breathing and abnormal volume and content of the bloodstream well after the actual crisis. Also, submersion in and inhalation of fresh water may have a damaging effect on the lungs, and salt water draws fluid from the bloodstream into the lungs. Treatment includes resuscitation techniques if the victim is not breathing and hospitalization to ensure the reoxygenation of the blood and maintenance of vital signs. Antispasmodic medication may be necessary to keep airways patent. Corticosteroids may be given to reduce lung inflammation, and antibiotics may be necessary in the case of

dyspnea 75 infection. Hyperbaric chamber therapy may be required. Even with modalities to prevent brain damage, some victims of near-drowning sustain permanent neurological impairment. See also CARDIOPULMONARY RESUSCITATION.

duct, thoracic Another term for the left lymphatic duct, or channel, that drains the left side of the body above the diaphragm and the entire body below the diaphragm. dyphylline (Dilor, Lufyllin)

A bronchodilator drug derived from xanthine and related to theophylline, used for the treatment of asthma.

dyspnea Difficulty breathing, also called air hunger, which may be painful and caused by a res-

piratory disorder or extremely strenuous exercise. Cyanosis, or blue coloration, indicates lack of sufficient oxygen in the blood in individuals experiencing dyspnea. Inspiratory dyspnea refers to difficulty breathing because of some blockage or interference with the individual’s ability to take in air. Expiratory dyspnea is usually seen in asthma and bronchitis patients, with wheezing and pain upon exhaling air. A shortness-of-breath attack that occurs at night and awakens an individual is known as paroxysmal nocturnal dyspnea and may be caused by heart failure and pulmonary pressure. In the past, this type of dyspnea was called cardiac asthma, which is erroneous.

E Eaton-Lambert syndrome Named for American physician Lee McKendree Eaton (1905–58) and American physiologist Edward Howard Lambert (b. 1915), a myasthenia syndrome characterized by muscle weakness, hyporeflexia, and autonomic dysfunction, frequently associated with oat cell carcinoma of the lung. See also CANCER, LUNG.

hormones through immunological and enzymatic activity.

Elixophyllin See also

A trade name for theophylline.

THEOPHYLLINE.

embolism, pulmonary

A type of artificial breathing technique in which electrodes providing intermittent electrical stimuli are applied over the phrenic nerves in the neck. This is used for patients with respiratory center injury.

A blood clot or obstruction of a blood vessel in the pulmonary artery or a branch of the artery, usually as a result of thrombosis, or blood clot, in a vein in the leg or pelvis. An embolus may also be an air bubble or consist of fat, amniotic fluid, bone marrow, or a tumor fragment. Anticoagulants such as heparin are used as prophylaxis before and after surgery and as treatment for thrombus formation. Acute dyspnea, chest pain, coughing, anxiety, and rapid breathing are often associated with pulmonary embolism. In addition to dextran (a plasma volume expander) and graduated compression elastic stockings, supplemental oxygen and mechanical ventilation may be required. An embolus may be diagnosed through chest X ray, electrocardiogram, a lung perfusion scan, lung ventilation scan, and pulmonary arteriography. Approximately 10 percent of patients with pulmonary embolism sustain a certain amount of lung-tissue death (also called pulmonary infarction), and large clots may cause sudden death. Treatment of a pulmonary embolism involves oxygen therapy and, if necessary, pain-killing medication, in addition to anticoagulants, thrombolytics (drugs such as streptokinase and urokinase that break up the clot), and surgery (pulmonary embolectomy).

ELISA (enzyme-linked immunoabsorbent assay)

emphysema

ECHO virus

A virus of the group of approximately 30 viruses whose acronym stands for Enteric Cytopathogenic Human Orphan, associated with acute respiratory infection, myocarditis, enteritis, pleurodynia, and nonbacterial viral meningitis.

edema, pulmonary

From the Greek oidema, or swelling, an accumulation of fluid in the lungs as a result of heart failure, in which more blood enters the pulmonary circulation than is released. In general, edema refers to any excessive amount of fluid in body tissues. Laryngeal edema typically occurs along with an anaphylactic allergic reaction that requires prompt treatment before it causes airway obstruction. Edema of the glottis refers to the cough, loss of voice, and feeling of suffocation when the submucosa of the larynx becomes infiltrated with excessive fluid.

electrophrenic respiration

A chronic lung disease named from the Greek word emphysan, meaning “to inflate,”

A method for detecting antigens, antibodies, and

endobronchitis 77 and characterized by difficulty in breathing, especially shortness of breath due to enlarged and damaged air sacs (alveoli) found at the ends of thin-walled air passages called bronchioles. Almost always, emphysema is caused by cigarette smoking; smoke as well as other pollutants stimulate the release of alveolar chemicals, which impede the oxygen and carbon dioxide exchange necessary for normal maintenance of the body’s metabolism. The lungs become progressively inefficient, which may result in pulmonary hypertension (increased blood pressure in the pulmonary artery), cor pulmonale (enlargement and/or failure of the heart’s right ventricle), edema (swelling due to excess fluid in the tissues), and chronic bronchitis (inflammation of the bronchial tubes). In mild cases this disorder may be confused with asthma. Symptoms of emphysema may not emerge until the disease is well under way. Initial signs include shortness of breath on exertion, such as climbing stairs, which gradually worsens until a person is short of breath even at rest. The chest may become barrel-shaped because air becomes trapped outside the lungs and pushes out the thorax. Coughing and wheezing may be present, too. When cor pulmonale develops, oxygen deficiencies cause edema of the legs, and a person looks blue or purplish. These persons are called “blue bloaters.” Individuals who breathe rapidly but retain normal coloring are referred to as “pink puffers.” In advanced emphysema, breathing becomes increasingly difficult. Chest X rays and pulmonary function tests determine the extent of the lung damage and breathing capacity. Emphysema is one of the causes of chronic obstructive pulmonary disease (COPD), which affects approximately 14 million people in the United States, second only to heart disease that results in disability. Treatment includes bronchodilating, diuretic, and corticosteroid drugs, nebulizers, and oxygen administration. In addition, patients are advised to avoid air pollutants, stop smoking, prevent respiratory infections with good pulmonary hygiene, lose weight if obese, improve nutritional status, and increase oral fluid intake. Smaller meals help reduce pressure on the diaphragm, which makes it easier to breathe. Breathing exercises also may

help to increase breathing efficiency and expiratory functional capacity, keep small airways patent, and educate the patient on the dangers of increased oxygen intake and other proper procedures in relation to ventilation therapy for hypoxic drive. See also CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

employment opportunities for individuals with allergies and asthma Occupations or professions in which persons afflicted with allergic disorders or asthma can function in an environment free from occupational allergens or pollutants. An example of an inappropriate choice for an asthmatic person might be a zookeeper, pet shop employee, veterinarian, or farmer. See also OCCUPATIONAL ASTHMA.

empyema A type of pleural effusion, the presence of pus in the pleural space that occurs when pneumonia or a lung abscess spreads into the space. Other causes of empyema are an infection from a chest wound or surgery, esophageal rupture, or an abdominal abscess. Thoracic empyema, i.e., caused by the pus-forming pneumococci, may require surgical drainage. Pus in the pleural cavity, also called pyothorax, stems from a primary infection and may involve chills, fever, gray, sweaty skin, poor appetite, chest pain, cough, emaciation, and dyspnea. Treatment of the primary infection is key. Interlobular empyema refers to pus occurring between the lobes of the lung. E-Mycin

See

ERYTHROMYCIN.

encephalitis

An inflammation of the brain that may be a result of influenza or other diseases, including rabies, measles, smallpox, and viral infections. Treatment consists of therapy for the primary cause and physical and emotional support of the patient, such as monitoring vital signs, hydration, motor function, sleep patterns, and behavior.

endobronchitis bronchi. See also

Inflammation of the smaller

BRONCHITIS.

78 endotracheal tube endotracheal tube A tube with an inflated cuff surrounding it placed in the trachea, or windpipe, to prevent aspiration of a foreign substance or object into the bronchus and to keep the airway patent. endotracheitis

An inflammation of the mucosa

of the trachea.

ephedrine (Ephedrine, Ephedrine Sulfate, Neorespin) A sympathomimetic drug, similar to adrenaline but less powerful, that dilates bronchial muscles, contracts nasal mucosae, and elevates blood pressure. In the past, ephedrine was important in the treatment of asthma. An alkaloid originally derived from a species of Ephedra, a genus of shrubs, it was used in ancient Chinese medicine as an antipyretic (fever reducer) and diaphoretic (perspiration or sweat inducer). Later, its actions were rediscovered, and it was produced synthetically for oral or parenteral administration. Side effects may include tremors, anxiety, insomnia, headache, dizziness, confusion, hallucinations, convulsions, central nervous system depression, palpitations, dyspnea, nausea and vomiting, urinary retention, and chest pain. epidemic A massive outbreak of an infectious disease in a particular geographical area. epiglottitis

An inflammation of the epiglottis, a slender, leaf-shaped, cartilaginous structure with an outer mucous membrane at the opening of the larynx, or voice box. When a person swallows, the epiglottis covers the larynx to prevent food or liquid from entering the airway. The inflammation, commonly experienced as a sore throat, fever, and a barking cough, may lead to cyanosis (blue coloration of skin), drooling, and coma, and may be fatal. In extreme cases, a tracheostomy may be necessary to reopen the airway. Treatment includes antibiotic therapy.

epinephrine (Adrenalin Chloride, Asthma Haler, Asthma Nefrin, Bronitin Mist, Bronkaid Mist, Epinal, Epinephrine HCl, Epinephrine Pediatric, Epipen Jr., Epitrate, Eppy/N, Glaucon, Medihaler-Epi, Micro-

Nefrin, Nephron Inhalant, Primatene Mist, S-2 Inhalant, Sus-Phrine, Vaponefrin) Also called adrenaline, one of the two active hormones, along with norepinephrine, produced by the adrenal glands, which sit on top of the kidneys (hence the combination of the Greek words epi, meaning upon, and nephros, or kidney). Epinephrine has long been used as a vasoconstrictor, especially to prolong the action of local anesthesia, a cardiac stimulant, a topical application for the eye, a bronchiolar relaxant, and as a treatment for asthma attack.

epipharynx

The portion of the pharynx, or throat, that connects with the nose. Another term for epipharynx is rhinopharynx.

episodic asthma

Symptoms of asthma occurring only sporadically, such as during an acute upper respiratory infection, or cold, or upon exposure to a specific trigger. In the interim, there is no shortness of breath or wheezing, and lung function studies are normal.

epistaxis

A nosebleed, or hemorrhage from the nose, caused by trauman to membranes or structure of the nose or by skull fracture, various diseases, and high altitudes. It may also occur after surgery. Allergy and asthma patients may suffer nosebleeds as a result of violent, repeated sneezing, picking or blowing the nose, or dryness of the mucous membranes. Rhinitis and sinusitis may also cause epistaxis. To treat a nosebleed, have the patient sit upright and help him or her lean forward to spit out blood in order to prevent nausea and vomiting swallowed blood and to prevent aspiration of fluid into the trachea. Pinch the nostrils against the nasal septum for five to 10 minutes while the patient breathes through the mouth. Cold compresses applied over the nose and at the nape of the neck and applying pressure across or under the upper lip may be helpful. Other treatment includes local epinephrine use; if required, balloon tamponade, posterior packing of the nasal cavity, and cauterization of the bleeding vessel are also treatments. Increased humidity may help if dryness caused the nosebleed.

exercise-induced asthma 79 Epstein-Barr virus

Named for English pathologists M. A. Epstein (b. 1921), and Y. M. Barr (b. 1932), a type of herpesvirus thought to be the cause of infectious mononucleosis. Discovered in 1964, the virus is also associated with Burkitt’s lymphoma in South African children and nasopharyngeal carcinoma in Asian populations. The Epstein-Barr virus first affects cells in the nasal lining and spreads to the white blood cells called B lymphocytes that produce antibodies. Infectious mononucleosis has been known to be common among teenagers and young adults, who come in contact with the virus by kissing or intimate relations with an Epstein-Barr–infected individual, hence the term “the kissing disease.” Approximately 50 percent of all children in the United States have had an Epstein-Barr virus infection before the age of five, and the virus affects people of all ages. Symptoms of infectious mononucleosis include fever, sore throat, and enlarged lymph nodes. Also associated with the disease is a pronounced fatigue, which may last for weeks or months. The spleen and liver may become enlarged, a skin rash may develop, and serious complications such as encephalitis, seizures, meningitis, nerve and behavioral abnormalities may require further treatment. Sometimes an enlarged lymph node may press on the airway; lung congestion may also develop but may not cause symptoms. The Epstein-Barr virus has been suspected of causing chronic fatigue syndrome, a debilitating disorder that affects adults between 20 and 40 years of age, but it has not been proven. Treatment frequently includes antibiotic therapy and rest. In the case of a severe swelling of the airway, a corticosteroid may be prescribed.

esophageal obturator airway A tube that is inserted into the esophagus to block vomitus and keep the airway patent for optimal lung ventilation. ethmoiditis

An acute or chronic inflammation of ethmoid cells (the air cells or space in the ethmoid bone, which open into the nasal cavity) accompanied by headache, pain between the eyes, and a nasal discharge.

eupnea

Normal breathing.

exercise-induced asthma

The onset of coughing, wheezing, shortness of breath, and a feeling of tightness or pains in the chest following exercise. Exercise endurance is limited and should be anticipated in all asthma or respiratory disorder patients. Symptoms usually begin after three to five minutes of strenuous exercise. They may be minimal, occurring only with extremes of effort, or severe enough to require emergency treatment. The presence of cold weather, air pollution, hay fever-causing pollens, or a coexisting cold or sinus infection may lessen the degree of exercise needed to cause symptoms. Although the exact cause of exercise-induced asthma is unknown, it is thought by experts to be related to water loss from the bronchial tubes and increased concentration of the remaining fluid in the lining of the bronchi, provoking smooth muscles in the airways to constrict. Well-conditioned athletes may experience symptoms only at the extremes of their abilities; however, even Olympic medal-winning athletes often require asthma drugs to restore their breathing to normal. Diagnosis is suggested by a history of the symptoms. Exercise-induced asthma is confirmed by a decrease of at least 15 percent in lung function after an exercise challenge. Lung function can be documented by using either an inexpensive peak flow meter or a more sophisticated computerized spirometer. Swimming, downhill skiing, gymnastics, and karate are sports less likely to trigger asthma, but some well-known professional football and basketball players have asthma. The use of two or three puffs of a beta-agonist bronchodilator metered-dose inhaler (MDI), such as albuterol, pirbuterol, terbutaline, and metaproterenol, or two to four puffs of the anti-inflammatory drug cromolyn sodium 10 to 15 minutes before the start of exercise will prevent exerciseinduced asthma in the majority of patients. Alternative drugs include the MDI ipratropium, an anticholinergic (two to three puffs 20 to 30 minutes before exercise), or albuterol; metaproterenol syrup, astemizole, or terfenadine one hour before exercise may be effective. Albuterol and cromolyn are often combined for resistant individuals.

80 expectorant Allergy and lung specialists urge the participation of all students and adults in exercise programs. Students should be excused from gym classes only if they are having symptoms on the day of activity and should not be given blanket excuses. See also ASTHMA.

expectorant

A substance or agent that stimulates the ability to remove bronchopulmonary mucus from the lungs, bronchial tubes, and throat. Expectorants may be sedative or stimulating. Ammonium carbonate and ammonium chloride are rarely used today, but they were frequently found in cough medicines. Guaifenesin (Robitussin), iodinated glycerol (Organidin), and ipecac may be used alone or in combination with cough suppressants. Proof of their effectiveness has been questioned by some experts.

expectoration

The act of ridding the mouth of saliva or the throat of sputum, mucus, or exudates from the bronchi or lungs by spitting.

expiration

Breathing out, or expelling air from the lungs. A duration of expiration, or exhalation, longer than inspiration may indicate emphysema, asthma, or other respiratory pathology. In active expiration, one uses muscles including those of the abdominal wall. Passive expiration occurs without muscular effort, but rather with the elasticity of lung and chest tissues and the weight of the chest wall.

expiratory center

Part of the medulla’s respiratory center in the brain that controls expiratory movements.

exsufflation The expulsion of air from the lungs that is accomplished by natural force or mechanical exsufflator. extracorporeal membrane oxygenator Known as an ECMO, a device outside the body that oxygenates blood and returns it to the body, particularly in patients suffering acute respiratory failure.

F face (cyanotic; flushing)

faucitis

The visage of a person suffering from respiratory or other disorders, either cyanotic (blue) or flushing (pink or red). Cyanosis indicates deficient oxygenation of the blood, such as in the case of asthma, whooping cough, pulmonary tuberculosis, croup, tracheal obstruction, asphyxia, drug poisoning, emphysema, or cardiac maladies. Flushing, or hyperemia, is often attributable to pulmonary tuberculosis, alcoholism, febrile, and other diseases. A swelling of the face from edema is seen in cases of pneumothorax, mediastinal tumors, and aneurysm. See also EDEMA, PULMONARY.

Inflammation of the fauces, or the constricted opening that leads from the mouth to the throat.

fexofenadine (Allegra)

Metabolite, or derivative, of the popular nonsedating antihistamine Seldane. Unlike Seldane, fexofenadine bypasses the liver and avoids the drug interactions that can cause potentially life-threatening heart irregularities. Allegra is effective for the treatment of sneezing, runny noise, itching, and other allergy symptoms.

fibrosis, pulmonary

Abnormal scar tissue that forms in the connective tissue of the lungs as a result of an inflammation, pneumonia, or pulmonary tuberculosis. The most common causes include the inhalation of dusts, such as silica, carbon, metal, asbestos, molds, and bird droppings; immune system disorders such as rheumatoid arthritis, scleroderma, systemic lupus erythematosus, and polymyositis; inhalation of gases, fumes, and vapors, especially chlorine and sulfur dioxide; therapeutic or industrial radiation, and drugs and poisons, including gold, methotrexate, sulfonamides, penicillamine, cyclophosphamide, busulfan, nitrofurantion, amiodarone, and paraquat. Idiopathic pulmonary fibrosis refers to an unknown cause of scarring in the lung, but symptoms and diagnosis may be determined by the extent of the lung damage, the disease process, and the manifestation of complications such as infection or heart failure. Coughing, loss of stamina, shortness of breath, weight loss, loss of appetite, fatigue, chest pain, cyanosis, and finger clubbing may develop. Chest X ray, arterial blood gas tests, and pulmonary function tests may confirm the condition of fibrosis. If the scarring is not too

failure, respiratory The inability of the lungs to function because of a disease of the lung tissue, or weakness or paralysis of the muscles of the respiratory system. falling drop

A clinking sound heard during auscultation with a stethoscope over large cavities in which there is air or fluid, such as in hydropneumothorax.

farmer’s lung A pneumonia-like allergic lung disease from exposure to bacteria-like microorganisms called actinomycetes. These organisms thrive in silos when the water content of the hay exceeds 28 percent. Emptying a silo often causes an attack. See also PNEUMONITIS. fascia, endothoracic

The fibrous membrane separating the pleura of the lung from the diaphragm and the inside of the chest, or thoracic, cavity.

82 fibrothorax extensive, a corticosteroid such as prednisone may be prescribed, along with oxygen therapy, medication to treat infection if necessary, and drugs for heart failure. In severe cases of fibrosis, lung transplantation may be an option. Variants of idiopathic pulmonary fibrosis include desquamative interstitial pneumonia and lymphoid interstitial pneumonia (which involves the lower lobes of the lung and may be secondary to HIV infection in children and adults). Both variants have been known to respond to corticosteroid therapy.

fibrothorax The development of scar tissue that causes the two pleural surfaces of the lung to stick to each other. fistula, pulmonary arteriovenous The congenital condition in which a fistula, or abnormal channel between an artery and a vein, forms in a pulmonary artery in the lung and then communicates with a pulmonary vein. The connection of the two vessels causes blood to bypass the oxygenation process. An arteriovenous fistula may also be acquired after birth, or as a result of an injury to an artery and vein in close proximity to one another. It may also be subsequent to kidney dialysis or other medical treatment in which a vein is pierced repeatedly and clotting and scar tissue develop. Small congenital fistulas can be excised surgically or destroyed by laser coagulation therapy; large acquired fistulas, which can cause heart failure if untreated, must be surgically corrected. flames, inhalation of Severe irritation of the nose, throat, windpipe, and lungs as a result of exposure to flames or smoke. Coughing, choking, difficulty breathing, facial and nasal burns, elevated carboxyhemoglobin, and shock are among the initial symptoms that may lead to adult respiratory distress syndrome (ARDS), pulmonary complications, upper airway obstruction, and carbon monoxide poisoning. flatness

Heard on auscultation with a stethoscope, the sound produced by the presence of fluid in the thoracic cavity.

flint disease

Also known as chalicosis, a type of pneumoconiosis resulting from the inhalation of dust from stone cutting. See also CHALICOSIS; PNEUMOCONIOSIS.

Flonase

Brand of fluticasone, a corticosteroid for topical use as a nasal spray for the prevention of nasal allergy symptoms.

Flovent Brand of fluticasone, a corticosteroid for topical use as a metered-dose inhaler for the prevention of asthma symptoms. It is available in three strengths. flow meter

A device that measures the flow of a liquid or gas, including the respiratory gases oxygen and carbon dioxide.

Floyer, Sir John

British physician (1649–1734) who designed a 60-second pulse watch that made it possible to study the pulse and respiratory rates as they are affected by sex, age, emotional state, temperature, climate, diet, drugs, and disease. Floyer also estimated blood volume according to an individual’s body weight. An asthmatic, Floyer wrote of his increased difficulty in breathing in the presence of tobacco smoke, dust, and other changes in the air as a sequel to ingesting certain foods, performing exercise, and experiencing emotional changes. Floyer is credited as the first to observe that asthma and predisposition to asthma are hereditary. In addition, he dissected a “brokenwinded mare,” and his findings provided the first description of a lung physically deteriorated by emphysema.

flunisolide (Aerobid, Nasalide) A corticosteroid for topical use as a nasal spray and metered-dose inhaler for prevention of nasal allergy symptoms and asthma. fluticasone (Flonase, Flovent) Corticosteroid for topical use as a nasal spray and metered-dose inhaler for the prevention of nasal allergy and asthma symptoms. flu vaccine

See

INFLUENZA.

fumes 83 forced expiratory time (FET) The amount of time one needs to strongly exhale a certain volume of air, called the forced expiratory volume (FEV). Spirometers are the devices that measure lung volumes and flow rates during forced breathing tests for the diagnosis of laryngeal or tracheal blockage, and other abnormalities. formaldehyde

A poisonous, foul-smelling, colorless gas that when dissolved in water is used as a preservative for animal tissues. Formaldehyde is found in abundance in our environment. Also a by-product of the combustion of gasoline and diesel, and from cigarette smoke, gas, wood stoves, and kerosene heaters in the home or workplace, this gas is an irritant to the respiratory system. Formaldehyde is also widely used in building materials, especially in mobile homes. Urea formaldehyde foam insulation was injected into the walls of homes until 1977, when it was replaced by safer materials. Plywood, molded plastics, and carpeting are additional sources of formaldehyde. It has been blamed as a cause of the strange symptoms referred to as “mobile home syndrome.” Although there is no evidence that formaldehyde causes allergy, it is a frequent cause of contact dermatitis.

4-Way Nasal Spray

A topical, vasoconstricting drug generically known as naphazoline hydrochloride. Other trade names are Privine HCL, Albalon Liquifilm, and Vasocon.

fraction of inspired oxygen

Abbreviated as FiO2, the percentage of oxygen in the air taken into the lungs. More than 50 percent oxygen indicates toxicity in air provided to patients through ventilation devices for extended periods of time.

Freeman, John

British physician (1877–1962) who investigated tests for immunity and contributed to the development of therapeutic immunization. He served as director of the clinic for allergic disorders and bacteriological services at St. Mary’s Hospital in London for many years. Freeman also published Hay Fever, a Key to the Allergic Disorders, which he dedicated to his colleague Leonard Noon, who died from tuberculosis.

fremitus Tremors or vibrations in the chest that can be felt by placing a hand on the chest. Tactile and vocal fremitus refers to vibrations felt through the chest wall of a person who is speaking, and tussive fremitus may be felt when a person coughs. This type of auscultation may help determine the symptoms of pleural effusions, emphysema, abnormal growths on the lung, and obstruction in a bronchus that may lead to collapse of the lung. friction rub, pleural The sound produced during respiration by inflamed pleural surfaces, frequently heard on auscultation of patients who have a newly developed pleurisy. Friedländer’s bacillus

Named for German physician Carl F. Friedländer (1847–87), the Klebsiella pneumoniae, a species of bacteria that causes pneumonia and is also known as a secondary invader in conditions including bronchitis and sinusitis.

fumes

Irritating vapors, such as smoke fumes and ammonia gas, that may cause sneezing, coughing, choking, tightness in the chest, and shortness of breath or trigger an attack in an asthmatic person.

G ganglia, thoracic The eleven or twelve sympathetic nervous tissue masses located in the thorax or chest.

gastrointestinal reflux and asthma A flow of acidic gastric juices from the stomach into the esophagus (also called heartburn or reflux esophagitis) because the muscle at the junction of the esophagus and stomach does not function well enough to keep the stomach contents from backing up into the esophagus or the throat. The juices may also flow into bronchial tubes and cause asthma symptoms or aggravate preexisting asthma. One of the adverse effects of theophylline, an effective, widely used drug for the treatment of asthma, is reflux esophagitis. Drugs used to treat reflux esophagitis include Tagamet and Zantac. However, Tagamet may increase blood levels of theophylline and therefore should be avoided in patients for whom theophylline products are prescribed.

gas, lung irritant

Chlorine, phosgene, and other gases that cause burning sensations in the eyes, nose, and throat and may trigger asthma or cause bronchitis and pneumonia.

gas, suffocating

Phosgene or diphosgene, or any gasses made with chlorine that cause severe irritation of the bronchi and lungs. Inhalation of these so-called war gases may result in pulmonary edema and other respiratory disorders.

gas exchange, impaired

See

ARTERIAL BLOOD

GASES.

gastropulmonary A term used to denote any condition or concern involving both the stomach and the lungs.

gasoline poisoning The toxic result of inhaling gasoline, a distillation of petroleum that may contain poisonous additives such as tetraethyl lead or tricresol phosphate. Some people are poisoned by gasoline during an attempt to siphon the substance from a gas tank by suctioning it through a tube. Putting the suctioning end of the tube in one’s mouth may lead to inhalation or swallowing the gas. Symptoms include headache, nervousness, dyspnea, cyanosis, pulmonary hemorrhage, and other disturbances. Treatment involves getting the victim into fresh air, administering oxygen and carbon dioxide, or cardiopulmonary resuscitation if necessary, removal of gasoline-soaked clothing, and cleaning of gas-contaminated skin. Every precaution should be taken to keep the victim away from sparks, open flames, or potential explosive substance or circ*mstance.

gating, respiratory

A radiological procedure that attempts to reduce image discrepancies that may be caused by involuntary movement, such as during a certain stage of the respiratory process. Respiratory gating refers specifically to images collected repeatedly during a patient’s respiration cycle.

general adaptation syndrome (G.A.S. syndrome) The body’s overall response to stress as described by Austrian-Canadian endocrinologist Hans Selye (1907–82). Selye noted that the response consists of three stages, the alarm reaction (also known as “fight or flight”); the resistance or adaptive stage; and the exhaustion stage. A consequence of the exhaustion stage may be the body’s inability to

granulomatosis, Wegener’s 85 fight disease, and certain types of asthma may manifest. See also ASTHMA.

glands, bronchial

Mixed glands, i.e., glands that produce both a clear, watery (serous) secretion and a viscous (mucous) secretion, located in the submucosa (connective tissue) of the bronchi and bronchial tubes.

glossitis From the Greek glossa, meaning tongue, an inflammation of the tongue causing symptoms that may include tenderness, pain, localized ulcers, swelling, burning, dark and furry patches, intensified sensitivity to certain foods, elevated temperature, edema, thickened saliva, and malaise. In the case of acute glossitis, edema in the tongue may lead to asphyxia, for which a tracheostomy may be necessary to create an airway. Glossitis is frequently treated with antiseptic mouthwashes, anesthetic oral solution, bland or liquid diet, and, if necessary, surgery. glossopharyngeal breathing

Taught to patients with inspiratory muscle weakness, a breathing technique in which one takes “gulps” of air and closes his or her mouth in order for the gulped air to reach the lungs. This technique increases the patient’s air intake.

glucocorticoids, inhaled

Named from the Greek gleukos, or sweet, and cortex, or shape, a class of adrenal cortical hormones that combat stress and promote protein and carbohydrate metabolism.

glue sniffing

The act of deliberately inhaling the fumes of glue or solvent chemicals such as benzene, toluene, and xylene for the effect of an altered state of consciousness. The practice can be fatal. See also INHALANT ABUSE.

hemosiderosis—characterized by bleeding into the lungs and eventually failure of the kidneys and respiratory system. The cause of Goodpasture’s syndrome, which typically affects young men, is unknown, but it has been established that in individuals with the syndrome, certain antibodies appearing in the filtering apparatus of the kidneys and of the lungs’ alveoli and capillaries are responsible for causing the deleterious inflammation and malfunction of those organs. Considered an allergic disorder, Goodpasture’s syndrome causes the presence of protein and blood in the urine, abnormal areas in both lungs, a specific pattern of antibodies in kidney tissue, anemia attributable to the rapid loss of blood, shortness of breath, and coughing up blood. Treatment includes high intravenous doses of corticosteroids and cyclophosphamide, removal, cleaning (of undesirable antibodies), and return of blood to the circulation, supplemental oxygen, blood transfusions, renal dialysis, and possibly kidney transplant. Early treatment is essential to prevent permanent damage to the kidneys and lungs.

goundou

An African word referring to the enlargement of nasal bones as a result of yaws or syphilis infection. Other colloquial descriptions of the condition include “big nose” or “dog nose.”

grain allergies

Symptoms of allergy caused by allergens found in flour, often leading to occupational asthma in up to 10 percent of bakers or those exposed to flour on a regular basis. See also OCCUPATIONAL ASTHMA.

Grancher’s disease Named for French physician Jacques J. Grancher (1843–1907), a disease known also as splenopneumonia. Splenization refers to any change in tissue, such as lung tissue, that creates a resemblance to tissue of the spleen. Grancher’s sign, heard on auscultation of the lungs, is the high-pitched murmur that occurs when a patient with Grancher’s disease exhales. See also PNEUMONIA.

Goodpasture’s syndrome

Named for American pathologist Ernest William Goodpasture (1886– 1960), a rare, often fatal disease—also known as progressive glomerulonephritis, hemoptysis, and

granulomatosis, Wegener’s

Named for F. Wegener, a German pathologist of the 20th century, a rare and potentially fatal disease that involves

86 grass pollen allergy inflammation of blood vessel walls of the sinuses, nasal passages, lungs and airways, kidneys, and skin. In some cases, only respiratory system structures are affected. The inflammation may be so severe that lung tissue is at risk of being destroyed. The vasculitis (swelling and inflammation of the vessel walls) is accompanied by granulomatous lesions throughout the respiratory tract and by glomerulonephritis, a kidney disorder. Granulomas are grain-like tumors that factor into the disease, affecting the skin and the other organs. Possibly attributable to allergic reactions but generally of unknown cause, Wegener’s syndrome may or may not be evidenced by symptoms including fever, fatigue, weight loss, shortness of breath, chest pain, coughing, purulent rhinitis, sinusitis, polyarthalgia, nasal septum ulcerations, and signs of renal dysfunction. After early diagnosis by chest X ray showing areas of the lung that appear to be cancerous, the syndrome is treatable with cyclophosphamide (an immunosuppressive drug) and corticosteroids, or, if there are intolerable side effects from the cyclophosphamide, with azathioprine. Untreated or not treated promptly, the disease may cause death within a year of detection.

grass pollen allergy Hay fever symptoms related to the seasonal exposure of more than 4,500 plant species of the family Gramineae in North America and approximately 9,000 grass species worldwide. Grasses cover roughly 20 percent of the world’s surface. These monocotyledonous, herblike, mostly anemophilous (having windborne pollen) plants reach their peak of pollination in temperate climates of North America from mid-May to mid-July. In tropical and subtropical regions, however, pollens may be present throughout the year. The grass flowers are open for only a few hours a day during the pollinating season. The pollen grains are viable for less than one day. A majority of hay fever sufferers experience symptoms when there is a concentration of pollen grains approaching 50 per cubic meter. The weather is largely responsible for pollen counts, with rain washing the air clean and higher winds blowing the pollens away. See also HAY FEVER.

green tobacco sickness

A nonallergenic, toxic disorder occurring in tobacco harvesters from absorption of dissolved nicotine from wet tobacco exposure. See also TABACOSIS.

grindelia

An American flowering, resinous herb known as gum weed whose dried leaves and stumps are used in making a remedy for bronchitis as well as a topical preparation for poison ivy rash.

grinders’ disease grippe

See

SILICOSIS.

INFLUENZA.

growing out of allergies and asthma Disappearance of childhood allergic symptoms and asthma upon reaching puberty. Generally the more severe the symptoms in childhood, the more likely the continuance during adolescence and adulthood. Usually the tendency for hyperreactivity of the airways remains for a lifetime, although often there are no symptoms. The tiny bronchioles of infancy widen profoundly with age, and therefore a greater triggering stimulus is required to cause wheezing or shortness of breath. British studies have established that most asthma begins during childhood. As many as 11 percent of all children experience asthma symptoms at least once. Eighty-five percent, or the vast majority, have mild asthma, and 50 percent stop wheezing once they achieve adulthood and almost all have milder attacks. Children, whose asthma develops after the age of six months and who do not have allergies, have the best chance to outgrow their asthma tendency by adulthood. guaifenesin (Robitussin)

An expectorant drug used singly to loosen thick mucus or to help expel mucus and in conjunction with cough suppressants.

Guillain-Barré syndrome

Named for French neurologists Georges Guillain (1876–1961) and J. A. Barré (1880–1967), a type of polyneuritis allegedly caused by an autoimmune attack of the

gustatory rhinitis 87 nerves’ myelin sheath. Severe weakness occurs in the muscles that support the respiratory system, and a respirator or tracheostomy may be necessary to sustain the life of the patient. The prognosis is good provided there is prompt and appropriate treatment, which includes corticosteroids, immunosuppressive drugs, physical therapy, plasma-

pheresis, infusion of autoimmune globulin, and other measures.

gustatory rhinitis

The nasal congestion and inflamed mucous membranes that follow smelling or tasting a substance to which an individual may or may not be allergic.

H Habitrol

See

hacking cough See also

ijuana cigarettes (joints). Despite its reputation for inducing euphoria and intensified perception, frequent smoking of marijuana can cause bronchitis, lung cancer, and any disorder caused by using cigarettes made from tobacco. Although marijuana has not been conclusively proven to be physically addictive, it may cause psychological dependence and lead the user toward addiction to other illegal drugs. See also CANNABIS; TOBACCO.

NICOTINE PATCHES.

A dry and recurrent cough.

COUGH.

Haemophilus influenzae

See

INFLUENZA.

Haemophilus influenza type b infections

See

INFLUENZA.

halitosis

See

BREATH, BAD.

hay fever A common name for allergic rhinitis or nasal allergy, also known as coryza spasmodica. The term originated in England when symptoms were observed as they occurred simultaneously with the harvesting of hay. However, exposure to hay does not usually produce the characteristic sneezing, runny and stuffy nose, or itchy, watery eyes, and does not cause fever. Seasonal hay fever occurs in the spring and fall with exposure to pollinating trees, grasses, and weeds in susceptible persons. Perennial hay fever affects some allergic individuals and occurs year-round from exposure to animal danders, house-dust mites, and molds. An estimated 22 million Americans suffer from seasonal allergies and spend approximately $225 million for 8.4 million doctor visits and testing, $300 million on prescription drugs, and $2 billion on over-the-counter medications. These individuals suffer six million days of bed rest, 28 million days of restricted activity, 3.5 million days out of work, and 2 million lost school days. A Type I hypersensitivity reaction also known as pollinosis and vasomotor rhinitis, this disease of the nasal mucosa and upper airways may also be caused by airborne fungus spores. Coughing and asthmatic symptoms may occur. In addition to

Hamman-Rich syndrome

Named for American pathologists Louis Hamman (1877–1946) and Arnold Rich (1893–1968), another term for idiopathic pulmonary fibrosis. See also FIBROSIS, PULMONARY.

Hamman’s disease Named for American pathologist Louis Hamman (1877–1946), another term for spontaneous mediastinal emphysema. See also EMPHYSEMA. Harrison’s groove Named for British physician Edwin Harrison (1779–1847), a groove or depressed area of the lower chest caused by the pulling of the diaphragm, usually seen in infants afflicted with an airway obstruction or rickets. hashish

The Arabic word for the extract of the female hemp plant, Cannabis sativa, to be smoked or chewed for its mind-altering effect. The gummy, concentrated resin extract is made from the plant’s flowers, stalks, and leaves. Also called “hash” and “charas,” the substance is often used to make mar-

hemithorax 89 treatment by antihistamine or corticosteroid medication in the form of nasal sprays, nose drops, pills, or liquid, the patient may benefit from air-filtration systems, air masks, nasal filters, removal of the irritating allergen, and, if required, hypersensitivity testing and desensitization. See also BOSTOCK, JOHN.

headache, histamine

Headache that appears to be a direct result of histamine given by injection or ingested through certain wines containing histamine. See also HISTAMINE.

heartburn

A burning pain typically arising between the esophagus and stomach and possibly radiating through the chest, neck, and throat often as the result of gastroesophageal reflux disease (GERD). Nearly one-third of the American population suffers from GERD, the backward flow of the stomach’s contents into the esophagus. The lower esophageal sphincter valve, the muscle at the base of the esophagus and stomach that is supposed to block food from getting back into the esophagus, may be weak in individuals with GERD, though anyone may experience occasional heartburn. Also, GERD patients may be breathing in gastric fluids that irritate the lungs, and in addition to heartburn, they may have asthma. Heartburn, indigestion, and regurgitation may trigger asthma. Heartburn is usually treated with antacids and lifestyle modifications, but there is a surgical option for those with severe heartburn called Nissen fundoplication, in which the upper portion of the stomach is wrapped around the esophagus to create a new sphincter valve and thus reduce reflux.

throat or windpipe. The three basic steps of the maneuver are: 1) standing behind the victim and putting your arms around his waist; 2) making a fist with one hand and putting it between the victim’s navel and rib cage while the other hand supports the intended thrust of the fist, and 3) pressing with the fist with a quick and forceful upward thrust, to create a burst of air pressure that will send the blockage out the victim’s mouth. This technique should be used only if a person is choking. The name “Heimlich sign” has been given to the natural instinct of a choking victim to grasp his throat with the thumb and index finger. In the event that the victim is alone, he may thrust the midsection of his body (between navel and rib cage) against a counter top, chair, table, or other strong, stable object to simulate the thrust a rescuer would provide. Most adults can effectively use the back of a chair to press against for self-administration of the Heimlich. The maneuver may also be performed if the victim is lying on his back. Instructions for the Heimlich maneuver are usually posted in restaurants and other public places and are available through most local first-aid squads.

Heiner’s syndrome A chronic lung disease, characterized by cold-like symptoms, caused by allergy to cow’s milk. Hypoventilation, that is, the reduction of the rate and depth of breathing, may occur in conjunction with other respiratory disorders, such as chronic obstructive lung disease, and with various obstructions in the respiratory tract. Less severe blockage may occur as an allergic reaction to cow’s milk. The condition usually improves with the elimination of cow’s milk protein from the diet. See also HYPOVENTILATION SYNDROME.

heart-lung machine

helium

Heimlich maneuver Named for American physician H. J. Heimlich, born in 1920, a lifesaving technique for expelling a foreign object from a person’s

hemithorax

Also known as a heart-lung bypass, a device designed to support the functions of both the heart and lungs when an individual’s body is unable to pump and deoxygenate blood in the normal exchange of blood gasses (oxygen and carbon dioxide).

A low-density gas often mixed with air or oxygen for the treatment of respiratory disorders including air pressure-related problems such as caisson disease. Helium and air administered to individuals subjected to high atmospheric pressure helps reduce the time they need to adjust to varying air pressure. See also BENDS. A term referring to half of the chest.

90 hemlock poisoning hemlock poisoning

Intoxication caused by the ingestion of the oil extracted from the unripe fruit of the hemlock, a species of evergreen plant, Conium maculatum. If respiratory failure occurs, the patient must be treated with artificial respiration and oxygen therapy.

hemopleura space. See also

The presence of blood in the pleural

HEMOTHORAX.

hemopneumothorax

The presence of blood and air in the pleural cavity.

hemoptysis From the Greek words haima, or blood, and ptyein, meaning to spit, the expectoration of blood from the mouth, larynx, trachea, bronchi, or lungs through a coughing attack. The sputum becomes salty-tasting, red, and frothy. Hemoptysis may be the result of hemorrhage, respiratory disease, or a lung infection caused by the parasitic fluke Paragonimus westermani. Treatment includes the application of ice packs over the chest, bedrest, sedatives, and other medication and procedures, depending upon diagnosis.

hernia, diaphragmatic

The protrusion or “dropping” of part of the diaphragm into the stomach through the esophageal hiatus. The hernia may be congenital, esophageal, or acquired (traumatic), the latter possibly caused by debilitating illness, weakness, tumors, physical exertion, or strenuous, chronic coughing. Hernia may also be characterized by an organ or part of an organ projecting into the diaphragm. Treatment may include surgery. See also HERNIA, PHRENIC.

hernia, phrenic The rupture or abnormal protrusion of an organ through the diaphragm into a pleural cavity. heroin toxicity

Poisoning from heroin, a morphine-derived narcotic drug, in which there is pulmonary edema and a decrease in respiration that may require artificial resuscitation and oxygen therapy. Treatment also may include the administration of a drug that stimulates the respiratory system, such as doxapram hydrochloride. Heroin toxicity is life-threatening.

hepatopulmonary

hiccough, hiccup A short cough or sound on inspiration caused by the sudden closure of the glottis after a spasm that lowers the diaphragm. Also known as singultus, hiccups may be the result of indigestion, respiratory irritation, growths within the pleural cavity, hysteria, cerebral lesions, or alcoholism. Prolonged hiccups often require treatment, including inhaling carbon dioxide (breathing into a paper bag), antiemetic drugs, nasopharyngeal stimulation with a rubber tube, or placing some granulated sugar in the hypopharynx. In severe cases, the phrenic nerve may need to be anesthetized.

Hering-Breuer reflex

hilitis Inflammation occurring at the root of the lungs at the fourth and fifth dorsal vertebrae level.

hemorrhage, lung The bright red, frothy blood coughed up as a result of a lung disease or other respiratory disorder. hemothorax The presence of blood in the pleural cavity caused by ruptured blood vessels as a result of pneumonia, pulmonary tuberculosis, traumatic injury, or malignancy. The term used in reference to both the liver and the lungs. Named for German physiologist Heinrich Ewald Hering (1866–1948) and Austrian physician Josef Breuer (1842–1925), the reflex inhibition of breathing in as a result of pressoreceptor-nerve stimulation when the lungs are inflated.

Hippocrates Greek physician who lived ca. 460–375 B.C., considered by many “the father of modern medicine.” Among his major tenets are that physicians should observe all, evaluate hon-

hoarseness 91 estly, assist nature, work for the good of the patient, treat the whole person and not simply the illness, and, above all, do no harm. Modern chiropractic also employs Hippocrates’ idea that all illness stems from anomalies of the spine. In Hippocrates’ writings, he described, for example, the symptoms of pulmonary edema: “Water accumulates; patient has fever and cough; the respiration is fast; the feet become edematous; the nails appear curved and the patient suffers as if he had pus inside, only less severe and more protracted. One can recognize that it is not pus but water. . . . If you put your ear against the chest you can hear it seethe inside like sour wine.” Hippocrates also wrote that some foods known to be safe and healthful for most people caused illness in some, possibly, he speculated, because of a “poison” in the food, such as cheese, to which some people were particularly sensitive.

histamine H2, receptor antagonist

A drug that blocks the effects of the chemical histamine by competing for receptor sites on the surface of cells in the stomach, thus preventing the secretion of gastric acid in the treatment of peptic ulcers. H2blocking drugs available in the United States include cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). Traditional antihistaminic drugs, called H 1-receptor antagonists, differ from H2 agents by blocking the allergic symptoms caused by histamine primarily in the respiratory system and skin. H1 and H2 antihistamines are sometimes combined for the treatment of hives. H2-antagonist drugs rarely have adverse effects; however, cimetidine causes a rise in theophylline levels and should be used with caution in asthmatic patients taking both drugs. The other drugs in this class are probably free of this problem. See also ANTIHISTAMINE.

hippus, respiratory

The condition characterized by the pupils of the eye dilating during inspiration and contracting during expiration.

Hismanal

See

ASTEMIZOLE.

histaminase

An enzyme found throughout the body that counteracts histamine. See also HISTAMINE.

histamine

A natural substance liberally distributed throughout the body (especially in the skin, heart, lungs, gastrointestinal mucosa, the brain, and other organs) and a major substance released by mast cells of the tissues to initiate an allergic reaction. Inflammation, excess acid production in the stomach, constriction of the bronchi in the lungs, red flushing of the skin (as occurs with a burn), red rashes, decrease in blood pressure, and headache are among the symptoms characteristic of histamine release. Antihistamines are substances that counteract histamine. See also ANTIHISTAMINE.

histamine headache

term for antihistamine.

An alternate

HEADACHE, HISTAMINE.

histoplasmosis A fungal respiratory infection characterized by acute shortness of breath, coughing, fever, pains in the joints, potential adrenal gland failure, and other symptoms if the disease goes untreated or becomes chronic. Infection may be caused in susceptible or immunocompromised individuals who inhale the spores of the fungus Histoplasma capsulatum, found in soil (especially when contaminated by fecal material of birds or bats) in the southern and central United States, regions of South America, Africa, and Asia. In severe cases ulcers may appear in the gastrointestinal tract, and the spleen and liver may become enlarged. Other aspects of the disease may include weight loss, leukopenia, anemia, and adrenal necrosis. Histoplasmosis may be fatal. Treatment with antifungal medications is usually effective. Histoplasmosis is not an allergic disorder, but it may easily be mistaken for symptoms of allergy or asthma. hoarseness

histamine H1, receptor antagonist

See

A raspy or rough-sounding voice caused by an inflammation of the throat and vocal cords. Among the causes are allergy to certain

92 holistic medicine foods, chemical irritants, tobacco, and alcohol. Persistent hoarseness may be a sign of benign or malignant polyps in the throat.

when taken by individuals with emphysema. Home remedies do not substitute for professional care.

holistic medicine

hormone

A recognized discipline of Western medicine that incorporates some theories of Eastern medicine and the recognition of the patient as both a physiological and psychological being. Holistic practitioners believe that psychological factors affect well-being and disease processes. They employ various techniques, including relaxation, guided imagery and visualization, and hypnosis, along with conventional methods of treatment appropriate to the ailment, and they advocate the patient’s participation in his or her own healing. See also HIPPOCRATES.

A natural substance produced in an organ or gland that, when conveyed by the bloodstream, stimulates either increased or decreased functioning in various parts of the body. Among the most commonly known hormones are thyroid hormone, parathormone, cortisone, estrogen, testosterone, progesterone, human growth hormone, insulin and glucagons, adrenocortical hormone, ACTH (adrenocorticotropic hormone), and gastric hormone. Cortisone-like synthetic hormones, known as corticosteroids, are often used in the treatment of asthma because they act against inflammation. See also CORTICOSTEROIDS.

homeopathy

An alternative treatment system based on the theory that “like cures like,” that is, if a substance causes a symptom, it can conversely cure it when taken in a highly diluted form or in minute quantity. Remedies are made from plant, animal, and mineral sources and are available at health food stores and pharmacies. Homeopathy relates to desensitization techniques to treat allergic patients. Depending upon the patient’s complaints, homeopathic remedies are reported to have had positive effects against allergies, sore throats, arthritis, indigestion, colds and flu, chronic pain, and infections.

home remedies

Actions that individuals can take on their own to help combat allergies, asthma, and other ailments and augment treatments prescribed by the physician. According to some experts, one can seal bedding in plastic liners to keep mattresses free of dust and dust mites, get rid of carpeting, use fungicides in damp areas of the house, avoid fireplace fires, install air-conditioning, maintain a sensible diet and avoid foods that may be allergenic, and other such measures. Other home remedies involve herbalism, a practice that relies on the use of various herbs as combatants of disease. For example, a syrup made with rhubarb, water, and sugar and then diluted with four inches of water to one inch of syrup is said to have a soothing effect

house-dust mites Microscopic members of the class Arachnida, subclass Acari. Species known to be important as allergens are Dermatophagoides pteronyssinus (skin-eating, feather-loving), D. farinae, D. microceras, Euroglyphus maynei, and Blomia tropicalis. Many asthma experts consider dust mites to be the single most important allergen associated with asthma. Two principal groups of allergens of considerable importance are digestive enzymes, one group of them found in high concentrations in the fecal pellets, and a second group found in both fecal pellets and mite bodies. Two micrograms of Der p I (mite allergen) per gram of dust is considered a risk factor for sensitization and the development of asthma in susceptible individuals. A concentration of 10 micrograms of allergen per gram of dust is a risk factor for triggering acute asthma in these persons. Prevalence House-dust mite exposure is especially great in the Gulf Coast region and Pacific Northwest of the United States, the United Kingdom, northern Europe, Australia, New Zealand, Brazil, and Japan. Dust mites require high humidity, moderate temperatures, and a food source that includes human skin scales.

house-dust mites 93 In the United Kingdom, an estimated 80 percent of asthmatic children are sensitive to house-dust mites. When placed in a dust-mite-low environment, such as a hospital ward or a high-elevation, mountainous region, sensitive individuals invariably improve. Unfortunately, it takes several months for the condition to improve; as soon as allergic individuals were placed in their former environment, the asthma returned. Dust Mite Control Removal of the dust mite from the environment by either killing them with acaricides, benzyl benzoate or tannic acid, or changing environment is an effective measure. The relative humidity in bedrooms should be kept below 60 percent. Uncarpeted floors are best, but treatment of carpets with acaricides is recommended. Vacuum cleaners with double bags may be beneficial, but most vacuuming increases airborne levels of mites. HEPA filters on vacuum cleaners are of little or no value. Covering mattresses, box springs, and pillows, and hot washing of bedding can reduce mite allergen levels significantly. Dust mites were discovered in 1964. House-dust mites are microscopic (approximately one-third of a millimeter in length), sightless, eight-legged arthropods that are natural inhabitants of our indoor environment. These mites are not an indicator of uncleanliness and do not transmit human diseases. However, they are a major cause of asthma, allergic rhinitis (hay fever), and atopic dermatitis (eczema). The most important house-dust mite allergens result from proteins in the mite’s digestive tract excreted in the fecal waste rather than the mite itself. The tiny fecal particles break down to an extremely fine powder that sticks to surrounding absorbent materials. The allergen-containing powder becomes airborne when carpets are walked on, upholstery is disturbed by sitting or rising, shaking out blankets and quilts, or airing out rooms. The growth and reproduction of house-dust mites are dependent on a food supply, relative humidity, and temperature. They feed on human and animal dander (flakes, scales, or dandruff) and other materials such as fiber and feathers. The

average human sheds up to 1.5 grams of skin particles per day. The mites thrive at temperatures between 68 degrees and 84 degrees Fahrenheit and a relative humidity of 65 to 80 percent. Distribution Moist areas such as the South, the Gulf Coast region, and the Pacific Northwest present excellent breeding grounds for these microscopic organisms. House-dust mites mature and breed from May to October and may be responsible for triggering as many as 44 percent of acute asthma attacks in these areas. Since the dust mites do not thrive where relative humidity is above 90 percent or below 33 percent, they are rarely found in dry climates over 3,600 feet above sea level. There are 47 recognized species in 17 genera of the family Pyroglyphidae. Species common in temperate and tropical regions are Dermatophagoides, Euroglyphus, Hirstia, Malayoglyphus, Pyroglyphus, and Sturnophagoides. Dermatophagoides or Euroglyphus species can be found in most homes in North America, Western Europe, Japan, New Zealand, and Australia. House-Dust Mite Control The highest number of dust mites are found in bedding, upholstered furniture, and carpeting. They also inhabit pillows, quilts, children’s stuffed animals, and areas where pets sleep. They are rarely found in hospitals. It has been established that a level of 100 dust mites per gram of dust is a risk factor for sensitization and the development of asthma in susceptible persons. A level of 500 mites per gram of dust is considered a major risk factor for the development of acute asthma in a sensitized individual. Bedrooms are usually the chief target of avoidance measures for dust mites because of the allergic individual’s continuous exposure. Asthma has been demonstrated to improve in mite-free environments. The following measures have been found to reduce dust mite exposure by tenfold or more: (1) covering mattresses and other bedding with encasings designed to prevent dust mites from penetrating them; (2) hot washing of all bedding at least every 10 days; (3) removal of carpets and upholstered furniture; (4) reduction of humidity,

94 Huang-ti and (5) use of acaricides. Other measures include replacing cloth curtains with blinds, vacuuming and dusting with a moist cloth every week, organizing and rotating clothes in your closet and dresser by season, and storing out-of-season clothes in plastic tubs, according to Gerald Vanderpool, M.D., past president of the American Association of Certified Allergists. More information on allergen barrier encasings is available at www.allergydirect.com or by calling (877) 283-2323. Test kits are available to measure the quantity of dust mites in a particular room. After treatment to reduce the mite population, tests can be repeated to determine the success or failure of the measures taken. Immunotherapy When avoidance measures are unsuccessful or impossible to achieve, standardized allergen extracts for Dermatophagoides subspecies farinae and pteronyssinus are available in the United States for immunotherapy.

Huang-ti

Legendary ruler of China in the 25th century B.C., according to Chinese historians, known as the “Yellow Emperor” because he reigned under the influence of the earth, whose elemental color was believed to be yellow. Huangti (Huangdi) is considered the author of the oldest recorded canon of internal medicine called the Nei ching su wen. In this work, Huang-ti conducts a discussion between himself and his physician-minister Ch’i Po on the physical and mental aspects of health and disease. The Nei ching is valued today by many for its observations on “noisy breathing,” serving as the original description of asthma.

huffing Slang term used by youths to describe the inhalation of airplane glue, aerosol gas, solvents, gasoline fumes, and other noxious substances in order to achieve euphoria, or a “high.” Because the exact contents of these substances may be unknown by the user, they have the potential of causing a life-threatening allergic reaction or of masking symptoms of asthma. If inhalant abuse is suspected, a hotline has been established to help: (800) 788-2800. See also INHALANT ABUSE.

humidifiers Devices that increase the humidity in a building or room by blowing moisture into the air, including ultrasonics, cool-mist impeller types, evaporative units, and steam vaporizers. Humidifiers may be part of a centralized or portable heating/air-conditioning unit. These units have the potential to cause harm because they may promote the growth of molds and distribute them as an aerosol into the local environment. Even if the units are kept mold free, increasing the relative humidity of a room may stimulate growth of molds and dust mites. Steam vaporizers are considered by some experts to have the lowest potential of contamination of the humidifying units in light of the fact that the steam kills many offending microorganisms. (However, the danger of burns exists if this type of unit is knocked over or the steam comes into direct contact with skin.) The Environmental Protection Agency discovered that ultrasonic units, which claim to kill microorganisms by ultra-high-frequency sound waves, can nonetheless send out particles of dead bacteria and molds into the room air. Evaporative units on central heating systems, some with tanks in which water stays warm, have also been criticized as potential breeding harbors for bacteria. Commercial units may be sources of microorganisms, such as actinomycetes and fungi, that may cause the allergic lung disease hypersensitivity pneumonitis. Severe sinusitis has also been linked to contaminated humidifiers. One report describes “humidifier fever,” a syndrome characterized by flu-like symptoms including fever, chills, cough, headache, and malaise. It was first recognized when large numbers of office and factory employees became ill and the origin of their illness was central humidifying systems contaminated by microorganisms. After the systems were cleaned, affected individuals recovered. According to research scientists at the University of Michigan, all humidifiers are contaminated, leading to warnings of possible health hazards issued by the federal Consumer Products Safety Commission. Some research indicates that humidifying dry air is of little or no health benefit because oral and nasal passages are designed to stay moist under all environmental conditions.

hypersensitivity pneumonitis 95 humidity

The amount of moisture, or water vapor, in the air, ranging from 100 percent humidity (air completely saturated with moisture) to small percentages. An extremely humid atmosphere may seem oppressive to some individuals; those with allergies or asthma may experience discomfort in cold, dry air, often an asthma trigger. In addition, dust mites and molds thrive in humidity greater than 60 percent. The ideal humidity for persons with allergies is 25 to 40 percent; higher relative humidity may be irritating to the respiratory system. Humidification of the air from swimming pool water is excellent for moisturizing bronchial tubes, and the slow, deep breathing during swimming can be beneficial to asthmatics.

hunger, air dyspnea. See also

BREATHING; DYSPNEA.

hydroconion spray. See also

Shortness of breath, breathlessness,

An atomizer that produces a fine

AEROSOL.

hydrothorax An accumulation of fluid in the pleural cavity that is non-inflammatory. Patients with hydrothorax may exhibit symptoms including dyspnea, lack of vesicular breath sounds, and flatness over the buildup of fluid. hyperbaric oxygen therapy

A treatment using a hyperbaric chamber of oxygen to combat various problems such as bends (caisson disease), carbon monoxide poisoning, smoke inhalation, and acute ischemia of tissues. Hyperbarism involves exposure to greater than atmospheric pressure, often the case of deep-sea divers and miners. Hyperbaric oxygen is oxygen that is one-and-ahalf to three times absolute atmospheric pressure. The chamber itself is large enough to accommodate a patient and a team of medical professionals, and its pressure may be increased if more oxygen is necessary to treat the specific needs of the patient. See also BENDS.

hyperinflation

An excess amount of air in the

lungs.

hydrogen

A highly flammable, colorless, odorless, tasteless gas that occurs in water (hydrogen oxide, or H2O) and in nearly all organic compounds. Hydrogen is also present in all acids and as a component of all carbohydrates, proteins, and fats. The most abundant element in the universe, it occurs in a quantity of only 0.00005 percent of Earth’s atmosphere.

hydropneumatosis

Liquid and gasses found in body tissues that cause edema (swelling) and emphysema. See also EMPHYSEMA.

hydropneumothorax A collapse of a lung or lungs in which gas and fluids have accumulated in the space surrounding the lungs (pleural cavity). See also PNEUMOTHORAX. hydrorrhea

Excessive watery discharge from the nose, eyes, or other body parts. This symptom may be suggestive of allergic rhinitis (hay fever). See also RHINORRHEA.

hyperpnea

Rapid breathing or increased respiratory rate, such as that after exercise, or deeper than normal breathing during normal activity. Hyperpnea may be experienced at high altitudes or as a result of pain, drug reaction, hysteria, fever, heart disease, or respiratory disorder.

hypersensitivity pneumonitis (HSP) Also known as extrinsic allergic alveolitis, an allergic lung disease caused by repeated exposure to organic dusts or other offending agents. In an acute case, flu-like symptoms may include cough, shortness of breath, fever, chills, sweating, headaches or generalized pains, malaise, and nausea with onset from two to nine hours after exposure. Symptoms peak between six and 24 hours and last from several hours to several days. A subacute form that may gradually worsen over a period of days to several weeks may be much more severe, with shortness of breath progressing to the point of cyanosis and requiring hospitalization.

96 hypersensitivity pneumonitis CAUSES OF HYPERSENSITIVITY PNEUMONITIS Disorder

Source

Aspergillosis Bagassosis Bible printer’s lung Bird breeder’s lung Budgerigar fancier’s lung Chicken handler’s lung Pigeon breeder’s lung Turkey handler’s lung Cephalosporium hypersensitivity Cheese washer’s lung Coffee worker’s lung Corn farmer’s lung Detergent lung Drug-induced Duck fever Epoxy resin lung Familial hypersensitivity pneumonitis Farmer’s lung Furrier’s lung Humidifier air-conditioner lung Laboratory technician’s lung Malt worker’s lung Maple bark stripper’s lung Miller’s lung Mummy handler’s lung Mushroom worker’s lung Paint refinisher’s disease Paper mill worker’s lung Paprika slicer’s lung Pituitary snuff syndrome (snuff taker’s lung) Plastic worker’s lung Rat lung Sauna taker’s disease Sequoiosis Smallpox handler’s lung Streptomyces hypersensitivity pneumonia Suberosis Summer type Tea grower’s lung Thatched roof disease Wheat weevil’s disease Wood joiner’s lung Wood pulp worker’s lung Wood trimmer’s disease

Aspergillus spores Moldy sugarcane Moldy typesetting water Avian droppings or serum Parakeets Chickens Pigeons Turkeys Contaminated sewage Cheese mold Coffee dust Corn dust Detergents (Bacillus subtilis enzyme) Amiodarone, gold, procarbazine Duck feathers and proteins Heated epoxy resin Contaminated wood dust in walls Moldy hay or grain Hair dust Thermophilic actinomycetes, amoebae Rat urinary proteins Moldy malt, malt dust Moldy maple bark Grain contaminated by wheat weevils Cloth wrappings of mummies Mushroom compost Automobile spray painting (diisocyanates) Moldy wood pulp Moldy paprika Bovine and porcine proteins Plastics, varnish (diisocyanates) Rat urinary proteins Pullularia in sauna water Moldy wood from maple logs, moldy redwood dust Smallpox scabs Contaminated fertilizer Moldy cork dust House dust contaminated with Trichosporon cutaneum Tea plants Dried grasses and leaves Infested wheat flour Sawdust Moldy logs Moldy wood trimmings

The chronic form has an even more gradual onset with increasing cough, shortness of breath, fatigue, and weight loss over several months. Diagnosis is based on a history of exposure to a recognized allergen and confirmed by positive skin tests, finding antibodies in the blood to that allergen, and biopsy. Chest X-ray findings range from normal to severely abnormal.

The diagnosis may be confused with immune deficiency diseases, pulmonary mycotoxicosis (atypical farmer’s lung), toxic organic dust syndrome (grain fever), idiopathic interstitial fibrosis (cryptogenic fibrosing alveolitis), cystic fibrosis, silofiller’s lung, psittacosis, eosinophilic pneumonias, allergic bronchopulmonary aspergillosis, collagen vascular diseases, granuloma-vasculitis syndromes, or sarcoidosis.

hypoxia 97 hyperventilation Rapid breathing resulting in diminished carbon dioxide levels in the bloodstream. Tingling or numbness in the extremities, muscle spasms, and a feeling of anxiety may simulate, or in some cases trigger, an asthma attack. hypnosis

Techniques including guided deep relaxation, trance or altered state of awareness, suggestions, ideas, and imagery performed by a hypnotherapist, psychologist, psychiatrist, or various certified health professionals with patients suffering from asthma, allergies, respiratory disorders, and other health-related ailments. According to Susan Bendersky Sacks, R.N., M.S.N., C.S., in an article in Nursing Spectrum, March 19, 2001, “Research studies have shown that hypnosis can significantly improve pulmonary function tests, increase compliance, decrease hospital admissions and medication requirements, and in some cases, result in discontinued medication altogether. Proposed explanations include: Hypnosis decreases bronchospasm and airway resistance by influencing cerebral metabolism and the vagal and sympathetic pathways; hypnosis decreases bronchoconstriction by activating the release of neurotransmitters that stabilize IgE-mediated mast cells; hypnosis creates the perception of reduced airway resistance; hypnosis reduces anxiety and increases coping and compliance with conventional treatment.” In addition to reporting that hypnosis as a technique is controversial, Sacks emphasizes that “hypnotic trance is attained solely by the control of the patient, while the hypnotherapist functions as a consultant, facilitator, and guide. . . . Myths and misconceptions about hypnosis are prevalent and often deter interested patients from seeking treatment. Patients commonly fear being controlled and manipulated into revealing secrets and engaging in embarrassing behaviors. . . . The truth is that patients can never be coerced into displaying unwanted or unnatural behaviors or disclosing personal information. During hypnosis, the patient is aware of everything that is said and is able to guard private issues.” More information is available at [emailprotected] or from the American Society of Clinical Hypnosis at www.asch.net.

hypocapnia

Abnormally low level of carbon dioxide in the blood.

hypoepinephria

A decrease in epinephrine secre-

tion in the body.

hypostatic pneumonia

Pneumonia occurring in a patient, usually elderly or severely debilitated, who does not move enough to ward off alveolar fluid congestion, poor aeration or collapse of the lungs, and capillary pooling. The congestion creates an opportunity for infection to set in. Preventive measures should be taken for immobile patients.

hypoventilation syndrome Abnormally diminished respiration with reduced depth of inspiration and rate. It is characterized by cyanosis (skin or nail beds that appear blue), clubbing of the fingers, decreased oxygen content with a subsequent increase in red blood cells and blood hemoglobin (in the body’s attempt to improve the oxygen supply to the tissues), and an increase in carbon dioxide (level builds up because of the inability to exhale adequately). Hypoventilation occurs with the severe chronic obstructive lung diseases such as chronic bronchitis and emphysema, and from massive body obesity (also called pickwickian syndrome). Severe obstruction of the upper respiratory tract, which may occur in cases of extremely enlarged tonsils or adenoids, may result in diminished breathing during sleep; it usually improves with adenoidectomy. Less severe blockage may occur in cow’s milk allergy (also called Heiner’s syndrome), and this usually improves with elimination of cow’s milk protein from the diet. See also CHRONIC OBSTRUCTIVE PULMONARY DISEASE; HEINER’S SYNDROME. hypoxemia

Lack of sufficient oxygen in the

blood.

hypoxia

Lack of sufficient oxygen circulating to body tissues.

98 hysteria hysteria A state of severe anxiety that can involve emotional and physical symptoms, uncontrollable laughter, crying, or fear reactions. Individuals who experience severe shortness of breath may become so stressed as to be hysterical. The

term, derived from the Greek word hystera, or womb, was once applied to a woman’s disorder; contemporary terms for such anxiety include conversion, dissociative, or somatization disorders, and psychoneurosis.

I idiopathic pulmonary fibrosis

immediate hypersensitivity An alternate term for immediate allergic reactions. See also HYPERSENSITIVITY.

A lung disease secondary to interstitial pneumonitis or fibrosis characterized by dyspnea, weakness and fatigue, anoxia, rapid respirations, progressing to cyanosis, clubbed fingers, and heart failure. Corticosteroids, cyclophosphamide, other antibiotics, and oxygen therapy are among the treatments of this disease, which is usually fatal four to five years after its onset. See also HAMMAN-RICH SYNDROME.

immune complex A cluster of interlocking antigens and antibodies found in the bloodstream and usually cleared away by cells known as phagocytes, which “consume” and destroy other cells recognized as invaders. When this process fails, immune complexes may be deposited in, injure, and cause inflammation in tissues, such as kidney, lung, skin, joints, and walls of blood vessels. Diseases in which these complexes are involved include those in the category of type III hypersensitivity (antigen-antibody complement reactions): drug-induced systemic lupus erythematosus, serum sickness, nephritis, and bacterial endocarditis.

idiosyncrasy An individual’s unexpected abnormal response to a food, drug, or other usually nonallergenic substance. ID tags

See

MEDICAL ALERT BRACELETS AND NECK-

LACES.

immune complex assay

Methods of detection of circulating clusters of antigens and antibodies, or immune complexes, that are used to measure disease activity in patients with vasculitis, systemic lupus erythematosus, some malignancies, and other diseases. Immune complex assay is of doubtful importance in allergy diagnosis. See also IMMUNE COMPLEX DISORDERS.

IgE-mediated reactions

An alternate term for immediate allergic reactions. See also HYPERSENSITIVITY; IMMUNOGLOBULIN E.

illuminating gas

A combination of combustible gases such as hydrogen and carbon monoxide, which can be poisonous. Resuscitation may be necessary as treatment.

Ilosone

See

immune complex disorders A group of diseases associated with failure of the complement system and other components of the immune system. Immune complexes are aggregations or clusters of interlocking antigens and antibodies. Usually, these complexes are removed from the circulation by large phagocytic cells (macrophages) in the spleen and Kupffer cells in the liver. Research suggests that deficiencies of certain components of the complement system or complement receptors disrupt

ERYTHROMYCIN.

imagery A technique using mental pictures, sounds, odors, tastes, feelings, and other sensory experiences in order to understand and resolve psychological and physical problems. Imagery is also employed as a relaxation technique.

100 immune system this process, allowing circulating immune complexes to accumulate inappropriately in certain organs such as the kidneys, lungs, skin, joints, or blood vessels and interfering with their function. An example is systemic lupus erythematosus (“lupus”). In this autoimmune disease, a continuous supply of autoantibodies overloads the immune system’s ability to remove the immune complexes. Immune complexes also play an important destructive role in many other diseases, including infections such as viral hepatitis, malaria, and allergic lung disorders such as farmer’s lung.

immune system A complex network of specialized cells and organs that protect the body against attacks by foreign invaders such as infections. When the immune system is intact, it fights off pathogenic, or disease-causing, bacteria, viruses, fungi, and parasites. When it is weakened or fails, the results can range from a minor allergy such as hay fever to the usually fatal acquired immunodeficiency syndrome, or AIDS. The immune system protects by barring the entry of, or destroying, dangerous foreign organisms while fostering peaceful coexistence of protective or beneficial organisms. The immune response requires a complex but cooperative interplay between the various cells of the system, including effector lymphocytes (killer T cells, antibody-producing B cells, mast cells), regulating lymphocytes (T-helper and T-suppressor cells), and phagocytes. Many other factors, some not yet understood by scientists, are involved in the control of and response to immune stimuli. The immune system is further influenced by genes that determine the body’s ability to respond to an antigen. Mutation, congenital or acquired, of certain genes may impair our response not only to allergens and infectious microorganisms but to cancerous cells as well. Tissues and Organs of the Immune System Immune system components are scattered throughout the body. Bone marrow, thymus, spleen, tonsils, adenoids, lymph nodes, the appendix, and Peyer’s patches in the small intestine are known as lymphoid organs, named for their ability to produce, develop, or control white blood cells, or lymphocytes.

There are two major types of lymphocyte: B cells and T cells. Bone marrow is soft tissue in the hollow shafts of long bones. The marrow produces all blood cells, including mature B cells. T cells migrate to the thymus, a gland located behind the breastbone, where they multiply and mature. In a process called “T-cell education,” these cells become immunocompetent—that is, they develop the ability to evoke an immune response and learn to distinguish self from nonself cells. B and T cells circulate throughout the blood vessels and lymphatics, a network similar to blood vessels. Clusters of lymph nodes, located in the neck, armpits, abdomen, and groin, contain collections of B and T lymphocytes and other cells capable of engaging antigens and causing an immune response. The spleen is a scavenger of the immune system. An encapsulated, highly vascular, fist-sized organ in the left upper portion of the abdomen, the spleen contains two distinct regions of tissues, the red and white pulp. Red pulp disposes of worn-out blood cells. Red pulp also contains immune cells called macrophages, which trap and destroy microorganisms in blood passing through the spleen during the circulatory process. White pulp contains lymphoid tissue similar to that of the lymph nodes and is similarly subdivided into compartments specializing in different types of immune cells. Patients with a nonfunctioning spleen or who have had the spleen surgically removed are highly susceptible to infections. The tonsils and adenoids in the respiratory tract and the appendix and Peyer’s patches in the digestive tract are nonencapsulated clusters of lymphoid tissue in the body’s main ports of entry—the mouth, nose, and anus. Lymph is a clear fluid that travels through the lymphatic vessels, bathing the body tissues. Lymph, along with lymphocytes, macrophages, other cells, and foreign antigens, drains out of tissues and seeps across the thin walls of lymphatic vessels to be transported to lymph nodes, where antigens can be filtered out and attacked by immune cells. Other lymphocytes enter and exit the nodes from the bloodstream. Tiny lymphatics feed into larger and larger channels, like small creeks joining larger streams and rivers. At the base of the neck, large

immune system 101 lymphatic vessels merge into the thoracic duct, where its contents are emptied into the bloodstream to begin the cycle again. Self and Nonself The ability of the immune system to distinguish between self and nonself is vital to its function. All body cells have distinctive molecules that allow them to be recognized as “self.” When the immune system malfunctions, it may attack its own body. This occurs in diseases such as rheumatoid arthritis and systemic lupus erythematosus, which are referred to as autoimmune disorders. Antigens, Allergens, or Immunogens Any substance capable of triggering an immune response is called an antigen, allergen, or immunogen. An antigen can be a bacterium, fungus, parasite, virus, or a part of a substance produced by those organisms. However, not all antigens are capable of causing an antibody response, and some may provoke a cellular, or delayed hypersensitivity, response or even tolerance. Tissues or cells from another individual, except an identical twin, are also antigenic, that is, recognized as foreign. The structure of antigenic molecules varies from proteins, polysaccharides, lipids, or nucleic acids. The molecular weight of antigens ranges from less than a thousand to several million daltons (a unit of mass = approximately 1.65 × 10 –24) but must reach a threshold size in order to stimulate an immune response. Although the exact size required for allergenicity is unknown, the larger the size of a molecule, the better the chance that it will invoke a reaction. From the human organism to the smallest and simplest microbes, all cells have structures called epitopes on their surfaces that are characteristic and unique to that cell. Epitopes enable the immune system to recognize foreign cells and are the smallest antigenic structure capable of recognition by an antibody. Most cells carry different kinds of epitopes, which may number up to several hundred, on their surface. However, these epitopes differ in their immune-stimulating capabilities. Haptens are molecules too small to elicit an immune response in themselves. However, when haptens are coupled to a carrier immunogenic mol-

ecule, usually a protein or synthetic polypeptide, they can cause a very strong allergic response. Penicillin is one of many drugs that are haptens that bind with serum protein. This complex molecule then stimulates an allergic reaction to the penicillin or other drug. Other examples are the allergic responses to plant substances or metals that cause rashes upon contact with skin. The sensitizing allergens in poison ivy, oak, and sumac are haptens that combine with proteins in the skin. Upon subsequent exposure to these substances, antibodies in the skin react, causing the often debilitating contact dermatitis. Antigens such as pollen grains or cat dander are categorized as allergens because of their ability to provoke an allergic response in susceptible individuals. The first time an allergic individual is exposed to an allergen, the immune system responds by making a corresponding antibody. The antibody molecules are called immunoglobulin E (IgE). IgE molecules attach to the surfaces of mast cells in tissues or basophils in the circulatory system. Multiple factors determine the potential for an immune response. Among these are foreignness and chemical structure of the antigen. The genetic disposition of the exposed individual and the method of exposure—by injection, orally, skin or mucous membrane contact, or inhalation—affect the strength of immune response. Cells of the Immune System The immune system maintains a huge array of cells, some always present and others manufactured upon demand. Some cell types control general body defenses, while others target specific, highly selective targets. A competent immune system relies on the interactions of many of these cells by direct contact or by the release of chemical messengers by some. When mast cells or basophils with IgE antibodies on their surface encounter specific allergens, they release biochemical substances called mediators. Mediators include histamine, heparin, prostaglandins, and leukotrienes. These chemicals cause allergic symptoms—wheezing, sneezing, runny nose, watery eyes, and itching. The most serious response of the immune system is anaphylaxis, characterized by edema or swelling of body

102 immune system tissues and a sudden, dangerous decrease in blood pressure that can be life-threatening. Antibodies Immunoglobulins, commonly called antibodies, are protein molecules produced and secreted by B cells (lymphocytes manufactured in the bone marrow) designed to attack a specific foreign invader called an antigen. The resulting antibody is capable of binding, or attaching, to that specific antigen. For example, a cold virus stimulates a B cell to produce an antibody against that specific virus. When a B cell encounters its triggering antigen, T cells and other accessory cells collaborate with it to cause the production of large plasma cells. Each plasma cell becomes a factory for producing antibodies. Transported through the circulation to the site of inflammation or infection, antibodies neutralize or combine with and identify antigens for attack by other cells or chemical mediators. All antibodies have a common Y-shaped molecular structure consisting of two light (L) and two heavy (H) polypeptide chains bound together by two disulfide linkages or bridges. The resulting light and heavy chain section is called the fragment antigen binding, or Fab. A third portion of the immunoglobulin, Fc fragment, does not combine with antigen. The Fc portion of the antibody binds to cells, fixes complement, and allows for placental transfer. The five classes of immunoglobulins (Ig) identified in humans are IgA, IgM, IgD, IgE, and IgG. These immunoglobulins are distinguished by the structure of heavy chains called, respectively, t, a, m, z, and (. The two types of light chains are kappa (k) or lambda (L). IgG is the predominant human antibody and along with the other immunoglobulins has special roles in maintaining body defenses. Genes direct the manufacture of all body protein molecules including antibodies. (Insulin is another example.) Although there is a limited number of genes, the immune system apparently can produce an unlimited number of antibodies. The DNA segment of most genes is fixed; however, antibody genes are constructed from fragments of DNA scattered throughout the genetic material. A B cell sorts through the available material, arranging and rearranging these fragments and piecing them

together to form a new gene that with the antibody it encodes is unique. Each B cell proliferates, or clones, identical antibody-producing cells. As the cells continue to multiply, mutants arise that allow for the selection of antibodies that target specific antigens. This process enables antibodies to respond to an enormous range of antigens. T cells, or T lymphocytes, are processed by the thymus gland, act directly by attacking viruses and fungi, and are involved in transplantation rejection reactions. T cells react with specific antigens similar to antibodies. There are three types of T lymphocytes: “killer” T cells, which directly attack antigens; “helper” T cells, which help the killer cells; and “suppressor” T cells, which regulate the killer cells’ activity and stop their action when an infection has been controlled. Phagocytic white blood cells destroy invading foreign microbes by directly engulfing them. Most phagocytes are macrophages, large mononucleated cells derived from monocytes, which are produced and mature in the bone marrow. After a few days, they leave the general circulation and enter various tissues. Other phagocytic cells include Langerhans cells of the skin, dendritic cells, keratinocytes, and brain astrocytes. These cells affect chemotaxis (cell movement) by engulfing foreign antigens, ridding the body of dead tissues and cells. In the process of phagocytosis, these cells process the antigen and present an immunologically active antigen to the T lymphocytes. The macrophages are not antigenspecific like lymphocytes. Microphages consume bacteria. Complement is a complex series of blood proteins whose action “complements” the action of antibodies. The complement system comprises about 25 proteins that coat bacteria or immune complexes. This coating facilitates their ingestion and destruction by phagocytes. Complement also destroys bacteria by puncturing their cell membranes. When the complement system is activated by either the “classic” or an “alternative pathway” (also called the “proteolytic” or “properdin” pathway), an inflammatory response occurs. Immune complexes, consisting of IgG or IgM classes of immunoglobulin antibodies combined with antigen, activate a pathway targeting an invading sub-

immunodeficiency disease, severe combined 103 stance. During this process, the enzyme C1 esterase sets off a cascading-type reaction against the invader. The “proteolytic” alternative, or “properdin” pathway, can be activated without the presence of antibodies. The complement system not only aids in the body’s defense against infection but also helps protect against immune-complex diseases. However, if there is a deficiency of certain components of the system or cell receptors are deficient, the complement can actually induce immune-complex disorders such as serum lupus erythematosus. Serum complement levels are often measured to help diagnose hereditary angioedema, bacterial endocarditis, acute glomerulonephritis, serum sickness, systemic lupus erythematosus, and other autoimmune diseases. A deficiency in any component of the immune system may result in an immune deficiency disorder. In some cases there are no clinical manifestations, but in others recurrent, minor, or life-threatening infections may occur. See also IMMUNOGLOBULIN A; IMMUNOGLOBULIN D; IMMUNOGLOBULIN E; IMMUNOGLOBULIN G; IMMUNOGLOBULIN M.

immunity

The quality of being protected from, or resistant to, infection, disease, and any “invasion” imposed on the body. Being immune involves the ability of the immune system—consisting of white blood cells manufactured by the bone marrow, thymus, lymph, and other structures—to prevent or fight an infectious disease. Natural resistance or immunity refers to the human body’s rejection of certain cells, such as those causing Texas cattle fever, which cannot live in human tissues. Immunity is described in various ways: natural, passive, humoral, and cell-mediated (cellular). See also ACTIVE IMMUNITY; IMMUNITY, PASSIVE.

immunity, passive

The protection from disease afforded by way of antibodies received by an infant from its mother through the placenta or breast milk, or antibodies conveyed by injecting immune serum globulin (gamma globulin) from an individual known to be immune to a certain disease into a susceptible individual. Passive

immunity is short-lived, but immediate protection against an infection. Serum from immune individuals or animals is pooled to achieve a highly concentrated suspension of antibodies against a specific infection such as hepatitis or tetanus. Immediate tetanus protection can be administered to a non-immunized person by injecting human tetanus immunoglobulin. Horse-derived equine tetanus antitoxin is rarely used because of the frequent occurrence of severe adverse reactions.

immunodeficiency disease

A defect or insufficiency of one or more components of the immune system resulting in an inability to fight off infections. A variety of immunodeficiency disorders can be inherited, acquired through infection or other illness, or caused by an adverse reaction to certain drugs. Some children are born with abnormal B-cell components and lack the ability to produce immunoglobulins or antibodies. These defects may be absolute, as in agammaglobulinemias, or partial, as in hypogammaglobulinemias. Injections of immunoglobulins can protect these children against infections. Children who lack T cells as a result of abnormal or missing thymus glands can be treated by thymus transplantation. Rarely, an infant lacks all immune defenses, which is referred to as severe combined immunodeficiency disease (SCID). These are the so-called bubble children who often live for years in germ-free rooms. Bone marrow transplants have cured a few of these children. Acquired immunodeficiency syndrome, or AIDS, is caused by the human immunodeficiency virus, or HIV. In AIDS, a virus destroys helper T cells, allowing microorganisms that are normally harmless to cause life-threatening infections. These are referred to as “opportunistic infections.” See also ACQUIRED IMMUNODEFICIENCY SYNDROME; IMMUNODEFICIENCY DISEASE, SEVERE COMBINED (SCID).

immunodeficiency disease, severe combined (SCID) A genetic disorder of the immune system giving rise to what has been called “bubble

104 immunofluorescence, direct babies”—children who are afflicted with SCID and require a highly protective environment to avoid contracting potentially fatal infectious diseases. Approximately one-third of SCID victims have shown a deficiency of the enzyme adenosine deaminase, which may be a cause of SCID. Enzyme replacement therapy treatments involve injections of the drug pegademase bovine. SCID is considered the most severe immunodeficiency disorder; victims lack adequate quantities of B lymphocytes and antibodies, and their T lymphocytes are either deficient or not functioning. SCID that afflicts infants usually begins with pneumonia and thrush (an oral fungal infection), and if untreated, an infant may not live into a second year. Diarrhea and other infections such as pneumocystitis pneumonia may also develop during infancy. Treatment options include antibiotics, immunoglobulin, and bone marrow or umbilical cord blood transplantation.

immunofluorescence, direct A test to detect antibodies in tissue specimens used to aid in the diagnosis of glomerulonephritis, systemic lupus erythematosus, Goodpasture’s syndrome, pemphigoid, pemphigus, and dermatitis herpetiformis, and herpes simplex infections. immunofluorescence, indirect A test to measure the presence and quantity of antibodies in body fluids. It is especially useful in detecting autoantibodies in diseases including diabetes mellitus, thyroiditis, myasthenia gravis, chronic active hepatitis, systemic lupus erythematosus, systemic sclerosis, pernicious anemia, pemphigus, and bullous pemphigoid. immunogen

Any substance capable of triggering an immune response. Immunogens may also be called antigens or allergens. An antigen can be a bacterium, fungus, parasite, virus, or a part of a substance produced by those organisms.

immunoglobulin A (IgA) (secretory antibody) The primary immunoglobulin in body orifices, or entrances. IgAs are concentrated in body fluids such as the bronchial and intestinal secretions,

especially tears and saliva. IgA recognizes invading microorganisms in the mucous membranes as foreign protein. It combines with these invaders in antigen-antibody reactions to prevent viral and bacterial infections such as brucella, diphtheria, and poliomyelitis. IgA deficiency is the most common primary immunodeficiency, occurring in about one in 400 to 800 individuals, and more frequently in those with allergy. Most persons with low IgA levels produce sufficient IgM antibodies to provide an adequate defense against infections. However, IgA deficiencies are commonly associated with chronic lung infections, autoimmune diseases, especially rheumatoid arthritis and systemic lupus erythematosus, gastrointestinal disorders, hepatitis, and some malignant tumors. There are no known cures, and treatment is directed at the underlying disease or infection. Human immune globulin contains only minimal levels of IgA and is of no value in treating IgA deficiency disorders. In addition, IgA may cause anaphylaxis in persons with this deficiency. See also IMMUNOGLOBULIN G.

immunoglobulin D (IgD) A class of antibodies found in very small concentrations in human serum. IgD antibodies, first discovered in the 1960s, are found on the surface of lymphocytes. Although the IgD antibody’s exact role has yet to be defined, it seems to play a role as a specific surface receptor in the immune response. immunoglobulin E (IgE)

Antibodies manufactured by the immune system that play an important role in primary type I hypersensitivity, or immediate allergic, responses. Once called “reaginic antibodies,” these antibodies are normally present in very small quantities. Allergic individuals generally have higher total IgE levels in their blood. However, other diseases can also be associated with very high levels of IgE antibodies. Skin-sensitizing, anaphylactic antibodies are of this type. IgE antibodies’ unique biologic properties are based on their ability to bind with special receptors on mast cells and basophils in body tissues. People differ in their ability to develop an IgE response to common allergens in the environ-

immunoglobulin G 105 ment. The tendency to produce IgE antibodies is genetic. When IgE antibodies specific to a previously sensitized allergen are reexposed to that allergen, cells degranulate and chemical mediators of anaphylaxis and type I reactions are released. DISORDERS ASSOCIATED WITH ELEVATED SERUM IgE LEVELS Acral dermatitis Allergic diseases (severely elevated levels in allergic bronchopulmonary aspergillosis) Bone marrow transplantation (immediately post-transplantation) Bullous pemphigoid Celiac disease (gluten-sensitive enteropathy) Drug-induced interstitial nephritis IgE myeloma Infectious mononucleosis Job-Buckley syndrome Kawasaki disease Laënnec’s cirrhosis Minimal change nephritis Parasitic infections Polyarteritis nodosa Pulmonary hemosiderosis Selective IgA deficiency T-cell deficiency (DiGeorge syndrome, Wiskott-Aldrich syndrome, Nezelof syndrome) Wegener’s granulomatosus

Serum levels of IgE antibodies can be measured as “total IgE” or to identify specific allergens. This measurement is performed by a method called radioallergosorbent tests (RAST). Testing for allergen-specific IgE by RAST is useful when skin testing is unreliable because of generalized skin disease or dermatographia, or if the patient is unable to discontinue antihistamines.

immunoglobulin E (IgE) assay (total IgE, PRIST, RIST) A quantitative test measuring immunoglobulin E antibodies in the blood serum to assess an individual’s tendency to have allergies. An elevated level of IgE antibody in blood obtained from the umbilical cord at birth correlates with an increased risk of the development of allergy in later life. Persons with high total IgE levels are usually sensitive to many allergens, but an individual can be sensitive to specific IgE allergens and have a low total IgE level. Furthermore, allergic bronchopulmonary aspergillosis, parasitic infections, and other

rare diseases can cause extreme elevations in total IgE. There may be elevations of circulating IgE antibodies in some persons with food allergies, but the Allergy Council on Scientific Affairs of the American Medical Association considers this test investigational and experimental. The Paper Radioimmunosorbent Test and Radioimmunosorbent Test (both blood tests) are methods of measuring total IgE. In 1981, the Immunology Unit, a committee of the World Health Organization, recommended against the measurement of total IgE as a screening test for allergy. RELATIONSHIP OF IgE LEVELS TO DIAGNOSIS OF ALLERGY Total IgEU/ml

Predictability of Allergic Tendency

>100 25–100 <25

Multiple allergens highly likely Intermediate Low probability of allergy

RADIOALLERGOSORBENT LEVELS (TRADITIONAL METHOD) RAST Class

Level of Antigen-Specific IgE

4 3 2 1 1/0 0

Very high High Moderate Low Very low Below detection

immunoglobulin E (IgE) immune complexes

The percentage (up to 50 percent) of immunoglobulin E (IgE) circulating in the bloodstream in immunecomplex form. The relevance of these complexes to allergy is unknown.

immunoglobulin G (IgG) The most common antibody in human serum, found throughout the circulatory system and other body tissues. IgG immunoglobulins enjoy a relatively long half-life (the time required for half the amount of a specific substance to be eliminated or to disintegrate in the body) of 23 days and readily cross the placenta. Antibodies of this class are involved in the immune system’s defense against bacterial, viral,

106 immunoglobulin G (IgG) subclasses parasitic, and some fungal infections. Receptors for IgG are found on the surface of monocytes, on polymorphonuclear leukocytes, or polys, on reticuloendothelial cells in the spleen and liver, and on some lymphocytes. IgG antibodies also activate complement.

internal environment and to protect the body from, and/or help the body fight, the invasion of disease-causing microorganisms. The field of immunology evolved from the ancient Chinese practice of variolation as early as the 11th century, in which intradermal applications of powdered smallpox scabs were used to prevent smallpox.

immunoglobulin G (IgG) subclasses

Minor differences in molecular structure among a specific class of antibodies. Two IgA and IgD and four IgG immunoglobulin subclasses have been discovered. The minor variations, however, may result in significant differences in the function of these subclasses. Repeated infections may occur in individuals who have normal levels of total IgG but absent or reduced levels of one or more of the subclasses. Such persons fail to develop antibody responses to naturally occurring infections or to vaccines.

immunoglobulin M (IgM) The largest antibody molecules of the immune system, found almost exclusively in the circulation. IgM is the major antibody of the early humoral response to foreign invaders, particularly to nonprotein bacterial antigens. Although its large molecular size prohibits transfer through the human placenta, its structure allows for IgM’s ability to agglutinate, or clump, particles of bacteria and red blood cells and fix, or attach, to complement. immunoglobulins

Another term for antibodies.

immunologist A physician who diagnoses and treats disorders of the immune system, such as acquired immunodeficiency syndrome, or AIDS. Many immunologists are also allergists, but some are nonphysician scientists who do not care for patients. Upon completion of medical school, a two- or three-year residency in pediatrics or internal medicine, and a two-year fellowship in allergy and immunology, these doctors are then eligible for a board-certification examination in their specialty. immunology The study of immunity and immune responses, which are the bodily processes whose main function is to maintain a constant

immunopathology

The study or science of the body’s immune reactions to disease-causing, or pathogenic, microorganisms.

immunopolysaccharide

Antigenic substances obtained from the bodies of specific infectious bacteria that have the ability to stimulate the production of antibodies to protect against that particular infection. Immunizations against pneumococcal pneumonia and Haemophilus influenzae (cause of meningitis in infants) are examples of polysaccharide vaccines.

immunostimulant Any foreign agent, including allergens, microbes, or vaccines, that will cause the production of antibodies. immunosuppressant Any agent, such as cancerfighting drugs, that inhibits the immune response. immunotherapy (allergy shots) A series of injections of solutions of allergenic extracts administered to a person suffering from allergies. By gradually injecting increasing doses of specific allergens to which that individual has been shown to be sensitive, the individual is expected to develop a tolerance to those allergens and experience few or no symptoms upon environmental exposure. Mechanism of Action Researchers believe a positive response to allergy immunotherapy requires an increase in immunoglobulin G (IgG)-blocking antibody, which is capable of blocking allergic reactions mediated by IgE antibodies. Five changes in the immune response have been recognized in persons receiving immunotherapy: (1) a rise in blood levels of

infection carriers 107 IgG-blocking antibodies; (2) a suppression of the usual seasonal rise in IgE antibodies followed by a slow decline in the level of specific IgE antibodies during continued immunotherapy; (3) an increase in levels blocking IgA and IgG antibodies in body secretions; (4) a diminished ability of basophilic cells to react to allergens; and (5) a tempering of the reactivity of lymphocytic cells in contact with allergens in vitro (tests performed in a test tube or an artificial environment). An individual may be sufficiently protected from allergy without demonstrating all five postulates. Treatment Course Treatment usually begins once or twice weekly until a maintenance dose is achieved. Therapy is usually continued at monthly intervals for three to five years. In most persons, however, symptoms eventually recur, and treatment is sometimes repeated. Immunotherapy usually requires six to 12 months of regular injections; if there is no beneficial response within two years, it is generally recommended that treatment be discontinued. Allergens included in immunotherapy are based on skin or blood tests and a detailed medical history of the patient to determine a person’s sensitivity to a particular allergen or multiple allergens. Many individuals show positive tests to substances that are not the cause of their allergy symptoms. Allergens not directly responsible for triggering an individual’s symptoms should not be included in the solution. Allergy immunotherapy is a consideration when avoidance of offending allergens and medications are ineffective. Immunotherapy has been shown to be effective for allergy symptoms associated with grass, tree, and weed pollens, house-dust mites, cat dander, and certain molds. Stinging insect venom immunotherapy is also highly effective. House-dust mixture is prepared from dust collected by beating carpets or vacuuming. Responsiveness is related to the presence of cat and dog dander, house-dust mites, co*ckroaches, and other allergens in the preparation. But variation in potency and effectiveness of batches of extract does not permit standardization, and the availability of house-dust extract may eventually be withdrawn by the Food and Drug Administration.

immunotherapy, oral

The administration of an allergen extract liquid by mouth, a method of immunotherapy now being investigated by researchers at the Johns Hopkins Asthma and Allergy Center. Administering an allergen dose 100 times that of a typical injected dose of ragweed antigen to patients resulted in clinically significant improvement of hay fever symptoms, such as sneezing, nasal congestion, and itchy eyes. Side effects have been minimal; a few patients show a mild worsening of symptoms, abdominal cramps, or a tightness in the throat. These adverse effects cleared up with slight reduction in dosage of the allergen. Oral immunotherapy has been shown to be effective against allergy through the body’s increased ability to promote an IgG-blocking antibody response.

immunotransfusion Transfusion of blood from a donor who has antibodies against a specific infection from having been inoculated with bacteria from the recipient patient or from the specific infection, or who has recently recovered from that infection. infarction, pulmonary

Necrosis, or death, of part of a lung because blood supply to the area has halted. Pulmonary embolism is usually the cause of the infarct, and treatment includes oxygen therapy, reduction of pain, and restoring the circulatory system.

infection carriers From the French word carier, meaning to bear, an individual who has no symptoms of infection but may be able to transmit it to others. Carriers may be human, animal, or substances, such as blood and bodily fluids. Microorganisms may also be carried by insects or intermediary hosts such as soil and water. Human carriers may asymptomatically harbor parasites or pathogenic microorganisms, a prime example of which is “Typhoid Mary.” Mary Mallon was an Irish domestic in the United States during the 1930s. When members of the family for whom she worked contracted typhoid fever, it was discovered that she was the carrier and that her questionable

108 infection, respiratory tract hygiene led to her spreading of the bacterium Salmonella typhi. The bacterium lives in the carrier. If a carrier handles food without applying fastidious cleanliness measures, as did Mallon, the bacterium may be transmitted. She spread typhoid fever throughout New York City before she died in 1938. In addition to asymptomatic contact carriers, there are incubationary carriers, or those who have just become infected by a pathogenic microorganism and have not yet gone through the incubation period, and convalescent carriers, or those who have recovered from the illness but in whose body the disease-causing organism still remains. Proper handwashing, especially before and after using the toilet, is essential in preventing the spread of disease. A genetic carrier refers to a parent-child transmission of a mutant, disease-causing gene. Prenatal genetic testing is available to determine prospective parents’ risks. One of the most volatile of carriers is an individual with an active infection from which he or she is suffering. Avoiding contact with the individual is the primary means of prevention. In hospital units that specialize in highly infectious diseases, methods for isolation, such as gloves, gowns, masks, and preventive techniques, are employed.

infection, respiratory tract (RTI)

An invasion of the body’s respiratory tract or organs by pathogenic, or disease-producing, microbes and the symptoms that occur from the presence of these bacteria, viruses, parasites, or fungi, or from toxins produced by these organisms. An infection may also be present without detectable symptoms.

inflammation Redness, heat, and pain associated with cellular injury upon the exposure to allergens or pathogens and occurring when white blood cells migrate to a traumatized or hypersensitive area of the body. Inflammation is a major contributing factor to chronic asthma. After each exposure to an allergen or pathogen that results in inflammation in lung tissues, the tissues attempt to repair themselves. This leads to subepithelial fibrosis, thickened noncellular (basem*nt) membranes that may be permanent and occur very early in the course of

asthma. Anti-inflammatory therapy is a mainstay of asthma treatment. Cromolyn sodium (Intal), nedocromil sodium (Tilade), and corticosteroids by metered doses are used to prevent inflammatory changes in the lungs. However, systemic corticosteroids, by injection or orally, are often required in moderate to severe cases. The inflammatory changes that occur with allergic skin disorders such as contact dermatitis result in the itching, burning, and rashes characteristic of these conditions.

influenza

Derived from the Italian word meaning influence, an acute, highly contagious infection of the respiratory tract caused by the influenza virus. Numerous forms of the virus have been identified, such as types A, B, and C, and subtypes, including human, swine, equine, and avian. The virus has a great capacity to vary, which is why epidemics of one form of flu may occur in populations that have already been exposed to a different form. Nicknamed the “flu,” influenza causes sudden fever of 101 to 103 degrees Fahrenheit, chills, headache, muscle pain (particularly in the back), sore throat, sneezing, coughing, lack of appetite, and other symptoms that last usually from two to seven or eight days. Nausea, vomiting, and diarrhea may sometimes accompany the infection, but the term “stomach flu” may actually describe gastrointestinal illnesses caused by other microorganisms. Most flu sufferers recover completely, but some develop secondary nasal infections of the sinuses, middle ear, and lungs, pneumonia or other complications that may be life-threatening. More than 100,000 hospitalizations and 200,000 deaths throughout the nation occur each year. The most susceptible members of the population are the elderly, individuals with chronic medical problems, and infants, although medical sources also claim that healthy, young adults may be very susceptible. Spread by discharges from the nose and mouth of infected individuals, the influenza virus is the only organism that still causes acute epidemics in America. In 1918, there was an influenza pandemic—the “Spanish flu”—that caused the greatest flu-related mortality rate. Approximately 500,000 people died

influenza 109 in the United States, and 20 million died throughout the world. The flu became so dramatic that a book by Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It, has been published. In 1957–58, the “Asian flu” caused 70,000 deaths in America. In 1968–69, the “Hong Kong flu” took the lives of 34,000 in America. Flu-virus A subtypes are identified by two viral proteins: hemagglutinin (H) and neuraminidase (N). Flu A viruses may undergo changes called “antigenic drift.” This means a virus mutates and gradually changes, enabling the virus to escape the efforts of a person’s immune system and cause a permanent susceptibility to influenza. Another “drift”—known as an antigenic “shift”—is characterized by a sudden change in the hemagglutinin and/or the neuraminidase proteins, which produces a new strain of influenza virus. Unlike influenza A viruses, influenza B viruses shift only through the slower process. According to the Morbidity and Mortality Weekly Report of March 23, 2001, printed by the U.S. government, influenza activity was summarized from October 1, 2000, to March 10, 2001. “Influenza increased in December and January and peaked at the end of January,” the report says. “The most frequently isolated viruses were influenza A (H1N1); however, influenza B viruses have been co-circulating and appear to be increasing. . . . The World Health Organization (WHO) collaborating laboratories and National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories tested 64,840 specimens for influenza, and 8,386 (13 percent) were positive. Of these, 4,885 (58 percent) were influenza type A and 3,501 (42 percent) were influenza type B. Of the 4,885 influenza A viruses identified, 1,826 (36 percent) were subtyped: 1,746 (96 percent) were A (H1N1) and 80 (4 percent) were A (H3N2). The percentage of specimens positive for influenza injections, an indicator of influenza activity, peaked at 24 percent during the week ending January 27, 2001. For the week ending March 10, 6 percent of tested specimens were positive for influenza.” The report also says the Centers for Disease Control and Prevention (CDC) antigenically characterized 436 flu viruses since October 1, although state

and territorial epidemiologists report that flu activity peaked during the weeks ending February 3 and 10, 2001, when 28 states reported regional or widespread activity. “This peak was lower than those reported during the 1997–98, 1998–99, and 1999–2000 seasons, when 46, 43, and 44 states reported regional or widespread influenza activity, respectively. . . . As reported by the 122 Cities Mortality Reporting System, the percentage of total deaths that resulted from P&I (pneumonia and influenza) remained below the epidemic threshold each week since October 1. During the previous three, the percentage of deaths attributed to P&I was above epidemic threshold for 10 consecutive weeks each season.” The CDC reports flu data October through May and is available by telephone at (888) 232-3228, the fax information system at (888) 232-3299 (request document number 261100), or on the web at http://www. cdc.gov1/ ncidod/diseases/flu/weekly.htm. Influenza A (H3N2) viruses predominated throughout the world for the third consecutive season during 1999–2000, according to the American Medical Association, and the influenza vaccine should be effective against the viruses. In addition, the AMA reported that the 2000–01 season was the first for which flu vaccination is recommended for everyone 50 years or older. Influenza A (H3N2) outbreaks occurred in Tunisia, China, Albania, Austria, Belarus, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, Italy, Latvia, Netherlands, Norway, Poland, Portugal, Romania, Russian Federation, Slovakia, Spain, Sweden, Switzerland, Ukraine, United Kingdom, United States, and Canada, with sporadic cases reported in Argentina, Australia, Brazil, Republic of Cyprus, Egypt, Greece, Guam, French Guyana, India, Republic of Syria, Taiwan, Thailand, Turkey, and the Federal Republic of Yugoslavia. Influenza A (H1N1) cases occurred in the Hong Kong SAR of China, Japan, and Spain, with isolates of the same virus sporadically occurring in Argentina, Australia, Belgium, Brazil, Canada, Chile, China, France, Germany, Iceland, Italy, Latvia, Philippines, Portugal, Russian Federation, Saudi Arabia, Singapore, South Africa, Spain, Thailand, United Kingdom, United States, and Vietnam.

110 influenza Influenza B incidences were low, but some cases were reported in Argentina, Australia, Brazil, Canada, China, Croatia, Czech Republic, Egypt, Finland, France, Germany, Hong Kong SAR of China, Hungary, Iceland, Israel, Italy, Japan, Republic of Korea, Madagascar, Malaysia, New Caledonia, New Zealand, Norway, Philippines, Russian Federation, Singapore, Senegal, South Africa, Spain, Sweden, Syria, Taiwan, Thailand, Tunisia, United Kingdom, United States, Vietnam, and the Federal Republic of Yugoslavia. Type C infections usually cause a mild respiratory illness or no symptoms, thereby posing no real threat to public health like the A and B viruses. Many aspects of the influenza viruses remain a mystery for researchers. Treatment is mainly bedrest, forcing fluids, analgesics, antipyretics, and nasal decongestants. Antibiotics are not treatment for flu unless there is another bacterial infection present. Amantadine or rimantadine given early may help prevent or treat influenza A infection. Vaccination against influenza is available. According to the CDC, flu can be prevented by an annual vaccine and is specifically recommended for people 50 years and older and people of any age who have chronic heart, lung, or kidney disease, people with diabetes or severe forms of anemia, and those who are immunosuppressed. In addition, the vaccine is recommended for nursing home or chronic care facility residents, women who will be more than three months pregnant during the flu season, and children and teenagers who are receiving long-term aspirin therapy and are at risk of developing Reye’s syndrome following a bout with influenza. Health caregivers and others in contact with individuals in the high-risk groups should also be vaccinated. Travelers may risk exposure to influenza depending upon the time of year and their destination. Flu occurs year-round in the tropics, April through September in temperate regions of the Southern Hemisphere. In temperate zones of both Northern and Southern Hemispheres, travelers may risk exposure during the summer months. Because flu vaccine may not be available during the summer in North America, individuals wishing to travel should consult with their physicians. Antiviral medications may be

advised for prevention or treatment of flu contracted outside the United States. An article in Blended Medicine, published by Rodale in July 2000, reported that a passenger with the flu took a five-hour flight, and three days later 72 percent of the other passengers contracted the disease. Alternative methods of prevention and treatment include (1) consume only liquids for a day or two after the onset of symptoms, because minor dehydration may make the flu worse; (2) Echinacea, an herb reported to boost the immune system; (3) Sambucol, a sweet medicinal syrup made from elderberries reported to reverse symptoms; and (4) see a doctor for prescription amantadine or rimantadine. Students, particularly those residing in institutional settings such as dormitories, are urged to be vaccinated to reduce the possibility of both suffering and transmitting the disease. Misconceptions about the flu vaccine include that it is not effective, it will cause the disease it is supposed to prevent, or that severe allergic reactions will occur. However, the only flu vaccine produced and licensed in the United States is made from killed influenza viruses that cannot cause infection. The risk of an allergic reaction or other adverse side effect is extremely small. Soreness at the site of the injection may last a day or two, but it is usually mild and does not impair normal functioning. Children who have never been exposed to flu virus may experience a fever and some achiness after the vaccination; these symptoms may last one or two days. The possibility of developing GuillainBarré syndrome (GBS), a severe paralytic disease, is also extremely rare and may occur in individuals who are severely allergic to any type of vaccine or to eggs, because the flu viruses used in the vaccine are grown in hens’ eggs. Such an allergy should be reported before vaccination. Although an estimated one or two cases of GBS per million persons vaccinated may be related to the flu vaccine, the risk of severe influenza is much greater and can be prevented by the vaccine. More information on the flu vaccine is available through http://www.cdc.gov/epo/mmwr or http:// www.cdc.gov/nip/publications/VIS/default.htm or by calling the toll-free number 888-CDC-FACT (888-232-3228).

inhaler 111 inhalant abuse

Potentially lethal sniffing, snorting, or otherwise taking in through the nose or mouth the fumes of substances including adhesives (toluene, ethyl acetate, hexane, and trichloroethylene, among others), aerosols (butane, propane, fluorocarbons), solvents and gases (acetone, petroleum distillates, esters, mixed hydrocarbons), cleaning agents (tetrachloroethylene, xylene, chlorohydrocarbons), dessert sprays such as whipped cream (nitrous oxide), and room deodorizers containing alkyl nitrite, butyl nitrite, and isopropyl nitrite. Because they are easily accessible, these substances may be abused by teenagers, though they are less abused by this group than marijuana and alcohol. Products’ fumes may be inhaled by spraying the substance into a plastic bag and sniffing it or inhaled directly from the container. Rapid intoxication occurs, and, in some cases, cardiac arrhythmia or severely depressed breathing may cause death even on the first experience, often called “huffing.” If one also lights a match while inhaling dangerous fumes, the fumes may ignite and cause a fire that would spread quickly through the nose and mouth and into the lungs, causing life-threatening internal burns. Some noxious sprays create a seal, or a coating on the lungs that prevents oxygen from going into the bloodstream, causing asphyxiation. Habitual inhalant abuse may also lead to brain, heart, lung, kidney, liver, and bone marrow damage. The inhalation of amyl nitrite, used therapeutically to relieve chest pain in patients with coronary artery disease, should not be used recreationally for the enhancement of sexual pleasure. Inhalation of any nitrite may have extremely dangerous effects on blood pressure and heartbeat. Although the recovery rate from inhalation abuse is among the most dismal of any substance abuse, treatment for inhalation abuse includes medical and psychosocial therapy. See also HUFFING.

inhalant allergies Symptoms of hay fever and asthma triggered by contact of the respiratory system with allergens, including pollens, house-dust mites, fungi, and animal dander, that have been inhaled through the nose or mouth.

inhalation anthrax

See

ANTHRAX.

inhalation challenges

The administration of a specific substance to determine an individual’s reaction to that substance, also known as provocative testing. In conjunctival, nasal, or bronchial challenge, the mucosae of the eyes, nose, or lungs are directly exposed to an allergen to determine that person’s sensitivity to a particular allergen. Methacholine is a substance frequently used to determine reactivity of the bronchioles as an aid in the diagnosis of asthma. (Oral challenges confirm or reject the diagnosis of food allergy.) Direct provocative testing is the most sensitive test for allergy. The principal disadvantage of a challenge is its ability to induce a serious allergic response. Therefore, these tests should be performed only if clearly necessary in a carefully monitored setting. Other disadvantages include difficulty in standardizing test materials and measuring responsiveness quantitatively.

inhalation therapy The act of breathing in medicines dissolved in water vapors or gasses through devices such as nebulizers and aerosolized metered-dose inhalers. Inhalation therapy is a mainstay of treatment for patients with asthma and other lung disorders. inhaled medications

Drugs dissolved in water vapors or gasses and administered by metered-dose inhalers or nebulizers for the treatment of asthma and other lung disorders. Inhaled drugs include albuterol (Proventil, Ventolin), metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire), and cromolyn sodium (Intal). See also AEROSOLS; BETA-ADRENERGIC AGONISTS; INHALATION THERAPY.

inhaler A small device, usually made of plastic, containing medication for the relief of allergy and asthma symptoms and other respiratory problems. Patients should be taught to use the various types of inhalers according to the manufacturer’s instructions and the desired dosage of medicine to be inhaled. See also ASTHMA.

112 inspiration

inspiration ing in. See also

inspirator

Taking in air (inhalation), or breathBREATHING.

insufficiency, pulmonary valvular

A condition characterized by the failure of the pulmonary valve between the right atrium and right ventricle of the heart to close properly.

A respirator or inhaler.

Instep International

A website that promotes the Buteyko asthma relief system, consisting of breathing techniques based on asthma severity and other information. The Australian Buteyko Asthma Trial was founded in 2000 by the Australian Association of Asthma Foundations. You may contact Instep International ACN 008207789; P.O. Box 2094, Townsville, 4810 Australia. Phone: (+61) 747 255 972. Or visit www.nqnet.com

insufficiency, respiratory Dysfunction of the respiratory system, or a condition characterized by inadequate exchange of oxygen and carbon dioxide necessary for optimal functioning of the body. See also BREATHING. insufflation The inspiration of a powder or vapor into the lungs or other body cavity. Examples of insufflation drugs for the treatment of

isthmus, pharyngonasalis 113 asthma include cromolyn sodium and albuterol powders. See also INHALATION THERAPY.

irrespirable Term used to describe any vapor, gas, or atmospheric condition unfavorable to breathing or incapable of being inhaled.

intermittent positive pressure breathing apparatus (IPPB) Device that forces air into the lungs

irritant

during inspiration but allows normal exhalation. This type of breathing assistance, formerly used to treat chronic bronchitis or patients with emphysema, should generally be avoided in these as well as asthmatic patients because lung tissues may be seriously injured by excessive pressure from the device.

interstitial lung disorders (ILD) A roster of approximately 200 diseases characterized as chronic, nonmalignant, noninfectious diseases of the lower respiratory tract. They cause inflammation and disturbances in the walls of the alveoli, which hinders the lungs in transferring oxygen from the alveoli to the pulmonary capillaries and causes difficulty breathing. Some of the causes of ILD include inhaling toxic dusts, fumes, vapors, aerosols, drugs and poisons, and radiation. See also DYSPNEA.

Any substance or agent that causes inflammation or adverse reaction either topically, such as skin reactions, or systemically, affecting internal body systems. Irritants trigger allergies and asthma even though they may not be considered allergens. Examples are dust, perfumes, insecticides, cleaning chemicals, cold air, paints and varnishes, smoke (especially tobacco smoke) or fumes, pollutants, and ozone.

isoetharine (Bronkometer, Bronkosol) A selective, beta-adrenergic agonist bronchodilating drug used for the treatment of asthma by inhalation. See also BETA-ADRENERGIC AGONISTS. isolation

Another term for quarantine, or limitation of the activity and social interaction of patients with communicable diseases. Isolation techniques protect health care personnel and patients who are immunosuppressed.

ipratropium (Atrovent) Atropine-like drug with bronchodilating properties useful for treating bronchospasm in patients with chronic obstructing lung disorders, such as chronic bronchitis, and occasionally asthma. The drug is especially effective in smokers or former smokers. Atrovent is available as both a metered-dose inhaler and solution. The latter is suitable for addition to nebulizers, where it can be combined with albuterol. The drug has virtually no adverse effects. There is also an Atrovent nasal spray effective against the runny noses of common colds and allergies. Combivent is the trade name for a combination of ipratropium and salbutamol.

isoproterenol A beta-adrenergic agonist bronchodilating drug (trade names include Duo-Medihaler, Isuprel, and Medihaler-Iso) formerly in wide use for the treatment of asthma by inhalation. However, isoproterenol has a greater potential for causing tremors and a feeling of nervousness than newer beta-agonist drugs such as albuterol or pirbuterol.

iron lung An artificial respiration device for patients with paralyzed respiratory muscles.

isthmus, pharyngonasalis The opening between the nasopharynx and the oral pharynx.

isoniazid (INH)

An antibacterial drug, also known as isonicotinic acid hydrazide, used mainly for the treatment of tuberculosis. Trade names include Cotinazin, Dinacrin, and Nydrazid.

J Jimson weed

Another name for stramonium, an atropine derivative formerly used in the treatment of asthma and the active ingredient in Asthmador Cigarettes.

juxtangina

Inflammation of the muscles of the throat or pharynx.

114

K kaolinosis Pneumoconiosis resulting from the inhalation of kaolin particles. Kaolin is a clay powder (hydrated aluminum silicate, also known as China clay) used as an absorbent. Kartagener’s syndrome A congenital disorder (also called immotile colia syndrome) inherited as an autosomal recessive trait that is characterized by a structural abnormality of the cilia, hairlike projections from the surface of epithelial cells that line the respiratory system. Normal cilia propel mucus, dust, and other debris, preventing excessive accumulation in the nasal passages, sinuses, and bronchi. The defective cilia do not move normally or at all, and the thick mucus that builds up obstructs the sinuses, eustachian tubes, and lungs, causing chronic sinusitis and bronchitis. Nasal polyps are also common. Kartagener’s syndrome may also be complicated by incomplete or total situs inversus (reversal of body organs including the heart) and fertility problems in both sexes—especially immotile sperm in males. The syndrome occurs in an estimated one in 50,000 births. Symptoms usually occur within the first year of birth and require frequent antibiotics as well as bronchodilator and decongestant medications. ketotifen

An oral drug with antihistaminic properties used prophylactically to prevent symptoms of asthma. Ketotifen appears to be only mildly effective and may take as long as one to three months to demonstrate an effect. Ketotifen is sedative but otherwise has few adverse side effects.

Klebs-Löeffler bacillus

Named for T. A. Edwin Klebs (1834–1913) and German bacteriologist Friedrich Löeffler, also Löffler (1852–1915). The diphtheria-causing bacillus is now called Corynebacterium diphtheriae.

Koch, Robert German physician (1843–1910) who won the Nobel Prize for his study of anthrax. Educated in Göttingen, he also did basic research that showed the reduced reaction of previously infected animals to being reinfected by the same infectious agent. Koch based his study on the inoculation of guinea pigs with tuberculosis and was startled to find that the reduced reaction also occurred if the original exposure had been to bacilli killed by exposure to extreme temperatures or certain chemicals. His scientific findings are also called Koch’s Grundversuch, or Koch’s phenomenon. koniosis From the Greek word konis, meaning dust, any adverse reaction or disease caused by dust. Koniology is the study of dust and its effects. A koniometer is an instrument to measure the amount of dust in the air. See also CONIOSIS; PNEUMOCONIOSIS. Korányi’s sign

Named for Hungarian physician Friedrich von Korányi (1828–1913), a sign of pleural effusion determined by increased resonance upon percussion of a patient’s dorsal spine. See also PLEURAL EFFUSION.

Kronig’s area Klebsiella pneumoniae

A cause of pneumonia, bronchitis, sinusitis, and other respiratory infections. See also PNEUMONIA.

Named for German physician Georg Kronig (1856–1911), a section over the thoracic cavity (chest) and lungs that resonates. See also RESONANCE.

115

L Kussmaul’s breathing

See

laryngismus stridulus

BREATHING.

Laborde’s method

Named for French physician Jean B. V. Laborde (1830–1903). Rhythmic traction movements made on a patient’s tongue to stimulate the respiratory center when asphyxiation is evident.

Laënnec’s pearls Round, gelatinlike mucous particles or “pearls” found in the sputum of patients with asthma. These particles were first described by Rene T. Laënnec, French physician (1781–1826) and inventor of the stethoscope. la grippe See also

A French term for influenza. INFLUENZA.

laryngeal reflex

A cough that results from irritation of the larynx (voice box) or fauces (the constricted opening from the mouth that includes the oral pharynx, the glossopalatine arch, and the pharyngopalatine arch).

laryngeal vertigo Dizziness and fainting that occurs during a coughing spell in a patient with chronic bronchitis. Laryngeal vertigo is also known as tussive syncope. laryngemphraxis laryngismus

Obstruction of the larynx.

Spasm of the larynx that occurs during a severe allergic reaction.

Also known as child crowing, a spasm that briefly causes closure of the glottis and is followed by a noisy inspiration.

laryngitis Inflammation of the larynx, or voice box, the musculocartilaginous upper end of the windpipe (trachea) lined with mucous membrane. Characterized by a sore throat and hoarseness or temporary inability to speak (aphonia), laryngitis may be caused by improper use or overuse of the voice, exposure to wet and cold, extension of a nose or throat infection, or inhalation of irritating vapors or dust. Although the larynx is part of the respiratory system, which is often affected by allergic symptoms, allergies themselves are not generally a cause of laryngitis. Patients with persistent hoarseness should be evaluated for polyps or other disorders of the vocal cords. laryngoceles

Outpouchings filled with air that form from the larynx’s mucous membrane. They can produce a visible, egg-shaped lump in the neck and cause hoarseness and airway obstruction. Musicians who play wind instruments often suffer from laryngoceles, which can also fill with mucuslike fluid and become infected. Surgical removal is the typical treatment.

laryngoplegia Paralysis of the muscles in the larynx, caused by brain tumors, strokes, nerve damage (stemming from tumors, neurotoxins, injury, or a viral infection) and demyelinating diseases. Symptoms of laryngoplegia include difficulty speaking, swallowing, and breathing, a hoarse, breathy voice, abnormal-sounding or weak voice, and high-pitched sounds on respira-

116

Leeuwenhoek’s disease 117 tion. The usual treatments are surgical repair, removal, or tracheostomy, which creates a permanent or temporary opening in the windpipe. Arytenoidectomy serves to widen the airway between vocal cords.

laryngorhinology

The study of diseases of the

larynx and nose.

laryngorrhea

Excessive mucus discharge from

the larynx.

laryngospasm

Sudden muscular contractions, or spasms, of the larynx.

laryngotracheobronchitis Inflammation of the larynx, trachea, and bronchi.

tion. When the vocal cords are removed, speaking or making sounds must be accomplished through the use of esophageal speech, in which a person is instructed to inhale into the esophagus and produce sound upon exhalation; a tracheoesophageal fistula, a surgically inserted valve between the windpipe and the esophagus that can help produce sound when a person inhales; or an electrolarynx, a device that is held against the neck to help an individual produce sound. All these methods tend to sound artificial. Other problems associated with the vocal cords are polyps, nodules, contact ulcers, and one- or two-sided paralysis. See also LARYNGOPLEGIA.

laughing gas

Nitrous oxide gas inhaled for use as a temporary general anesthetic. See also INHALANT ABUSE.

larynx

The vocal cords, or voice box, the part of the respiratory system located at the upper end of the trachea below the root of the tongue. The larynx, a Greek word meaning the “upper part of the windpipe,” is made of nine cartilages bound by an elastic membrane and lined with mucous membrane. When moved by muscles and aided by air pressure, the mouth, and the tongue, the larynx produces sounds, including speech. According to the American Lung Association, the incidence rate for cancer of the larynx has decreased 20 percent between 1973 and 1997, although incidences among white and black women have slightly increased. The 1997 statistics show that in 11.5 per 100,000 black males, the incidence is 88 percent higher than it is in 6.1 per 100,000 white males. Larynx cancer is one of the most common types of head and neck cancer and is usually associated with abuse of alcohol and cigarettes. One of the symptoms of larynx cancer is hoarseness, especially chronic hoarseness that lasts for more than two weeks, which requires medical attention. Difficulty swallowing, pain, and a lump in the neck may also indicate laryngeal cancer. Treatment is surgery or radiation therapy for early-stage cancer, but advanced cancer may require partial or total removal of the larynx (laryngectomy) and radia-

learning disabilities and theophylline Behavioral changes and inattentiveness that are attributed to the use of theophylline as treatment of childhood asthma, resulting in poor performance in school. See also THEOPHYLLINE. lecithin-sphingomyelin ratio A method of determining the maturity of the lungs in a fetus, the ratio of lecithin to sphingomyelin in the amniotic fluid. In the process of development, fetal lungs (after the 34th week of gestation) becoming more mature produce more lecithin—a type of fatty substance known as phospholipids, than sphingomyelin—one of the phosphorus-containing sphingolipids found in nervous tissue and blood. If a fetus is delivered before the lungs produce more lecithin than sphingomyelins, there is a high risk of the infant’s having hyaline membrane disease. Leeuwenhoek’s disease Named for Dutch microbiologist Anton van Leeuwenhoek (1632–1723), a disorder known also as respiratory myoclonus, which stems from an abnormality in the respiratory control system in the brain stem. The disorder is characterized by shortness of breath and epigas-

118 Legionnaire’s disease tric pulsations caused by involuntary contractions of the diaphragm and other proximate respiratory muscles. Treatment may include the drug diphenylhydantoin and surgical section of the phrenic nerve, which arises in the cervical plexus, goes into the chest and then to the diaphragm. See also DIAPHRAGM.

immunosuppressive disorder, use of corticosteroids, alcohol abuse, and exposure to aerosolproducing devices. It is estimated that Legionnaire’s disease accounts for 1 to 8 percent of all cases of pneumonia and 4 percent of fatal pneumonias contracted by individuals while they are hospitalized. The death rate is about 20 percent.

Legionnaire’s disease

A type of pneumonia caused by the gram-negative bacillus Legionella pneumophila, named for a group of people who contracted the disease during a 1976 convention of the American Legion in Philadelphia, Pennsylvania. Also known as legionellosis, the disease may include dry cough, muscle pain, shortness of breath, confusion, headache, fever, fatigue, and sometimes gastrointestinal symptoms such as diarrhea. If untreated, cardiovascular collapse may occur. The bacillus can be inhaled from droplets from air conditioners, humidifiers, water cooling towers, faucets, shower heads, evaporative condensers, whirlpool spas, decorative fountains, ultrasonic mist machines (used to mist produce in supermarkets), and respiratory therapy equipment that is contaminated, but there is no direct contagion between individuals. Treatment of choice consists mainly of the antibiotics azithromycin, fluoroquinolones (trovafloxacin, sparfloxacin, pefloxacin, levofloxacin, ofloxacin, and grepafloxacin), tetracycline, and erythromycin, preferably administered immediately after diagnosis, or rifampin. Patients who are immunocompromised or have had a prolonged illness and respiratory failure caused by pneumonia or nosocomially acquired disease prior to infection with the Legionnaire’s bacillus often have an approximately 50 percent higher risk of dying. Recovery rate is slow. Legionnaire’s disease may be indistinguishable from other forms of pneumonia caused by bacteria, and chest radiographs may not be totally reliable in the diagnosis. The presence of Legionella pneumophila in sputum, blood, and urine specimens may indicate Legionnaire’s disease or Pontiac fever, a self-limited illness that does not include pneumonia. Risk factors that point to a possible diagnosis of Legionnaire’s disease are recent travel, recent plumbing repairs in one’s home, smoking, diabetes, kidney or liver failure, a systemic malignancy or

leishmaniasis

An infection caused by a species of Leishmania, a genus of parasitic flagellate protozoa named for Sir William B. Leishman, a British medical officer (1865–1926). In the form of American leishmaniasis, the organism mainly affects the nasal cavities, mucocutaneous membranes, and pharynx.

leprosy, tuberculoid

A form of a chronic disease caused by the Mycobacterium leprae, also known as Hansen’s disease, characterized by asymmetrical nerve lesions and skin anesthesia. The infection in this form resembles tuberculosis. Treatment includes dapsone or a combined chemotherapy of dapsone, rifampin, and clofazamine. In severe cases, corticosteroids or thalidomide may be administered. Individuals who have undergone three months of dapsone or clofazamine therapy, and those who have taken rifampin for three days are not considered infectious and isolation is not necessary. As opposed to the obsolete idea that leprosy is incurable, the prognosis is good if the patient receives proper therapy.

leukocyte histamine release assay Another name for basophil degranulation and histamine release. leukocytes White blood cells produced in bone marrow, lymph nodes, and cells lining capillaries in organs such as the spleen. There are two types of leukocytes: granulocytes, which have granules on their cytoplasm, and agranulocytes, which do not have granules. Granulocytes include juvenile neutrophils, segmented neutrophils, basophils, and eosinophils, and agranulocytes include lymphocytes (produced in lymph nodes) and monocytes, all of which participate in helping the body fight

locations ideal for asthma and allergy patients 119 infection and in the inflammatory processes that occur during allergic reactions. Leukocytes of all types circulate throughout the body, especially to troubleshoot in areas where there are injured tissues or infections. The normal adult white blood count is approximately 4,000 to 10,000 leukocytes per cubic millimeter of blood. Leukopenia refers to fewer than 4,000 white blood cells; leukocytosis is indicated by a count greater than 10,000. A white blood cell differential count, which examines the various types of leukocytes in the circulating blood and other body secretions, helps diagnose many medical disorders, including allergies and infections. For example, bacterial infections usually cause an increased number of total white blood cells, whereas viruses may slightly increase, decrease, or maintain a normal count. Bacterial infections most often result in an increase in polymorphonuclear cells (also called neutrophils, polys, or segs) relative to the increase in total white cells. Viral infections may cause an increase in the number of leukocytes. The presence of more than 5 percent eosinophils in the white blood count frequently suggests an allergic or parasitic disorder.

leukotrienes

Potent biochemicals produced and secreted by various types of immune cells such as macrophages, mast cells, eosinophils, basophils, and monocytes, along with other chemical mediators (natural substances in the body that act like drugs), including histamine. Leukotrienes and other substances including prostaglandins, collectively called eicosanoids, are fatty acids derived during the metabolism of arachidonic acid, an essential component of the cell membrane. Certain leukotrienes may be held partly accountable for effects of asthma such as bronchospasm or constriction, increased airway hyperresponsiveness to triggers, increased microvascular permeability (the ability to pass substances through the walls of tiny blood vessels), and excessive production of mucus. These chemicals may be 100 to 1,000 times more potent and exert a more prolonged effect than histamine in contracting the smooth muscle of airways. The presence of leukotrienes may also be a reason that antihistaminic drugs, which block the

action of histamine, do not fully alleviate allergic reactions. Zafirlukast (Accolate) is the first of a class of drugs effective for the treatment of leukotrienemediated reactions. Accolate antagonizes or blocks the effects of LTD4 (a type of leukotriene) and is useful to prevent inflammatory changes that occur in mild to moderate asthma. It is not known if the effects of these agents will be an additive to other inflammatory drugs such as corticosteroids. Accolate is approved for the treatment of mild to moderate asthma. There do not appear to be any serious adverse effects. Zileutron (Zileutrol) inhibits, or prevents, the action of 5-lipoxygenase, and may have additive effects to inhaled corticosteroids.

Leutrol

See

ZILEUTRON.

licorice A flavoring, demulcent, and mild expectorant derived from the root of the plant Glycyrrhiza glabra. Licorice may be included in cough medicines. ligament, pulmonary A fold of pleura located from the root of the lung to the base of the medial surface of the lung. lingulectomy The surgical removal of the lingula, a tongue-shaped projection from the upper lobe of the left lung. lobar pneumonia

An inflamed condition in one or more lobes of the lung. See also PNEUMONIA.

lobes of lungs

Segments, or large divisions, of the lungs consisting of the superior and inferior lobes of the left lung, and the superior, middle, and inferior lobes of the right lung.

lobules of lungs

The smaller parts of the lungs, including the respiratory bronchiole and its branches, known as the alveolar ducts, alveolar sacs, and alveoli.

120 loratadine locations ideal for asthma and allergy patients Geographic areas considered to provide improved living conditions, depending upon the specific allergens to which an individual is sensitive. Some people feel the need to move from their present homes to avoid allergens indigenous to that area, but climates and geographic characteristics can change in time, causing previously favorable areas to become havens for new allergens and pollutants. For example, Arizona was once thought to be an ideal climate for asthmatics. However, pollutants (including the introduction of pollinating plants and grasses by the incoming new residents) and environmental changes such as urbanization and irrigation have turned populated areas of this state into high-risk zones. In addition, the stress of moving and new environmental exposures may intensify asthma and allergy symptoms.

loratadine

An antihistamine (trade name Claritin) with a lower potential for sedation than traditional allergy drugs. Introduced in the United States in 1993, loratadine is taken once daily on an empty stomach.

Lucas-Championnière’s disease

Pseudomembranous bronchitis (related to croupous bronchitis, inflammation of the bronchi including some of the symptoms of croup: difficulty breathing and spasm of the larynx), named for French surgeon J. M. M. Lucas-Championnière (1843–1913). This condition may be confused with asthma. See also BRONCHITIS.

lung

The main organs of the respiratory system. The lungs are two spongelike structures located in the chest within the rib cage that provide life-sustaining oxygen to the body. Lungs contain air sacs, called alveoli, that accommodate air taken into and expressed out of the lungs by inhalation and exhalation, respectively, during which oxygen is transmitted to the bloodstream and carbon dioxide is expelled. In the process of breathing, air from the atmosphere enters the trachea, or windpipe, and passes into the two large bronchi, each branching into a

lung on either side, then to the smaller bronchi and bronchioles. The entire structure resembles a tree. The lungs, which move upon inhalation and exhalation, are encased by pleurae, protective membranes that allow each lung to expand and contract. (In the event of pleurisy, these membranes swell and rub against each other, causing pain during respiration.) The right lung is divided into three lobes, or sections, and the left lung is divided into two lobes. In the adult male, the approximate weight of the right lung is 625 grams, and the left lung 570 grams. The lungs contain 300 million alveoli, with a respiratory surface of about 70 square meters. In the left lung is the cardiac depression, an indentation that accommodates the heart. Pulmonary circulation describes blood traveling from the heart to the lungs and back to the heart. The primary lung function is to bring air in contact with the blood to add oxygen and remove carbon dioxide. Respirations in adults average at 18 per minute, and the total capacity of the lungs ranges from 3.6 to 9.4 liters in adult males and from 2.5 to 6.9 liters in adult females. Nerve supply to the lungs consists of parasympathetic fibers by way of the vagus (cranial) nerve and sympathetic fibers from the anterior and posterior pulmonary plexuses. The main blood vessels are the bronchial and pulmonary arteries and the pulmonary veins. Diseases of the lung include bronchial asthma, tumors, and anomalies caused by injury to the lungs. Many diagnostic procedures include chest X ray, pulmonary function tests, bronchoscopy, biopsy of lung tissue, blood tests, and sputum analysis. See also BREATHING.

lung abscess The formation of pus in the lung that causes high fever, sweats, pallor, loss of appetite, chest pain, dyspnea, coughing, foulsmelling, purulent expectoration, cavernous breathing, and possibly bubbling rales. Lung abscess is usually caused by bacteria from the mouth or throat that is then inhaled into the lungs, especially when an individual’s immune system is impaired for some reason, such as unconsciousness attributable to anesthesia, sedation, or substance abuse, or if a person has pneumonia, an infected pulmonary embolus, a blood infection, a lung tumor, or a neurological disorder. With proper

lung cancer 121 treatment, which, depending upon the severity and size of the abscess, may include draining the abscess, respiratory therapy, dietary measures, surgery, and oral or intravenous antibiotic therapy, the prognosis is fair. Lung abscess causes death in approximately 5 percent of the cases, particularly if a patient has lung cancer, an impaired immune system, or other pre-existing serious condition. See also BREATHING.

lung cancer

Cancer manifesting in the trachea, air sacs, and structures of the lungs of the respiratory system, or originating in lung cells and then metastasizing to other parts of the body, such as the lymphatic system and bloodstream. According to the American Lung Association, lung cancer is the leading cause of death from cancers in the United States, and incidence and mortality have continued to increase since the 1930s. Lung cancer accounts for 28 percent of all deaths from cancer. Approximately 156,900 deaths were estimated for the year 2000. The lung cancer rate in 1997 was 54.4 per 100,000. In 1987, lung cancer surpassed breast cancer as the prime cause of cancer mortality among women, largely attributed to the fact that more women are smoking cigarettes. Incidence is declining in men (80 per 100,000) and rising in women (42 per 100,000). Cigarette smoking is the most significant cause of lung cancer in America, with an estimated 87 percent of all lung cancer incidences resulting from smoking. According to the Surgeon General’s latest report, in 1998 there were 47.2 million smokers in the United States: 24.8 million male, 22.4 million female. For both sexes combined, the percentage of lung cancer deaths attributed to smoking increased between 1990 and 1995. However the National Cancer Institute says men’s lung cancer rates have been steadily declining from a high of 87 men per 100,000 in 1984 to 70 men per 100,000 in 1996, while lung cancer deaths among women have increased 600 percent over the past 50 years and now account for a quarter of women’s cancer deaths, surpassing both breast and ovarian cancer statistics. According to estimates from National Vital Statistics, 1994, 126,999 people of both sexes and all ages died in 1990, and in 1995 the number

grew to 151,075. The National Cancer Institute’s calculated lifetime risk of dying from lung cancer includes smokers and nonsmokers. Based on statistics set forth between 1995 and 1997, 7.62 percent of males of all races and 4.77 females of all races risk dying from lung cancer. It is also the most common form of cancer among African-American men and women. Other causes of lung cancer include occupational hazards, such as exposure to asbestos, radiation, arsenic, chromates, nickel, chloroethyl ethers, radon gas, mustard gas, co*ke-oven emissions, etc., and pre-existing diseases such as fibrosis, tuberculosis, or cancer that has spread from the skin, kidney, thyroid, stomach, bone, rectum, or other part of the body to the lung. Many lung cancers begin as small cell (or oat cell) lung cancer (SCLC) and nonsmall cell lung cancer (NSCLC) in the bronchial lining, in the trachea, or in the bronchioles or alveoli. SCLC, making up approximately 20 percent of all lung cancers, is mostly attributable to smoking. The other 80 percent of lung cancers are the nonsmall varieties including squamous cell carcinoma, adenocarcinoma, and large-cell undifferentiated carcinoma. Less common lung cancers include carcinoid tumors, hamartomas, sarcomas, lymphomas, and adenoid cystic carcinomas, which may warrant special treatment regimens. The diagnosis of lung cancer usually involves chest X rays, CT scans, bronchoscopy, pulmonary function tests, needle biopsy, and sputum analysis after a person complains of symptoms such as chest pain, a persistent cough or hoarseness, blood in the sputum, shortness of breath, and significant weight loss. However, once these symptoms appear, the disease may be well advanced and perhaps beyond a curable stage. Diagnostic tests for early detection of lung cancer, a low-dose helical or spiral CT scan among them, are being developed, along with new combinations of chemotherapy, immunotherapy, and drugs that can stop tumor blood vessels from thriving. Treatment of lung cancer includes surgery, typically followed up by chemotherapy and radiation depending upon the type of cancer and effectiveness of having removed the diseased portion of tissue. Cancers such as small-cell lung cancer may

122 lung cancer

* 0.0

6.8

8.1

33.3 131.4 296.7 387.7 289.9

85 15-24 25-34 35-44 45-54 55-64 65-74 75-84 and up

SOURCE: NATIONAL CENTER FOR HEALTH STATISTICS: REPORT OF FINAL MORTALITY STATISTICS, 1998 NOTE: (1) Includes lung, larynx and other respiratory cancers. *Represents data greater than zero but statistically unreliable

RATE

AGE GROUP

100

200

300

400

RATE PER 100,000 RESIDENT POPULATION

FIGURE 2: DEATH RATES FOR MALIGNANT NEOPLASMS OF THE RESPIRATORY SYSTEM (1) BY AGE, 1998

lung cancer 123

124 lung cancer

AK 44.4*

NV 43.9

AZ 35.6

UT 47.3*

ID 0.0*

CO 26.4

NM 31.0*

WY 0.0*

MT 64.2*

HI 15.3*

OK 47.3

KS 39.7

TX 49.2

NE 66.7

SD 0.0*

ND 0.0*

SOURCE: CDC WONDER: UNPUBLISHED MORTALITY DATA, 1998 NOTES: (1) Rates are per 100,000 and age-adjusted to the 1940 U.S. Standard Population. * These rates should be interpreted with caution as they represent 20 or fewer deaths.

CA 40.6

OR 29.9*

WA 49.0

LA 54.7

AR 50.2

MO 58.3

IA 68.4

MN 49.5

MS 49.9

IL 54.6

WI 54.8

AL 39.7

NH 0.0*

FL 36.9

NC 43.1

VA 46.8

PA 53.4

NY 32.2

VT 59.9*

SC 40.9

WV 38.2

GA 40.5

OH 49.9 KY 58.3

TN 51.1

IN 54.1

MI 45.2

FIGURE 4: LUNG CANCER AGE-ADJUSTED DEATH RATES (1) IN BLACKS, 1998

DC 49.1

MD 45.7

DE 41.1

NJ 44.0

RI 52.8 CT 39.1

MA 35.2

NATIONAL LUNG CANCER DEATH RATE IN BLACKS: 44.6

ME 0.0*

lung cancer 125

126 lung cancer

lung cancer 127

128 lung cancer

lycoperdonosis 129 respond to chemotherapy, but there exists the possibility of drug resistance after repeated treatments. Surgery or radiation may be combined with chemotherapy, and in the event that a cure is not accomplished, symptoms may respond well to palliative therapy. Radiation therapy is significant in treating and often curing early-stage non–smallcell lung cancer. One of the newest treatments still under investigation is dose-intensity chemotherapy, which is used to treat recurring tumors that have become resistant to the drug to which they formerly responded. The dose is increased in an attempt to kill more cancerous cells at a time. The side effects of dose-intensity chemotherapy include damage to the bone marrow. New radiation therapies include proton or neuron beam, radiation-activated dyes and photodynamic therapy. In addition, immunotherapy techniques have been designed to boost the immune system, and new drugs are being developed to prevent or reduce the recurrence rate of cancers such as those of the mouth, larynx, and lungs. Retinoids, derived from vitamin A, have been effective against those forms of cancer. The most common chemotherapies are Paraplatin (carboplatin), Platinol (cisplatin), and Taxol (pacl*taxel), as well as Gemzar (gemcitabine hydrochloride) and Taxotere (docetaxel), both of which are still in clinical trial stages. See also APPENDIX III.

lung collapse Atelectasis, or the result of a decrease in intrapulmonic pressure or an increase in intrathoracic pressure. An obstruction in the bronchial tubes, a tumor, an enlarged heart, or pressure placed on the lung by air or fluid in the pleural cavity may cause the change in pressure. When a lung collapses suddenly, the victim also suffers circulatory collapse and has difficulty breathing. A gradual onset may not be indicated by these symptoms. Hypostatic lung collapse refers to lung congestion related to asthenic, or debilitating, diseases, especially when the patient remains inactive and in a recumbent position for prolonged periods of time. Passive lung collapse refers to obstructed blood flow from the lungs to the heart. Treatment may include deep-breathing exercises,

changing positions, prevention of congestion, and assisted respiration. See also ATELECTASIS.

lunger

An obsolete term used in the 1800s to describe a person with tuberculosis or a chronic pulmonary disorder.

lung hemorrhage

Bleeding that arises from the mouth, larynx, trachea, bronchi, or lungs, usually accompanying an attack of productive coughing up of sputum that contains frothy bright red blood and tastes salty. Lung hemorrhage may also be caused by a parasitic fluke infection of the lungs. Treatment includes cold compresses on the chest, keeping the patient warm, teaching the patient to cough without straining, bedrest with the head slightly elevated, ice packs, sedatives, and tepid fluids. Any hemorrhage requires the attention of a physician.

lung inflammation See also

Another term for pneumonia.

PNEUMONIA.

lungmotor

A device that forces air or a combination of air and oxygen into the lungs.

lung surfactant

The substance that regulates the amount of surface tension of the fluid that lines the alveoli, or air sacs. The naturally produced substance has been synthesized and is being used investigationally in cases of infants with respiratory disease syndrome.

lung transplantation The transferal and surgical installation of a lung from a deceased donor into an individual with an imminently life-threatening lung disease. Transplantation of both a single lung and both lungs has become a highly successful surgery and the majority of patients survive. lungworm Organisms called nematodes that use the lungs of humans and animals as hosts in which to thrive. Nematodes include roundworms and

M threadworms, certain species of which are parasitic. Infestation requires medical treatment.

lungwort The herb Pulmonaria officinalis from which is derived a tonic or remedy for respiratory disorders. lycoperdonosis A respiratory disease caused by inhaling significant quantities of Lycoperdon spores from the mature mushroom commonly known as “puffball.” Most puffballs belong to this genus of fungi. macrophage Important monolytic white blood cell involved in the immune response. Macrophages overtake bacteria and other foreign materials and break them down as an immunological defense. In the respiratory system, alveolar macrophages enter lung tissue and degrade with their enzymes the cell walls of the bacteria or other invader, or transport the bacteria from the lung tissue to the lower airways until they are trapped in mucus and expelled from the respiratory tract via the cilia (also known as the mucociliary transport escalator). Also, macrophages are capable of transporting bacteria to the lymphatic system, where they are filtered and then destroyed by other cells.

if diet, excretions, and spiritual emotions are regulated; and if proper rest and exercise are maintained. Educated by his father, who was a judge, and by Rabbi ibn Migas, Cordova-born Maimonides also wrote about religion and religious law, logic, astronomy, preventive medicine, drugs, toxins, Galen’s teachings, sex, and other topics. He became known as the greatest Jew after Moses and one of the preeminent figures of modern medical ethics along with Hippocrates. Because of religious persecution, Maimonides’ family fled to Cairo, where he became a physician. His holistic practice included advocating bathing and massage.

Mantoux test

Named for French physician Charles Mantoux (1877–1947), an intracutaneous injection to determine the presence of tuberculosis. One-tenth milliliter of Purified Protein Derivative is injected into the skin, and within 24 to 72 hours the puncture site becomes hard if a person has an active or inactive (exposure to) tubercular infection. The Mantoux test is also known as the tuberculin test.

maple bark disease

A form of pneumonitis caused by the inhalation of mold spores (Cryptostroma corticale) found in the bark of maple trees. See also PNEUMONITIS.

Maimonides, Moses

Jewish physician (1135– 1204) who wrote Treatise on Asthma, among other scientific and philosophical works, which was the first of his medical books available in English translation. In the treatise, Maimonides recommends that attacks of various illnesses, including asthma (which he called shortness of breath), can be made less frequent and less severe if the air is kept clean;

marijuana

See

CANNABIS.

massage An expanded form of the traditional back rub. Various methods of massage are popular, including the Japanese shiatsu, which concentrates on pressure points of the body, and massag-

130

meningitis, pneumococcal 131 ing the hands and feet. Essentially, any type of massage induces relaxation and may be particularly useful when stress acts as a trigger for asthma. See also ACUPRESSURE.

massive collapse of the lung

A severe reaction to shock or abdominal or thyroid surgery characterized by chest pain, difficulty breathing, and cyanosis. The collapse is caused by a mucous plug or foreign substance in the main bronchus or by a tension pneumothorax. Treatment includes the administration of carbon dioxide, antibiotics, removal of a foreign body, and oxygen therapy. See also PNEUMOTHORAX.

son can inhale in approximately 30 seconds or other specified time.

maximum expiratory flow rate (MEFR)

A measure of a maximal inhalation from a spirometer and a maximal exhalation that yields a calculation of the person’s vital capacity, or the total amount of air a person takes in and out. The MEFR is used clinically to approximate the peak expiratory flow rate (PEFR or PEF). See also PEAK FLOW MEASUREMENTS; SPIROMETRY.

measles, cough accompanying Respiratory symptoms associated with the viral communicable disease known as measles, including coughing that sounds brassy, sneezing, and nasal congestion.

mast cells

One of the major cells in body tissues responsible for the onset of allergic symptoms. Mast cells contain histamine and other chemically active substances. During a type I, or immediate, allergic reaction, mast cells are activated. There are two types of mast cells, connective tissue mast cells and mucosal mast cells. Each are coated with immunoglobulin E (IgE) antibodies, which bind to receptors on the mast cell’s surface. The receptors correlate to individual allergens (substances capable of causing allergy). One mast cell may have from 5,000 to 500,000 individual IgE antibody receptors on its surface. After exposure to an allergen, the surface antibodies “recognize” their specific allergens, causing the mast cell to release chemical mediators. Chemical mediators are potent biochemicals, including histamine, prostaglandins, and leukotrienes, among others. In an asthmatic patient, the release of the mediators causes a sudden constriction and inflammation of the bronchioles, which results in wheezing and shortness of breath. The mast cells also produce proteases and cytokines, substances involved in the process of tissue inflammation, growth, and repair. See also LEUKOTRIENES.

Maxair

See

PIRBUTEROL.

maximum breathing capacity The largest amount of air, measured in liters per minute, a per-

medical alert bracelets and necklaces Engraved metal plates worn like jewelry to identify a chronic medical condition or allergy in the event an individual becomes unable to communicate. Medihaler-Epi

Brand of epinephrine bitartrate,

USP.

melanemia Also called melanosis and anthracosis, a black deposit found in the lungs. See also ANTHROCOSIS; COAL WORKER’S PNEUMOCONIOSIS. melioidosis

A disease resulting from infection by Pseudomonas pseudomallei that causes pneumonia. Melioidosis is derived from the Greek word melis, meaning a distemper of asses, and eidos, meaning form. The causative bacterium thrives in soil and lakes in Asia, Africa, and Australia, but the disease, with pneumonia-like symptoms including high fever, is reportedly nonexistent in the United States and Europe. Similar to glanders, a horse and donkey disease also caused by the inhalation of P. mallei but rarely transmitted to humans, melioidosis is potentially fatal. With early detection through pus, sputum, or blood sample analysis, it is curable with antibiotics. See also PNEUMONIA.

132 meningitis, tuberculous membrane, mucous

The soft, pink lining of certain body structures, including the mouth, nose, throat, eyelids, bladder, vagin*, and intestinal tract, that secretes mucus, a sticky fluid that keeps the surfaces of these and other organs moist.

meningitis, pneumococcal

Inflammation of the membranes of the brain or the spinal cord caused by the pneumococcus, a type of bacterium. Young children are frequently the victims of this disease, which may be life-threatening, but pneumococci may affect any age group. The disease is transmissible through a lung, blood, ear, skull bone, or sinus infection. Individuals who have had their spleen removed or who have a nonfunctioning spleen (the organ that produces antibodies that prevent pneumococcal infection) are particularly at risk should they contract the bacterium. Treatment includes large doses of intravenous or oral antibiotics, usually penicillin. Meningitis caused by viruses is milder and more common than bacterial meningitis, which requires immediate treatment and may be prevented by a pneumococcal vaccine that protects against the most common strains of the bacteria. The vaccine is recommended for people with lung and chronic heart disorders as well as other diseases such as diabetes, sickle cell, Hodgkin’s, and HIV. See also PNEUMOCOCCUS; PNEUMONIA.

meningitis, tuberculous Inflamed cerebral meninges as a result of infection by the tubercle bacillus. See also TUBERCULOSIS.

fireproof fibers used as an effective fire retardant. Asbestos has been used in numerous building materials and products, including hot-water pipe coverings, boilers, furnaces, soundproof tiles, floor coverings, fireproofing and insulation in buildings, trains, and ships, brake and clutch linings in cars and airplanes, plasters, drywall, roof shingles, oven liners, toasters, cements, paints, hair dryers, ironing board covers, joint compounds and tapes, and protective clothing. When asbestos is inhaled into the lungs and other organs, some of the fibers may remain in the body. Buildings made before 1975 may contain asbestos products, and persons living and working in these buildings risk contracting an asbestos disease, largely because the fibers can be blown into the air through the ventilation system. Asbestos may also be ingested, particularly when tiny fibers are released into the air during construction work, sanding, cutting, or mixing substances containing asbestos. In addition, workers in industries involving the use of asbestos may contract the disease from bringing home asbestos dust on their clothes. The three most common diseases attributable to prolonged exposure to asbestos are lung cancer, asbestosis, and mesothelioma. Mesothelioma is the only one that may not require a latency period, in which disease develops over long periods of time. See also ASBESTOSIS; LUNG CANCER.

metal fume fever

mesopneumon The hilus of the lung at which two pleural layers meet.

Also called polymer fume fever, a disease resembling influenza caused by inhaling high concentrations of metallic oxide fumes, including zinc oxide, arsenic, cadmium, cobalt, copper, iron, lead, magnesium, manganese, mercury, nickel, or tin. Symptoms are excessive thirst, diaphoresis (excessive sweating), inflammation of the eyes and respiratory tract, chills, and weakness. Treatment involves leaving the offending environment and getting fresh air. Metal fume fever is considered an occupational disease.

mesothelioma

metallic tinkling

mesobronchitis

Bronchitis in which the middle layer of the bronchi is inflamed. See also BRONCHITIS.

A rare form of cancer characterized by a malignant tumor that lodges in the mesothelium (lining) of the pleura, pericardium, or peritoneum. Victims of mesothelioma are workers who have inhaled asbestos, a rock made up of silky

A ringing, like the sound of metal being tapped, heard through a stethoscope over the chest area in which the lung is collapsed. See also PNEUMOTHORAX.

mold allergy 133 metaproterenol

A beta-adrenergic agonist, or bronchodilator, drug widely used in the treatment of asthma. Metaproterenol is available as a metered-dose inhaler, tablet, liquid, and solution for nebulizer use. See also BETA-ADRENERGIC AGONISTS.

methacholine challenge A test to diagnose asthma in individuals with confusing or minimal symptoms by the inhalation of the drug methacholine in gradually increasing quantities. An asthmatic person will have a diminished flow rate during spirometry (pulmonary function study), whereas a normal individual will maintain normal flow rates. methotrexate A chemotherapeutic agent used in the treatment of cancer, psoriasis, and rheumatoid arthritis. Its effectiveness is being studied as a steroid-sparing, anti-inflammatory drug for severe asthma. Although reports indicate conflicting results, methotrexate is thought to be especially beneficial to corticosteroid-dependent asthmatics. One report recommends that methotrexate be discontinued after 36 months because of the possibility of inducing bronchial hyperreactivity or exacerbation of asthma. Prolonged use and higher doses than those used for the treatment of asthma have been known to cause hepatotoxicity, fibrosis, and cirrhosis; in addition, methotrexate may be lethal to a fetus or cause congenital abnormalities and therefore should not be administered to pregnant women with rheumatoid arthritis, psoriasis, or asthma. Other adverse effects of methotrexate include lung disease, bone-marrow depression, and gastrointestinal disturbances. methscopolamine nitrate

The generic name for an ingredient in the drugs Dura-Vent DA, Extendryl, Histaspan, Histor-D, Rhinolar, and Dallergy. Methscopolamine nitrate, in conjunction with other agents in these preparations, acts as an antihistaminic decongestant prescribed for relief of respiratory congestion, allergic rhinitis, and allergic skin reactions.

methylprednisolone The generic name for the adrenal corticosteroid drugs Depo-Medrol and Medrol. An anti-inflammatory glucocorticoid agent, methylprednisolone aids the body in modifying immune responses to various stimuli. It is prescribed for treatment of endocrine, rheumatic, ophthalmic, hematologic, neoplastic, respiratory, and gastrointestinal disorders. In addition, methylprednisolone can control severe allergies, including seasonal allergic rhinitis, contact dermatitis, atopic dermatitis, serum sickness, pemphigus, bullous dermatitis herpetiformis, and bronchial asthma. See also CORTICOSTEROIDS. mice allergens Hair, feces, urine, and other physical aspects of mice, especially in infested buildings or areas, that cause adverse effects, or allergic reactions, in some individuals. Research laboratory workers may experience allergic symptoms and asthma in conjunction with exposure to the urine, skin, and saliva of mice and rats. See also OCCUPATIONAL ASTHMA. microlithiasis, pulmonary alveolar

The development of microscopic particles of bone in the lungs.

middle lobe syndrome

See

ATELECTASIS.

midge

A small-winged fly of the order Diptera. The larvae of nonbiting midges (chironomids) may cause occupational asthma in those who handle fish foods. See also OCCUPATIONAL ASTHMA.

miliary tuberculosis An acute form of tuberculosis characterized by minute tubercles, or small, gray nodules reminiscent of the seeds of millet, in the affected tissue or organ. military service and asthma The correlation of armed forces’ policies and candidates with asthma. Anyone who has had symptoms of asthma over the age of 12, whether symptoms still occur or not, may be excluded from the military academies. During Operations Desert Shield and Desert

134 molysmophobia Storm, nearly 10 percent of admissions to a fleet hospital in Saudi Arabia were for asthma. Although 12 of the 94 patients did not have asthma, 51 needed to be evacuated from the country. Nearly half of the asthmatics displayed a gas-mask intolerance or phobia. The nerve-gas antidote pyridostigmine increased asthma symptoms in more than 25 percent of asthmatic patients. Desert sand storms triggered asthma in 34 percent of the patients.

mold allergy Symptoms of allergic rhinitis (hay fever) and asthma caused by the inhalation of indoor and outdoor fungal spores commonly called molds. Wind-borne pollen allergens and dry fungal spores are usually removed from the environmental air during rain. Therefore, allergy symptoms during periods of high humidity are most likely due to high mold spore counts found in clouds and mist. Few individuals are sensitive to fungal allergens alone, but fungal sensitivity is common.

meningitis, heart and kidney diseases, and individuals in a coma. See also APNEA.

monitoring, respiratory Also known as respiratory function monitoring, alarm devices and techniques used to alert caregivers when a patient’s lung function and breathing require attention. Measuring the amount of oxygen in the blood or carbon dioxide in expired air, pulse oximetry, and use of devices that measure respiratory muscle function and breathing patterns are included. Montelukast

See

mountain fever

SINGULAIR.

See

ALTITUDE SICKNESS; BENDS.

mountain sickness, chronic See ALTITUDE SICKNESS. movement, respiratory

See

RESPIRATORY SYSTEM.

molysmophobia

Morbid fear of contamination or contracting an infection.

mucormycosis

mometasone furoate A topical corticosteroid nasal spray that when used once a day has equal effectiveness of older twice-a-day products. It may prevent allergic nasal symptoms if begun prior to the onset of pollen seasons. The drug has a safety profile that does not differ from that of a placebo. See also CORTICOSTEROIDS.

mucosa

Monge’s disease Chronic mountain sickness named for Peruvian pathologist Carlos Monge (1884–1970). See also ALTITUDE SICKNESS.

mucus

monitor, apnea A device such as an apnea alarm mattress that sets off an alarm when the person, particularly an infant, sleeping on it stops breathing. Apnea monitors are useful in the prevention of sudden infant death syndrome (SIDS) and employed in the care of patients with brain injury,

See

ZYGOMYCOSIS.

The membrane or layer of tissue that is consistently moistened by mucous secretion, such as in the mouth, nasal passages, throat, and other body cavities and organs.

mucosal tests

Diagnostic tests for bacteria and other harmful microorganisms in mucus. See

MEMBRANE, MUCOUS.

Müller maneuver

Named after German physician Johannes P. Müller (1801–58), a technique for producing negative intrathoracic pressure. The patient exhales and tries to inhale while the glottis is closed (similar to holding one’s breath) to achieve better visualization for the physician during fluoroscopy of the esophagus.

myxiosis 135 multiple systems organ failure A highly lethal condition of the body in which two or more of the systems malfunction or become nonfunctional, including the respiratory system.

murmur, bronchial A vibration that causes a blowing or rasping sound that can be heard in the large bronchi through a stethoscope. A murmur may or may not indicate illness.

N murmur, pulmonary

A soft blowing sound heard through a stethoscope when placed over the orifice of the pulmonary artery. See also MURMUR, BRONCHIAL.

Mycobacterium From the Greek work meaning little rod, an organism of the Mycobacteriaceae family that causes tuberculosis and leprosy. See also LEPROSY; TUBERCULOSIS. mycoderma

Mucous membrane.

Mycoplasma pneumoniae A group of tiny organisms that lack the ability to form cell walls and cause infection of the lungs and upper respiratory tract. The disease is usually treated with tetracycline or erythromycin. myxasthenia

Insufficient production of mucus, which may aggravate respiratory disorders such as asthma.

myxiosis

A secretion of mucus.

Nasacort, Nasacort AQ Nasal Spray

Brand of the cortisone-like anti-inflammatory drug triamcinolone.

nasal cavity

The open space between the cranium floor and the roof of the mouth.

ally helpful when allergy skin-test results do not correlate with a person’s medical and allergy history. When performing a nasal challenge, the physician must carefully observe the patient for signs of a systemic reaction. The patient should be relatively free of allergic symptoms and must not have taken antihistaminic drugs for the past several days. Positive challenge results are indicated by itching, sneezing, watery discharge from the nose, and swelling of the nasal mucosa. In some cases, the tests fall short because they are time-consuming and because only one allergen at a time can be tested; in addition, if nasal symptoms are already present, the test may not be valid.

nasal congestion Swelling of the nasal passages, which is a symptom of allergic rhinitis (hay fever), vasomotor (nonallergic) rhinitis, upper respiratory infections (colds), and rhinitis medicamentosa (rebound congestion caused by abuse of nasal sprays). Complications of nasal congestion include sinus and ear infection and worsening of asthma. Decongestants are the main treatment of nasal congestions; however, antihistamines and the preventive nasal sprays, cromolyn, and corticosteroids are useful for allergy patients. Nasalcrom nasal douche

See

CROMOLYN SODIUM.

See

nasal endoscopy

NASAL IRRIGATION.

See

RHINOSCOPY.

nasal challenge

Also called nasal provocation tests, diagnostic allergy tests involving either inhalation or direct mucosal contact with a suspected allergenic substance. The tests are occasion-

nasal feeding The process of administering liquid food to a patient through a tube that goes into the nose and to the stomach. Nasal feeding is used only

136

nasosinusitis 137 when circ*mstances prevent a patient from taking in nutrients by mouth.

Nasalide A brand of flunisolide, a corticosteroid for topical use as a nasal spray and metered-dose inhaler for prevention of nasal allergy symptoms and asthma. See also CORTICOSTEROIDS. nasal irrigation A procedure that helps rid the nasal passages of excess mucus and bacteria. Saline (salt water) is available from local pharmacies or can be made fresh daily at home with one teaspoon of table salt and a pinch of baking soda in one pint of warm water. Many proprietary brands (Ocean Spray and Salinex are examples) are available as nasal sprays. Saline irrigations should be done before using other medications in the nose. One may inhale or “snuff” the saline solution from the palm of the hand or squirt it into the nose with a rubber ear syringe. When injecting the solution into the nostril, one should keep his mouth open and glottis closed so fluid does not go into the throat and bronchus. Also, no great force should be used.

nasal secretions

Mucus discharge from the nose that is characterized by quantity (none, minimal, moderate, or profuse), consistency (none, thin, mucoid, or crusted), and color (colorless, clear, white, or colored). The description aids the diagnosis of allergy, infection, or other anomaly.

nasal septum

The wall separating the two nasal cavities (nostrils).

nasal sinuses

See

NOSE.

nasal smear

A screening test used to diagnose nasal symptoms. Nasal secretions are obtained by blowing the nose into waxed paper and transferring the collected material to a glass slide. Hansel’s or Wright’s stain is applied to the slide, which is examined microscopically for leukocytes, or white blood cells, such as eosinophils or polymorphonuclear leukocytes, or polys. Allergic diseases may be present if eosinophils account for 10 percent or greater of the total white blood cells observed on a nasal smear. A predominance of polys suggests an infection, and absence of a significant number of cells suggests vasomotor, or nonallergic, rhinitis.

nasal obstruction

Blockage of the nasal passages either uni- or bilaterally. The most common cause of unilateral stuffiness is a deviated septum, which may be a congenital deformity or a result of trauma to the nose. It can be surgically corrected by rhinoplasty (“nose job”) if the obstruction is severe. In babies, a frequent cause of obstruction is a foreign body, a tiny object such as a button or a piece of a toy. Unilateral nasal obstruction may also indicate benign or malignant tumors, which should be discovered and treated by the physician.

nasal polyp

See

POLYP.

nasal provocation tests nasal reflex

See

NASAL CHALLENGE.

Sneezing, usually caused by an agent that irritates the nasal mucosa. See also SNEEZE.

nasal spray

Nebulizer or aerosol used to treat excessive nasal discharge and congestion characteristic of hay fever, colds, or other nasal disorders. Nasal sprays include over-the-counter decongestants. However, many individuals quickly develop tolerance, or loss of effectiveness, to these sprays, which leads to a worsening of congestion referred to as rebound. The rebound phenomenon is called rhinitis medicamentosa. Saline solution is used to irrigate dry, inflamed nasal passages but has no therapeutic effect to prevent discharge or congestion. The prescription drugs cromolyn sodium and corticosteroids (cortisone derivatives) are effective for long-term prevention of allergy symptoms. See also CORTICOSTEROIDS.

nasal spray habituation

See

NASAL SPRAY.

138 nasotracheal intubation nasal turbinates

Four bony structures arising from the nasal septum. The two most important ones are the inferior and middle turbinates. The turbinates are lined with cells similar to those in the tracheobronchial tube and regulate the airflow into the upper respiratory system. See also NOSE.

naturopathy

nasitis

nebulizer

nasopharyngeal airway Part of the nose that extends to the portion of the throat located above the soft palate or postnasal space.

necropneumonia

Inflammation of the nose. See also RHINITIS.

nasopharyngitis

An inflammation of the nasopharyngeal airway, which may occur in conjunction with postnasal drip and allergic rhinitis.

nasoscope A medical instrument used for examining the nasal passages. nasoseptitis See also

Inflammation of the nasal septum.

NASAL SEPTUM.

nasosinusitis

Inflammation of the nasal accessory sinuses and cavities. See also SINUSITIS.

nasotracheal intubation The insertion of an endotracheal tube, which helps airways remain open, through the nose in patients with clenched teeth or cervical spinal injury, used particularly because the patient’s neck does not need to be hyperextended for the insertion of the tube. nasus

The Latin word for nose. See also NOSE.

“natural way” to control asthma

The option of home remedies to treat asthma, or the myth that asthma does not require drugs for treatment.

An alternative healing method that uses natural forces such as air, water, light, and heat and massage instead of drugs and surgery characteristic of allopathic (Western) medicine. Patients with respiratory disorders may seek the advice of a naturopath in conjunction with traditional therapy.

An atomizer or device that produces a fine spray used to deliver allergy and asthma drugs to the nasal passages or lungs. Another term for pulmonary gangrene, which refers to death of lung tissue caused by infection, inflammation, degenerative changes, disease, injury, and lack of blood supply to the affected area.

nedocromil sodium (Tilade) A preventive allergy and asthma anti-inflammatory drug approved for use in the United States in 1993. Although nedocromil has properties similar to those of cromolyn, its effectiveness may be apparent within hours; however, it may take two weeks of regular dosage to realize its full potential. Cromolyn may require several months to realize benefits. Nedocromil may also be needed only twice a day, whereas cromolyn requires use three to four times a day. Similar to cromolyn, nedocromil does not interact with other asthma drugs, such as theophylline, and is available as a metered-dose inhaler. This drug works for children and adults. A solution for aerosol nebulizers, a nasal spray, and eyedrops may also be available. There are no significant side effects of the product, although slightly more than 10 percent of patients complain of an unpleasant taste. See also CROMOLYN SODIUM. Neisseria sicca

A bacterium named for German physician Albert Neisser (1855–1916) that is associated with forms of meningitis and gonorrhea. Neisseria sicca is a species of the bacterium that thrives in mucous membrane of the respiratory tract and may cause bacterial endocarditis. Bran-

nocardiosis 139 hamella (Neisseria) catarrhalis can be found in the upper respiratory tract and may be mistaken for meningococci.

Neo-Synephrine Brand name of nosedrops made from phenylephrine hydrochloride, an alphaadrenergic decongestant drug also used in eyedrops. Phenylephrine hydrochloride is also used in combination with antihistamines for the treatment of hay fever and colds. Tolerance to phenylephrine nasal products often causes a dependency known as rhinitis medicamentosa, which may require treatment with corticosteroids in order to break the cycle and symptoms of dependency. See also NASAL SPRAY.

nicotine poisoning A potentially fatal intoxication of nicotine, a poisonous alkaloid that acts as quickly as cyanide when ingested. Less than 5 milligrams of nicotine per kilogram of body weight may indicate a lethal dose. Death is usually the result of paralysis of the respiratory muscles and respiratory failure. Antidotes include activated charcoal, tannic acid, strong tea and gastric lavage or an emetic substance, oxygen therapy, barbiturates if the victim is having severe convulsions, artificial or mechanically assisted respiration, and maintenance of a patent airway. nitric acid fuming Vapors or fumes emanating from a concentration of the corrosive toxin nitric acid. If inhaled, the fumes cause choking.

nephrotuberculosis

Condition caused when the Mycobacterium tuberculosis affects a kidney. See also TUBERCULOSIS.

nitrites

nerve gas

nitrogen A gas that constitutes 80 percent of atmospheric volume. Nitrogen is colorless, odorless, tasteless, and a component of all proteins, which makes it essential to plant and animal life.

See

BIOTERRORISM; WAR GASSES.

neuraminidase

An enzyme found on the surface of influenza virus particles that allows the particles to detach from cells. When an individual has high levels of antibodies that counteract neuraminidase, he or she may be more resistant to the influenza virus than others.

nicotine gum (Nicorette)

Chewing product containing nicotine that allows smokers to gradually reduce their dependency on the addicting substance in tobacco while avoiding withdrawal symptoms such as irritability and chest pains.

nicotine patches (Habitrol, Nicoderm, Nicotrol, Pro Step) Band-Aid–like adhesive delivery system containing the drug nicotine. The patch is placed on the skin of smokers as a means to stop smoking. Nicotine is the addicting substance in tobacco. The patches contain a varying amount of nicotine, and doses are gradually tapered, usually in two or three steps, to avoid the withdrawal symptoms of nicotine. The adhesive in the patch frequently causes an allergic contact rash.

See

INHALANT ABUSE.

nitrogen dioxide An environmental pollutant present in the atmosphere that has been associated with an increased incidence of lung disease following prolonged exposure in homes and workplaces. nitrogen narcosis Euphoria and impaired judgment, motor function, and coordination akin to alcohol intoxication caused by an increased concentration of nitrogen gas in the brain and body tissues. The imbalance of gasses occurs in high altitudes or any situation in which air pressure changes drastically, such as that experienced by divers and submariners. See also BENDS. nitrous oxide

Also known as laughing gas, a colorless, sweet-tasting, pleasantly aromatic gas used as a light general anesthetic, especially by dentists. In high doses, nitrous oxide may cause asphyxiation. Use of a local anesthetic agent such as lidocaine is probably safer in patients with asthma. See also INHALANT ABUSE.

140 nocturnal asthma N.K.A. An abbreviation for “no known allergies” in medical charts. Nocardia

Named for French veterinary pathologist Edmund I. E. Nocard (1850–1903), a grampositive bacterium that, when stained on a slide, may be mistaken for Mycobacterium tuberculosis. Nocardia causes the disease nocardiosis. See also NOCARDIOSIS.

nocardiosis A pneumonia-like infection caused by a Nocardia bacterium called Nocardia asteroides, present in soil dust throughout the world and transmissible by inhalation, skin contact, and ingestion. It may occur in the lungs and spread to the brain, skin, and other parts of the body. It may also be the cause of lower-extremity tumors, particularly a condition known as Madura foot. Nocardiosis may be contracted by individuals with immunodeficiency disorders or other chronic diseases or by those with no preexisting disease. Sometimes nocardiosis is a complication in patients with AIDS. Symptoms include chills, chest pain, shortness of breath, weight loss, loss of appetite, accumulation of fluid in the pleural space, fever, and cough that do not respond to short-term antibiotic therapy and may progress to brain abscess or lung damage. Diagnosis requires analysis of the patient’s sputum or body fluid or tissue. Treatment of choice is sulfadiazine, among other drugs, but depending upon the medical condition of the victim and whether or not the infection is contained in the lungs or has already metastasized, nocardiosis may be fatal.

nocturnal asthma The occurrence of asthma symptoms during the night. Nearly 40 percent of asthmatics experience nightly symptoms; approximately 64 percent have episodes three nights a week, and about 75 percent at least one night per week. Asthma attacks seem to occur most often between 10 P.M. and 7 A.M., peaking at about 4 A.M. When several things simultaneously trigger asthma, results can be severe. The most devastating asthma attacks that lead to respiratory arrest, and possibly death, most often occur between midnight and 6 A.M. During sleep, mucus secretions accumulate in the bronchial tubes, and the backup, or reflux, of stomach acid may spill over into the lungs, causing irritation and inflammation of lung tissue. The circadian fall in the body’s production of cortisone and adrenaline and the rise of other chemicals, such as histamine, further worsen the situation during the night. In addition, the cell counts of neutrophils and eosinophils (cells that release mediators of inflammation) are higher in patients with nocturnal asthma symptoms. Timing medications to coincide with peak effectiveness and times of greatest need can greatly reduce symptoms and allow patients to sleep through the night. See also ASTHMA. nose

One of the chief organs of the respiratory system through which air flows in and out of the body. The external portion of the nose is made of a triangle of cartilage (the top of which constitutes the bridge of the nose, where the two nasal bones are joined) and skin-covered bone lined with

O mucous membrane. The internal portion contains two chambers divided by a septum. The chambers lead to various sinuses, including accessory nasal sinuses. The nose is also an olfactory organ that facilitates the sense of smell and warms, moistens, and filters air breathed in. Physicians may observe a patient’s nose for its size, shape, color, evidence of injury, discharge, tenderness over sinuses, and interferences with breathing. For example, chronically red nose caused by dilated blood vessels may be a result of alcoholism, acne, boils, or digestive disorders. An offensive discharge may indicate local infection, cavities in the teeth, a cold, or an impacted foreign body. A chronic, clear, watery discharge usually suggests the presence of allergy. Rhinitis refers to inflammation of the nasal mucous membrane; allergic rhinitis refers to seasonal allergy such as hay fever.

nostril reflex

A diminishing of a nostril, or opening at the base of the nose, on the side corresponding to lung disease in which there is a lessened alveolar air capacity in one lung.

notifiable diseases Highly contagious illnesses that must by law be reported to local authorities, including the board of health. They include tuberculosis, AIDS, chickenpox, rubella, cholera, polio, typhoid fever, typhus, meningococcal meningitis, and syphilis. obstructive lung disease, chronic OBSTRUCTIVE PULMONARY DISEASE.

See

CHRONIC

occupational asthma Shortness of breath, coughing, wheezing, and other symptoms of asthma from exposure to sensitizing substances found in the workplace. These substances may be allergens, or they may be nonallergic or toxic substances, such as ammonia, chlorine, smoke, or other noxious fumes that inflame the lungs of workers accidentally exposed to them. History As early as the second century A.D., miners covered themselves with clothing as protection from dust. In 1713, Bernardino Ramazzini, considered to be the father of industrial or occupational medicine, recommended in his book, De Morbis Artificum Diatriba, inquiry into a patient’s occupation when he discovered attacks of shortness of breath in sifters and millers exposed to grain dust. Ramazzini described asthma as an occupational hazard in individuals who “are short of breath and cachectic and rarely reach old age.” In 1877, the term byssinosis was coined for asthma in cotton workers, and in 1911 platinum salt exposure was recognized as a cause of asthma in photographic workers. More recently British physician Jack Peppys stimulated interest in this problem in the 1960s. Prevalence It is estimated that 2 to 15 percent of all asthma cases are caused by occupational or workplace exposure. Up to 44 percent of bakery workers and up to 10 percent of persons exposed to laboratory animals have symptoms. In Japan, an estimated 15 percent of asthma cases in males may be from industrial exposure. In some industries, very few workers develop symptoms, but in others, large numbers are affected. For example, nearly 100 per-

141

142 occupational asthma cent of workers exposed to platinum salts for at least five years develop some symptoms. Causes More than 200 substances have been reported to cause occupational asthma, and the list continues to grow. To cause an immediate immune response, a substance must have a molecular weight of at least 1,000 daltons, with most weighing more than 20,000. These allergens are proteins or glycoproteins, including animal proteins, biologic enzymes, grain dust, or irritants such as dusts, gases, or fumes that cause early or immediate onset of symptoms and are relatively easy to correlate with exposure. Lower-molecular-weight allergens (irritants of less than 1,000 daltons), such as anhydrides, diisocyanates, formalin, freon, metals, pharmaceuticals such as penicillin dust, solder fluxes, urea formaldehyde, and wood dust, usually cause latephase responses; symptoms may not be evident for many hours after exposure. High-molecular-weight compounds cause a true allergic reaction. The worker inhales the allergen, which stimulates the immune system to produce immunoglobulin E (IgE) antibodies. The antibodies then become attached to structures called receptors on immune cells (mast cells and basophils) in the body tissues. After a person has been sensitized in this manner, subsequent exposures to the same allergen cause a reaction between the allergen and its corresponding antibody that results in the rupturing of these cells and the release of chemicals such as histamine. The released chemicals cause the allergic response or symptoms. Most of the lower-molecular-weight substances fail to elicit such a response, although they do cause similar symptoms to occur via other mechanisms. Many of the substances responsible for occupational asthma can also be encountered outside the workplace, and materials can be transported outside the original areas of contact on clothing, in the hair, or on the skin of workers. They can also pollute the surrounding environment. Common fungal and bacterial species may contaminate air-conditioning units and water-cooled machinery, causing an infectious pneumonia such

as Legionnaire’s disease, or the allergic-type hypersensitivity pneumonitis. Other occupational exposures include the inhalation of iron particles in dust or fumes, resulting in siderosis, also called arc welder’s disease, or hemosiderosis, a pneumonia-like lung disease. Tributyl tin oxide (TBTO) is an organic compound contained in a carpet deodorizer that is a suspected cause of asthma. TBTO is also used in the manufacture of plastics, silicone, and paint products and is an antifungal agent in paper. This substance can also cause an irritant dermatitis. Talc triggers occupational asthma by acting as an irritant. In the 1970s and 1980s the Bacillus subtilis enzyme added to detergents became a major cause of allergic symptoms in workers as well as consumers. Hog trypsin used in the plastics industry is another industrial allergen. Castor bean allergy not only may affect factory workers, but also neighboring inhabitants may become sensitized by exposure to smoke from castor oil factories. Smoking is a complicating factor because of its influence on increasing airway reactivity. Symptoms Accompanying the asthma resulting from allergen exposure in the workplace is a latent, or waiting, period between the initial exposure and the onset of symptoms. Often symptoms do not appear for several weeks or take several years to appear. Only about 20 percent of those exposed to occupational allergens develop allergies. Once symptoms occur, they usually become progressively more severe with continued exposure. If exposure is stopped soon enough, symptoms will usually cease unless a person is reexposed. However, if exposure is prolonged, symptoms of asthma may become persistent even after exposure is terminated. Conjunctivitis, or inflammation of the eyes (commonly called “pinkeye”), may be the earliest symptom of allergen or irritant exposure in the workplace. Rhinitis, or runny nose, may also be an early sign. Wheezing, coughing, and shortness of breath can occur within minutes of exposure or not until later in the day or even 24 to 48 hours afterward. The later onset of symptoms often makes diagnosis or proof of cause difficult. A valuable clue to the existence of workplace allergy is that symp-

occupational asthma 143 toms often improve over the weekend or on holidays; however, it may take weeks, months, or years to improve depending on the length of previous exposure. The asthma caused by a single heavy exposure to toxic fumes may last for years. Medical-Legal Issues Documentation of occupational cause of symptoms is often difficult because individuals may have preexisting asthma.This issue may be clarified if other employees have similar symptoms. A survey may be necessary to uncover this. Federal or state public health agencies may be called upon to help affected employees. Patients’ symptoms of asthma can be monitored by using objective measuring devices such as a Wright’s Peak Flow Meter or much less expensive meters made by various manufacturers such as Access, Mini-Wright, and Vitalograph. These devices can measure the patient’s airflow rates both at home and in the workplace every one to two hours for a period of one or two weeks or until a pattern develops. Individual peak flow should not vary beyond 10 percent of the flow predicted for a normal person throughout the day. A 20 percent or greater decrease in flow rate is considered significant. If peak flow results are inadequate for legal documentation, an inhalation challenge may be necessary to identify the suspected allergen. The challenge carries a risk of a severe attack of asthma and should be performed only by specially trained medical personnel with resuscitation equipment available. Although it may be difficult, it may be necessary to determine if the patient’s symptoms are solely a result of an occupational exposure. The individual with preexisting asthma may have a worsening of symptoms when he or she experiences some trigger such as a dusty environment in a new job or change in working conditions in an existing job. A patient with preexisting but dormant asthma may be exposed to an occupational allergen and then finds it difficult to prove that this is a new occupationally caused asthma. The best objective criterion for diagnosing occupational asthma is the specific bronchoprovocation test, in which the suspected worker is challenged with the implicated substance. In this test, the worker is given the suspected substance by inhalation under carefully

controlled conditions. The patient’s lung function is studied before and after this challenge. Unfortunately, this is very difficult to arrange, and less accurate methods of assessment are used instead for practical reasons, including expense and nonavailability of experienced specialists, equipment, or standardized testing materials. The incriminated agent must be standardized so that repeated testing will give the same results (reproducibility) and be specific for the involved materials. An example is the chemical toluene diisocyanate used in plastics and varnishes. When this substance was administered to a control group of known asthmatic patients with no prior exposure to this substance, they did not react to a challenge. However, when previously exposed workers suspected of being sensitized to this substance were given the challenge, they showed a decrease in their lung function tests. Two main questions must be addressed in these situations: First, is there a disability? Second, can the work environment be improved to allow continued employment? About 70 percent of patients with workplace-induced asthma will continue to have symptoms even years after exposure has stopped. Disability from occupational asthma is often lumped together with that from exposure to silicon and asbestos, a cause of serious lung disease. Evaluation and Management of Work-Aggravated Asthma and Occupational Asthma Evaluation Potential for workplace-related symptoms: • Recognized sensitizers (e.g., isocyanates, plant or animal products) • Irritants or physical stimuli (e.g., cold/heat, dust, humidity) (NOTE: Material Safety Data may be helpful for identifying respiratory irritants, but many sensitizers are not listed.) • Coworkers may have similar symptoms Patterns of symptoms (in relation to work exposures): • Improvement during vacations or days off (may take a week or more) • Symptoms may be immediate (<1 hour), delayed (most commonly, 2 to 8 hours after exposure),

144 occupational asthma or nocturnal

that are laid on concrete

• Initial symptoms may occur after high-level exposure (e.g., spill)

• co*ckroaches: Use poison bait or traps to control. Do not leave food or garbage exposed

Documentation of work relatedness of airflow limitation:

• Pollens (from trees, grass, or weeds) and outdoor molds: To avoid exposure, adults should stay indoors with windows closed during the season in which they have problems with outdoor allergens, especially during the afternoon

• Serial charting for 2 to 3 weeks (2 weeks at work and up to 1 week off work as needed to identify or exclude work-related changes in peak expiratory flow): Record when symptoms and exposures occur; record when a bronchodilator is used; measure and record peak flow every 2 hours while awake • Immunologic tests • Referral for further confirmatory evaluation (e.g., bronchial challenges) Management Work-aggravated asthma: • Work with onsite health care providers or managers/supervisors • Discuss avoidance, ventilation, respiratory protection, and tobacco smoke-free environment Occupationally induced asthma: • Recommend complete cessation of exposure to initiating agent Control Measures for Environmental Factors That Can Make Asthma Worse Allergens: Reduce or eliminate exposure to the allergen(s) the patient is sensitive to, including: • Animal dander: Remove animal from house or, at a minimum, keep animal out of patient’s bedroom and seal or cover with filter air ducts that lead to bedroom • House-dust mites: (Essential) Encase mattress in an allergen-impermeable cover; encase pillow in an allergen-impermeable cover or wash it weekly; wash sheets and blankets on the patient’s bed in hot water weekly (water temperature of greater than 130 degrees Fahrenheit is necessary for killing mites). (Desirable) Reduce indoor humidity to less than 50 percent; remove carpets from the bedroom; avoid sleeping or lying on upholstered furniture; remove carpets

• Indoor mold: Fix all leaks and eliminate water sources associated with mold growth; clean moldy surfaces. Consider reducing indoor humidity to less than 50 percent Tobacco smoke: Advise patients and others in the home who smoke to stop smoking or smoke outside the home. Discuss ways to reduce exposure to other sources of tobacco smoke, such as from day care providers and the workplace. Indoor/outdoor pollutants and irritants: Discuss ways to reduce exposure to the following: • Wood-burning stoves or fireplaces • Unvented stoves or heaters • Other irritants (e.g., perfumes, cleaning agents, sprays) Allergens Known to Cause Occupational Asthma abirukana acacia adipic acid African maple African zebra wood Alternaria aluminum fluoride aminoethyl ethanolamine aminophylline ammonium persulfate amprolium hydrochloride animals, laboratory apple tree mite aspergillus azobisformamide azodicarbonamide Baby’s breath Bacillus subtilis enzymes bee moth

occupational asthma 145 bromelain buckwheat butterflies California redwood carmine carmine beetle castor beans cats cattle cedar of Lebanon Central American walnut cephalosporins chromates chrysanthemum cibachrome brilliant scarlet cimetidine cinnamon cobalt cocabolla co*ckroaches coffee beans colophony (pine resin, or abietic acid) cotton1 crickets crop storage mites cyanoacrylate Daphnia diastase dichloramine diisocyanates dimethyl ethanolamine dioazonium salt dogs Douglas fir tussock moth Drimaren brilliant blue and yellow eastern white cedar electrocardiography ink endofluorane anesthetic ethylenediamine feathers flaviastase flax fluoride, fluorine formaldehyde Freon fungal amylase fungal food products furan base resin

garlic gentian powder glue gluteraldehyde grain dust1 grain dust mite grain field fungi grain weevil guinea pigs hemp hexachlorophene hexahydrophthalic anhydride hog trypsin hops horses housefly maggots hoya (sea squirt) humidifiers ipecac iroko ispaghula karaya kejaat lanau Levafix brilliant yellow locusts lycopodium magnolia mahogany maiko mayfly mealworm methyldopa methyl methcrylate Mexican bean weevil mice midges mother of pearl mulberry mushroom spores nickel salts oak organophosphate oyster shells pancreatic (extract) enzyme papain parakeets paraphenylenediamine

146 oleothorax pectinase penicillins pepsin persulfate and henna phenylene glycine acid chloride phthalic anhydride pigeons piperazine dihydrochloride platinum salts Plexiglas dust polyetheralcohol polypropylene glycol polyvinyl chloride poultry mites prawns protease bromelain psyllium quillaja ramin rabbits rats salbutamol intermediate screwworm fly sheep silkworm moths and larvae sky blue snow crab South African boxwood soya bean spiramycin sponge stainless steel strawberry pollen styrene sugar beet sulfathiazole sulfone chloramide (chloramine T and halazone) sunflower tamarind Tanganyika aningre tannic acid tea dust tetrachlorophthalic tetracycline tobacco toluene diisocyanate tragacanth triethyl tetramine trimellitic anhydride

tungsten carbide urea formaldehyde vanadium zinc welding fumes western red cedar dust (plicatic acid) wheat flour 1 Cotton,

hemp, and grain dust are irritants and not true

allergens.

See also

ASBESTOSIS; PNEUMONITIS; SILICOSIS.

oleothorax The injection of oil into the pleural cavity in the chest, or thorax, as a therapeutic method (oleotherapy) for patients with pulmonary tuberculosis and other respiratory disorders. olfactory nerves The first pair of the 12 cranial nerves that facilitate the sense of smell by enervating the mucous membranes of the nose. oligopnea

The medical term for infrequent, or abnormally shallow or deep, respiration, often as slow as six to 10 respirations per minute, usually as a result of intracranial pressure, hemorrhage of certain parts of the brain, brain tumors, certain forms of meningitis, shock, disease, or drug poisoning. Oligopnea is derived from the Greek words oligo, meaning little or few, and pnoia, or breath.

Ondine’s curse

Named for Undine (French spelling), a mythical water nymph who had a human lover upon whom a curse was cast that he would sleep forever, a reference to primary alveolar hypoventilation, a condition of hypoventilation in the alveoli of the lungs caused by a dysfunction of the respiratory center, such as excessive carbon dioxide, or a lesion in the cervical (neck) portion of the spinal cord. This occurs when the respiratory center does not respond adequately to carbon dioxide. Ondine’s curse also refers to a loss of respiratory function as a result of a lesion in the spinal cord. See also HYPOVENTILATION SYNDROME; PRIMARY PULMONARY HYPERTENSION.

ozone 147 Opticrom A brand name for cromolyn sodium eyedrops used for allergic disorders. organic dust toxic syndrome

Abbreviated as ODTS, a respiratory disorder caused by inhaling dust of moldy hay, silage, or similar substances. Symptoms include fever, coughing, and muscle pain. ODTS is a nonallergic and noninfectious illness.

oropharyngeal airway

A tube that can be inserted into the mouth of a patient who is unconscious to prevent obstruction of the air passages by his or her tongue.

ogy is the medical specialty concentrating on diagnoses and treatments of disorders of the ears, nose, and throat.

overventilation

See

HYPERVENTILATION.

oximeter

Photoelectric device for measuring the amount of oxygen in the blood.

oxitriphylline (Choledyl) A derivative of theophylline, a bronchodilating drug used in the treatment of asthma. See also THEOPHYLLINE. oxygen

orthopnea

From the Greek words ortho, meaning straight, and pnoia, or breath, a discomfort upon breathing that is relieved by an orthopneic position, i.e., sitting nearly upright in a bed or chair, or standing. Individuals experiencing orthopnea, which may accompany congestive heart failure, bronchial and cardiac asthma, pulmonary edema, emphysema, pneumonia, angina pectoris, and spasmodic coughing, may also be anxious, blue in the face, and using their respiratory muscles forcibly or bracing themselves in order to breathe. Patients usually prop themselves up with several pillows or sit in a chair to sleep in order to avoid feeling as though they are suffocating. A patient may be referred to as having “two-pillow” or “three-pillow” orthopnea, depending on the number of pillows needed to allow him or her to breathe more comfortably.

osmethesia From the Greek words osme, or odor, and aisthesis, or sensation, the ability to perceive and distinguish odors. otolaryngologist Physician who treats diseases of the ears, nose, and throat medically and surgically. Otolaryngologists (also called otorhinolaryngologists) also may perform surgery of the head and neck, and plastic surgery of the face. Otolaryngol-

An odorless, tasteless, and colorless gas that is essential to life. It is used therapeutically for patients with respiratory distress in diseases such as asthma, emphysema, severe pneumonia, and congestive heart failure. Oxygen content in the body can be determined by measuring arterial blood gases or oximetry. See also ARTERIAL BLOOD GASES.

oxygenator

A mechanism for the purpose of infusing oxygen, such as into the bloodstream during thoracic or open-heart surgery.

oxygen capacity

The oxygen measured in cubic centimeters per 100 milliliters of blood. Normal blood contains approximately 20 cubic centimeters of oxygen.

oxygen content

The amount of oxygen in the

blood.

oxygen debt The deficit of oxygen induced by intense bodily activity (anaerobic exercise) that may be relieved by rest, during which the body has the ability to replenish itself. oxygen tent

An enclosure that surrounds the patient’s head and shoulders for the purpose of

P administering air in which the oxygen content has been increased. See also OXYGEN THERAPY.

layer, dubbed in 1929, is located at heights of approximately 20 to 30 miles above Earth.

Abbreviation for pulmonary artery.

oxygen therapy

Treatment of oxygen deficiency by administering oxygen via oxygen mask, tent, or nasal catheter.

oxygen toxicity The inability to ventilate the lungs as a result of pure oxygen breathed for a long period of time. Impaired ventilation causes a lack of oxygen tension in the blood. oxymetazoline

Generic name for the alpha-agonist drug or decongestant nasal sprays or solutions available under the trade names Afrin, Dristan, 4Way Nasal Spray, NTZ, and Neo-Synephrine. These drugs are noted for their rapid facilitation of nasal decongestion; however, tolerance may develop after only a few days of continuous use. This phenomenon is called rhinitis medicamentosa, or rebound, and is treatable by corticosteroids.

ozone A type of oxygen with a pungent odor and a bluish color, formed by three oxygen atoms and known as the molecule O3. An environmental pollutant, ozone causes asthma-like hyperreactivity of the bronchioles similar to that in a viral respiratory infection. Inhalation of ozone and other environmental pollutants (including tobacco smoke, nitrogen dioxide, and sulfur dioxide) produces inflammation in the airways. Adverse response to ozone can also be seen in nonasthmatic, or normal, persons. Ozone is formed naturally in the atmosphere by a photochemical reaction. The ozone

PA catheter

An intravenous catheter (tube) inserted into the pulmonary artery.

pachyderma laryngitis

An abnormal thickening and enlargement of the laryngeal mucous membrane, usually a result of chronic laryngitis. See also LARYNGITIS.

pachypleuritis

Inflammation thickening of the pleura. See also RESPIRATORY SYSTEM.

pachyrhinic

and

abnormal

Referring to a flat, thick nose.

pain, chest

Any severe pain in the chest caused by cardiac problems, overexertion, pleurisy (in which there is pain accompanying a deep breath), arthritis, fibrosis, or hiatal or diaphragmatic hernia.

pansinusitis See also

Infection involving all the sinuses.

SINUSITIS.

panting

Heavy breathing or rapid gasps for breath, usually caused by strenuous physical activity or the onset of fear.

papaverine hydrochloride (Cerespan, Pavabid) Derived from the poppy plant, the salt of an alka-

148

peak flow 149 loid from opium that is used as a smooth muscle relaxant for treating bronchial spasm, and stomach and intestinal disturbances.

parainfluenza viruses

A variety of microorganisms that cause acute respiratory infections.

paraldehyde poisoning papilloma, Hopmann’s

Polyps or epithelial tumors (also warts and condylomas) growing excessively in the nasal mucosa.

para-aminosalicylic acid (PAS)

An antituberculosis drug, also known as aminosalicylic acid, often combined with isoniazid and streptomycin. PAS is believed to help delay bacterial resistance to drug therapy.

paracentesis pulmonis

The removal of fluid from a lung through puncturing the lung. Patients with excess fluid in a lung may require paracentesis pulmonis, or, in the case of pleural effusion of other abnormal accumulation of fluid in the chest cavity, paracentesis thoracis. See also ASPIRATION.

paradoxical respiration In the case of collapsed lung, a condition in which the lung inflates on exhalation and deflates on inhalation. Paradoxical respiration also refers to a paralyzed diaphragm that rises during inhalation instead of exhalation. See also PNEUMOTHORAX.

The toxic effect of a liquid polymer of acetaldehyde (trade name Paral), used as a sedative and hypnotic to treat delirium tremens and acute alcoholism. Symptoms include cardiac and respiratory depression. Induced vomiting (if the poisoning is mild), oxygen therapy, artificial ventilation, and tracheostomy are among the treatment options.

paramyxoviruses

A subgroup of viruses called myxoviruses that cause parainfluenza, respiratory syncytial viruses, measles, mumps, and Newcastle disease.

paranasal sinuses

The frontal, ethmoidal, sphenoidal, and maxillary sinuses that open into the nasal passages. See also RESPIRATORY SYSTEM.

parapleuritis

Inflammation occurring in the chest wall or in the pleura.

parrot fever

See

passive smoking

PSITTACOSIS.

See

SMOKING, PASSIVE.

150 peak flow

penicillins 151 pastille

A type of lozenge, or medicated disk, used to soothe or medicate the mouth and throat.

Patanol The brand name of olopatadine hydrochloride, an ophthalmic solution for the treatment of itchy eyes caused by allergic conjunctivitis. Rare adverse reactions include pharyngitis, rhinitis, sinusitis, and cold syndrome. PBZ

Abbreviation for the antihistamine tripelennamine (Pyribenzamine).

peak flow The maximum flow rate that can be generated with the most forcible expiration a person can manage. One of the important indicators of asthma, the peak flow of expired air is measured by a peak flow meter in liters per second. The best of three readings is considered the peak expiratory flow rate (PEFR). The PEFR determines if there is an obstruction in one’s airway. This objective measurement is similar to taking a person’s blood pressure with a sphygmomanometer. The PEFR provides an accurate way to monitor the response to asthma therapy and exacerbations of asthma, detect asymptomatic deterioration in lung function before it becomes critical, determine the degree of airflow obstruction and detect early stages of obstruction, and indicate when emergency care is required. Because the peak flow measurement tests patency only of the large airways, an individual with mild asthma relating to small airways may be undiagnosed unless spirometry, which measures flow rates at low lung volumes, is employed. An objective measurement of airflow obstruction, such as PEFR, in persons with asthma is desirable because subjective measurements (dyspnea and wheezing, for example) by physicians and patients may be inaccurate. One study demonstrated that only 44 percent of physicians could estimate PEFR with 20 percent of the actual measured PEFR of patients. By the time wheezing can be detected with a stethoscope, the PEFR has already decreased 25 percent or more. Patients’ symptoms are also an unreliable indicator of airway obstruction. One of the major factors causing delay in treatment of severe asthma and asthma exacerbations is poor

perception of the severity on the part of the doctor and the patient. The accuracy of the PEFR measurement depends on the person’s willingness and ability to exhale as hard as he or she can into the peak flow meter.

peak flow meter A portable device that measures patency of the airways, especially useful in the management of asthma. Various types of peak flow meters are available. The patient takes a deep breath and blows forcibly into the device, after which the flow of air from the lungs can be compared with the normal values predicted for the patient’s age, height, and sex. The peak flow meter aids in the diagnosis of asthma and exerciseinduced asthma and the detection of an impending asthma attack. It also indicates the severity of an attack and helps to optimize medication dosage. pearl, Laënnec’s

See

LAËNNEC’S PEARL.

pectoriloquy

From the Latin words pectoralis, or chest, and loqui, to speak, words spoken by the patient that can be heard through the chest wall over a particular part of the chest during auscultation, such as over a large bronchus, a pneumothorax, or a pleural effusion.

peenash An Indian word referring to rhinitis, or inflammation of the nasal passages, caused by insect larvae in the mucous membrane. Certain larvae, such as chironomid larvae (of the red midge, which is a tiny dipteran fly) used as fish food by aquarists have been known to cause an IgE-mediated allergic disease reaction that involved respiratory symptoms, including asthma. Particles of the larvae may be inhaled or crossreact with other allergens, such as mosquitoes, mites, shrimp, and other potentially sensitizing substances. Airborne insect products, insect proteins among them, may result not only in rhinitis and asthma, but also in conjunctivitis and dermatitis. The deliberate ingestion of insects may cause the life-threatening allergic reaction called anaphylactic shock, and individuals with known

152 Peptostreptococcus or unknown hypersensitivity who eat or inhale insect particles may experience an allergic reaction. For example, mealworm ingestion or inhalation has been reported to cause sensitivity in certain people. Rhinitis, asthma, and rhinoconjunctivitis also can occur in people who fish in rivers and use certain types of live bait, such as the earthworm Eisenia foetida, beetle larvae, and marine worms. In addition, a condition called nasal myiasis (infestation of the larvae, or maggots, of Chrysomia flies) exists mostly in the tropics. With atrophic rhinitis as a predisposing factor, the maggots that have reached a body cavity through inhalation or direct contamination can erode the nose, face, and intracranial structures and may cause meningitis and death. A mixture of chloroform and turpentine is among the treatments for killing and removing the maggots. Hypersensitivity treatment includes various medications depending upon the allergen and the specific reaction and condition of the patient. Nasosinusal myiasis also infects sheep and goats, and dogs can be infected by the Pneumonyssoides caninum, or dog nasal mite, irritating and eroding the nasal cavities and frontal sinuses. See also CORTICOSTEROIDS; HYPERSENSITIVITY; OCCUPATIONAL ASTHMA; RHINITIS.

PEEP

Positive end-respiratory pressure.

penicillins

A group of antibiotics derived from cultures of the mold Penicillium or made synthetically and used to kill bacteria, especially cocci, which cause infections. The many derivatives of penicillin include penicillin G, V, ampicillin, amoxicillin, coxicillin, dicloxicillin, carbenicillin, and nafcillin. Penicillins’ bactericidal (bacteria-killing) action depends on their ability to interfere with cell wall synthesis of actively multiplying bacteria. Hypersensitivity reactions, which are common, to the antibacterial drugs of the penicillin family may be of any of the Gell and Coombs allergy types I through IV. The penicillin molecule, called a hapten, is too small to cause an allergic response, but it is highly chemically reactive: When it combines

with a large carrier molecule, usually a protein, it becomes allergenic. Individuals allergic to one form of penicillin should be considered allergic to all penicillins because they are so chemically similar. The cephalosporin antibiotics are also structurally related to the penicillins. An estimated 5 to 15 percent of penicillin-allergic persons will also react to cephalosporins. An estimated 13 percent of penicillin-allergic reactions are type I (anaphylactic, immediate, or IgE mediated), and as many as 9 percent, or from 400 to 800, of these prove fatal each year in the United States. Most severe reactions occur when penicillin is administered by injection. Other allergic reactions may result in rashes or serum sickness. Unfortunately, a history of penicillin allergy is often unreliable. In a study by the American Academy of Allergy, only 19 percent of approximately 3,000 persons with a history of penicillin allergy were positive when skin-tested. Seven percent of a group of 1,229 patients with no prior history of penicillin allergy proved positive by skin-test. Furthermore, penicillin can often be detected in individuals who have no knowledge of ever having received it. Exposure is possible from contaminated meat prepared from animals treated with penicillin. A genus of broomlike molds belonging to the Ascomycetes (sac fungi), Penicillium forms the blue molds that grow on fruits, cheese, bread, and other substances. A number of Penicillium species are the source of the antibiotic drug penicillin. More than a dozen common types of Penicillium are common indoor and outdoor allergens that produce respiratory, external ear, skin, and certain occupational allergies, such as suberosis, caused by the inhalation of Penicillium frequentans (a cork-dust mold). Individuals allergic to Penicillium mold are not necessarily allergic to penicillin.

Peptostreptococcus

An opportunistic bacteria of the Peptococcaceae family that may be normal inhabitants of or cause disease in the respiratory and intestinal tracts of humans.

photodynamic therapy, pulmonary 153 perennial allergic rhinitis Allergic rhinitis and asthma that are present throughout the year, as opposed to seasonal allergies such as hay fever. Perennial allergens include exposure to animal danders (especially cat and dog), house-dust mites, feathers, and molds. perfume Alcohol-based liquid (named perfume from the Latin-based French words literally meaning “to smoke thoroughly”) made fragrant by adding floral essences or synthetic substances and used cosmetically. It can cause contact skin allergy or trigger asthma by its irritant properties (fumes). Incense was one of the first perfumes in history. Perfumes are eliminated from many products designed to be hypoallergenic. perfusion

Providing an organ or bodily tissue with oxygen and nutrients through the bloodstream.

peribronchial smooth muscle

See

pertussis vaccine Developed in the 1930s, a preventive substance usually combined with diphtheria and tetanus vaccines for the immunization of infants and children. Pertussis vaccine is not routinely advised after age seven because the infection is rarely serious after this age. Unfortunately, serious adverse effects occur in a small number of infants and the use of this vaccine was severely limited during the 1980s until a government fund was established to deal with liability issues related to the product. Newer vaccine production measures promise to lessen the frequency and severity of reactions. pharyngalgia

Pain in the throat.

pharyngitis, chronic Inflammation of the throat associated with chronic tonsillitis, excessive smoking, dryness caused by mouth-breathing, chronic sinusitis and/or allergic rhinitis, and other ongoing irritation.

RESPIRATORY

pharyngorhinitis

SYSTEM.

Inflammation of the throat and

nasal passages.

peribronchiolitis Inflammation that occurs in the area around the bronchioles. Peribronchitis refers to inflamed areas around the bronchi. peribronchitis

See

PERIBRONCHIOLITIS.

peripleuritis Inflammation of the connective tissues between the chest wall and the pleura. See also RESPIRATORY SYSTEM. permissible exposure limits The maximum amount of time an individual may be safely exposed to radiation, chemicals, and other physical agents or substances in the environment, particularly the workplace. Workers exposed to hazardous materials or toxic substances may be endangered unless precautions are taken and maximum allowable concentrations of the materials are determined.

pharynx

The throat, or airway from the nasal cavity to the voice box, or larynx. A musculomembranous tube, the pharynx goes from the base of the skull to the sixth cervical vertebra, and then continues as the esophagus, which leads to the stomach. See also RESPIRATORY SYSTEM.

phenylephrine hydrochloride (Alconefrin, NeoSynephrine, Nostril) Alpha-adrenergic, decongestant drug in over-the-counter nasal drops, sprays, and eyedrops. Phenylephrine hydrochloride is also used in combination with antihistamines for the treatment of hay fever and colds. Tolerance to phenylephrine nasal products often causes a dependency known as rhinitis medicamentosa, which may require treatment and corticosteroids in order to break the cycle and symptoms of dependency. See also RHINITIS MEDICAMENTOSA.

phenylpropanolamine pertussis

See

WHOOPING COUGH.

A derivative of the stimulant drug amphetamine used as a decongestant

154 phrenic avulsion drug for the treatment of nasal allergies and colds. The safety of phenylpropanolamine has been questioned, but in normal decongestant doses it probably does not significantly increase blood pressure. However, the drug is available in higher doses as an over-the-counter appetite suppressant and may be a risk for hypersensitive persons.

phenyltoloxamine An antihistamine usually combined with decongestant drugs for the treatment of hay fever. See also ANTIHISTAMINE. phlegm

From the Greek word phlegma, thick mucus formed in the airways. Also called sputum, phlegm is secreted by cells lining the respiratory tract and capable of causing congestion in upper respiratory passages including the nose and sinuses.

phonasthesia Weakness or hoarseness of the voice attributable to straining the voice. phosphodiesterase

An enzyme that may be involved in causing asthma. Asthma drugs such as theophylline may block this enzyme’s action.

photic sneezing

Sneezing caused by exposure to bright light or light stimulus.

photodynamic therapy, pulmonary (PDT)

A nonsurgical, minimally invasive, localized treatment option for early-stage lung cancer involving a flexible bronchoscope and lasers. In PDT, nonthermal laser light in the visible red to infrared range, or 630 nanometers, activates a light-sensitive drug in order to pinpoint and kill tumor cells. The laser (an acronym meaning light amplification by stimulated emission of radiation) will not burn body tissue, and there is no danger of laser burn because cell destruction occurs through a photochemical reaction. The patient is given the photosensitive, antineoplastic intravenous drug porfimer sodium (Photofrin), which is absorbed by body tissue and retained only by cancerous and precancerous cells.

When exposed to laser light by way of flexible bronchoscopy 40 to 50 hours after injection of the drug, the drug becomes active and creates a chemical radical known as singlet oxygen. The singlet oxygen targets cell membranes and proteins through oxidation, after which the cancerous cells are destroyed. Twenty-four to 72 hours thereafter, the patient undergoes another bronchoscopy to remove dead cells and, if necessary, for an additional laser treatment. As opposed to chemotherapy and radiation, there are few adverse effects of PDT, which may be repeated as many as three times without damage or abrasion to tissues, pain, or significant risk to the patient. The major side effect is photosensitivity, and patients may need to wear protective clothing and sunglasses when in direct sunlight or bright indoor lighting. Until the porfimer dissipates from the body, patients may also need to limit outdoor activities and take other precautions to minimize exposure to direct sunlight for approximately four to six weeks. Other adverse effects may include localized swelling and inflammation, chest discomfort, nausea, fever, and constipation, but these are easily controlled. A reaction to porfimer specifically may only rarely cause coughing, dysphagia, breathing problems, or hemoptysis. According to an article in the July 30, 2001, New York–New Jersey edition of Nursing Spectrum, “Flexible Scopes and Photodynamic Therapy,” “The extent of bronchial invasion and/or nodal extension determines appropriate candidates to PDT. For example, PDT is a local modality only and cannot treat regional lymph nodes. If laser light can’t reach the tumor, PDT can’t be used. This therapy provides palliative treatment for hemoptysis and shortness of breath secondary to obstructing lung tumors. It is used to treat Stage I lung cancers diagnosed at an early stage as an alternative to surgical resection and as a potentially curative treatment. PDT is also used in combination with chemotherapy and radiation therapy for more comprehensive, localized tumor control. Studies have shown that PDT can produce significant reopening of the bronchial lumen in 70 percent of patients with obstructive bronchial cancers. Clinical trials have found a response rate as high as 89 percent in PDT treatments of patients with early-stage lung tumors. On the other hand, PDT is contraindicated

pleural effusion 155 in patients who have tumors that are eroding into a major blood vessel, the trachea, or bronchial tree; a tracheoesophageal or bronchoesophageal fistula; known allergies to porphyrins; or porphyria, a hereditary genetic disorder characterized by a disturbance in porphyrin metabolism. Porphyria causes an abnormal increase in biological pigments (such as the red pigment heme) or coloring (i.e., porphyrins), which are made in the liver, resulting in an abnormal sensitivity to light.” Additional information is available at www.cancerlynx.com/ photodynamic.html and www.merseyworld.com/ lasers.

pimelorthopnea

Caused by obesity, difficulty in breathing when reclining.

Pins’ sign Named for Austrian physician Emil Pins (1845–1913), the disappearance of pleurisy symptoms in a patient with pericarditis when the patient is in the knee-chest position. pirbuterol (Maxair)

phrenic avulsion The condition of one side of the diaphragm that is elevated, and a collapse of the corresponding lung when part of the phrenic nerve is removed, called phrenicectomy or phreniconuerectomy. A motor nerve, the phrenic nerve arises in the cervical plexus and goes into the thorax to the diaphragm.

A beta-adrenergic agonist, or bronchodilating drug, available as a metereddose inhaler for the treatment of asthma. Maxair opens bronchial tubes to promote easier breathing in individuals with asthma or chronic obstructive pulmonary disease. Nervousness and tremor are the most common side effects, and overuse of Maxair may cause cardiac problems or potentially fatal cardiac complications. This may be seen in patients who are not experiencing significant relief from pirbuterol and who may require further testing or treatment.

phrenospasm

Pirquet’s test

the diaphragm.

A skin test for tuberculosis, especially for children. It was named after Austrian pediatrician Clemens P. Pirquet (1874–1929).

phthisis Pulmonary tuberculosis, black lung, and other wasting or atrophic diseases of the lung. Phthistic, from the Greek word phthisikos, refers to asthmatic or an asthma sufferer.

plague, pneumonic

A sudden contraction or spasm in

Pickwickian syndrome Also known as hypoventilation syndrome, a state of diminished respiration because of obesity, named for the massively obese character Joe, in Pickwick Papers, written by Charles Dickens. The syndrome is characterized by decreased pulmonary function, obesity, and polycythemia. pigeon breast

Also called chicken breast, a deformity caused by rickets or a childhood respiratory obstruction in which the sternum, or breastbone, projects forward.

pigeon breeder’s disease A pneumonia-like lung disease caused by allergy to pigeon droppings and feathers. See also HYPERSENSITIVITY; PNEUMONITIS.

A severe type of plague that extensively involves the lungs. See also BUBONIC PLAGUE.

plague, white See also

Another term for tuberculosis.

TUBERCULOSIS.

plastic bronchitis A type of bronchial inflammation in which fibrin (a protein) exudate sticks to the bronchial tubes like a cast. See also BRONCHITIS. platypnea

Shortness of breath or difficulty breathing that occurs when a patient is standing or sitting. See also ORTHOPNEA.

pleura The moist membrane lining the lungs and the walls of other structures in the thorax and the diaphragm. Because of their serous secretion, both

156 pleurisy the right and left pleurae help reduce friction between the lungs and other structures during the movements of breathing. Pleurisy refers to inflammation of a pleura, which often results in painful respiration, coughing, and fever. Pleural fibrosis is a complication of pulmonary tuberculosis in which the pleura thickens and causes crowding in the pleural cavity (space between the layers of the pleurae). See also RESPIRATORY SYSTEM.

pleural effusion

An abnormal amount of fluid between the visceral and parietal pleura (spaces around the lungs). Effusions, from the Latin word meaning to pour out, may contain serum (hydrothorax), pus (pyothorax), lymph (chylothorax), air (pneumothorax), or combinations of these such as hydropneumothorax and pyopneumothorax. Pleural effusion may result in pain, which may lessen as the fluid builds up due to heart failure, cirrhosis of the liver, pneumonia, or other disorder. Hemothorax, or blood in the pleural space, may be a result of injury or chest trauma, an aortic aneurysm, or impaired blood clotting. Empyema, pus in the pleural space, may be attributable to pneumonia, lung, or abdominal abscess, esophageal rupture, thoracic surgical procedures, and other problems. Lymph, or milky, fluid may be the result of a tumor or injury in the thoracic duct (the main lymphatic duct in the chest. Other causes of pleural effusion include pancreatitis, rheumatoid arthritis, systemic lupus erythematosus, histoplasmosis, blastomycosis, low blood protein levels, coccidiomycosis, tuberculosis, feeding tubes or intravenous catheters that are not properly placed, an abscess under the diaphragm, and certain drugs, such as hydralazine, procainamide, isoniazid, phenytoin, and chlorpromazine, among others. Treatment for severe pleural effusions may include drainage by way of thoracentesis (aspiration of fluid through a small needle or catheter inserted into the pleural space), or by way of a chest tube. Depending upon the cause of the effusion, corresponding treatment can be administered, such as antibiotics, antitubercular and antitumor drugs, cancer or blood clotting medications, sealing the pleural space, and surgery.

pleurisy

See

PLEURA.

pleuroclysis

Washing out the pleural cavity by

injecting fluid.

pleurodesis A treatment for pneumothorax involving the surgical production of adhesions between the parietal and visceral pleura. pleuropneumonia The condition of having pneumonia and pleurisy. pleuroscopy

Examination of the pleural cavity through a surgical incision in the chest.

plombage Derived from the French word plomber, which means to plug, a procedure for a therapeutic deflating of part of a lung in which the parietal pleura is removed from the chest wall and the remaining space is packed with an inert substance such as plastic. See also DECORTICATION, PULMONARY. pneodynamics breathing. See also

The mechanism or mechanics of

BREATHING; PNEUMODYNAMICS; RESPIRA-

TORY SYSTEM.

pneopneic reflex

A change in respiratory rate and depth that occurs as a result of inhalation of an irritating vapor. Coughing, shortness of breath, and pulmonary edema may result.

pneumatics

In physics, the study of gases and air.

pneumatocele A hernia, or protuberance, of lung tissue, usually caused by trauma or a disease process. Pneumatocele also refers to intracranial, extracranial, and scrotal swellings that contain gas. Extracranial pneumatocele refers to gas that collects under the galea aponeurotica (connective tissue of the occipitofrontalis [cranial] muscle), following a fracture in the paranasal sinuses. Intracranial pneumatocele refers to gas pockets in the cranium, brain, or meninges.

pneumomycosis 157 pneumatosis The abnormal presence of air or gas in the body, such as in the peritoneum or in the walls of the intestines, associated with obstructive lung disease caused by pneumatosis coli, or gas in the wall of the colon. pneumatotherapy Any treatment of or therapy for the lungs, or a treatment using rarefied or condensed air. pneumatothorax An accumulation of air or gas in the pleural cavity. See also PNEUMOTHORAX. pneumatype

The moisture that remains on glass from exhaled breath from the nostrils, used to examine the airflow through the nose.

pneumectomy

A surgical removal of a lung or part of a lung, usually as a treatment of malignancies or traumatic injury. The success rate of pneumectomy depends largely on the patient’s diagnosis and the presence of aggravating factors, such as concurrent diseases.

pneumoangiography

An X ray of the lung’s

Hodgkin’s disease, lymphoma, multiple myeloma, chronic renal failure, and nephritic syndrome; persons who have had organ transplantation; and anyone who is HIV positive. Other high-risk patients are those with chronic medical conditions such as heart or lung disease, diabetes mellitus, alcoholism, cirrhosis, and leakage of cerebrospinal fluid. Protective antibody levels from the pneumococcal vaccine are usually present five years following immunization but then may fall. Revaccination is recommended only for children at extremely high risk of pneumococcal pneumonia, those without a spleen or with nephrotic syndrome. Adverse effects from pneumococcal vaccine are rare. Most common reactions are cloacal swelling and redness at the injection site or a slight fever. The vaccine should be avoided during an active infection and in children younger than two, and it should not be given during pregnancy unless there is a clear need.

pneumococcus A gram-positive organism in more than 80 strains that causes pneumonia, meningitis, bronchitis, conjunctivitis, keratitis, mastoiditis, and blood infections. See also PNEUMONIA.

blood vessels.

pneumocentesis

The surgical aspiration of fluid

from the lung.

pneumoconiosis Lung disorder caused by chronic inhalation of dust and other irritating particles. See also SILICOSIS.

pneumococcal vaccine polyvalent (Pneumovax, Pnu-Imune) Immunization for protection against 23 strains of bacteria that cause approximately 90 percent of pneumococcal pneumonia. This type of pneumonia occurs in all age groups but is especially prominent in the elderly. Despite antibiotic therapy, there are still many deaths attributed to this type of pneumonia. Immunization with pneumococcal polysaccharide vaccine is advised for any individual at higher-than-normal risk for serious complications from pneumonia. High-risk persons include anyone older than 65, children older than two, and adults who are immunocompromised, such as those without a spleen or whose spleen is nonfunctional; persons with

pneumocystitis carinii pneumonia See PNEUMONIA. pneumoderma the skin. See also

Emphysema occurring beneath

EMPHYSEMA.

pneumodynamics The process of respiration, or the mechanics of breathing involving the exchange of oxygen and carbon dioxide. See also BREATHING; RESPIRATORY SYSTEM. pneumoenteritis Inflammation in the intestinal tract seen in combination with pneumonia.

158 pneumonectasia pneumography

Documentation of the lungs (and also respiratory movements) with a drawing, description, or graph. A pneumograph records frequency and intensity of breathing.

pneumohemorrhagica of the lung, also known Hemorrhage, which is bleeding, may be caused tered to increase blood pulmonary infections.

Bleeding into the air cells as apoplexy of the lungs. abnormal or excessive by certain drugs adminisvolume in patients with

pneumohemothorax

More commonly known as hemopneumothorax, the presence of gas, air, and blood in the pleural cavity.

pneumohydrothorax

More commonly known as hydropneumothorax, the presence of gas, air, and fluid in the pleural cavity.

pneumolithiasis

Stone formations, called calculi, in the respiratory tract. Calculus is composed of salts, organic and inorganic acids, and other substances, including cholesterol, and may form in the bronchi, pleura, nose, pharynx, and lungs.

pneumology A rare term for pulmonology, or the study of diseases of the lungs and airways. pneumolysis A surgical procedure performed to loosen a lung that has adhered to the chest wall. See also PNEUMOTHORAX. pneumomelanosis

Blackened areas of the lung as seen in pneumoconiosis. See also PNEUMOCONIOSIS.

pneumometer

See

SPIROMETER.

pneumomycosis A pulmonary disorder caused by a yeast or filamentous fungal infection. Fungi include various forms of mildew, mold, yeasts, and other parasitic life as well as harmless forms that inhabit parts of the body such as the mouth and the intestines. Fungal spores are continually present in

the air and in soil. Pathogenic forms of fungi may be inhaled into the respiratory system, especially in individuals who have been on long-term antibiotic therapy for a systemic infection or those who require corticosteroid or immunosuppressive medications. Mycoses, or fungal infections, range from mild to life-threatening, and treatment depends upon the specific fungus and symptoms. Certain fungi cause asthma, allergic rhinitis, and allergic alveolitis, which are not infections but allergic reactions or disorders.

pneumonectasia

Air that causes distention in the

lungs.

pneumonia Inflammation of the lungs characterized by chest pain, fever, cough (often producing bloody or purulent sputum), and other symptoms. The more than 50 causes of various types of pneumonia include bacteria, viruses, and irritating fumes from chemicals. Pneumonia symptoms may be confused with those of hypersensitivity pneumonitis, which is sometimes an allergic reaction to drugs, chemical irritants, plant and animal material, and dust. In addition, allergic alveolitis, or inflammation of the alveoli (air sacs) of the lungs, may produce similar symptoms; the most common causes are inhalation of mold spores, and animal and plant material. Occupational allergies (such as farmer’s lung) can simulate pneumonia symptoms. Pneumonia caused by pneumococci, staphylococci, or bacilli infection is characterized by the sudden onset of high fever, chills, chest pain, cough, and bloody or purulent sputum, and requires immediate treatment with antibiotics. These types of pneumonia are preventable by adhering to rules of hygiene and by immunization. Bronchial pneumonia refers to infections by mixed bacteria and is often associated with chronic pulmonary conditions including bronchiectasis and emphysema, or as a complication of surgery or anesthesia. Caseous pneumonia is that associated with tuberculosis involving necrosis (death) of the lung tissue that makes it resemble cheese. In desquamative interstitial pneumonia, the pulmonary interstitium (tissue surrounding air passages) becomes infiltrated with cells or fibrosis

pneumotomy 159 for unknown reasons. This causes dyspnea, cough, clubbed fingers, and an abnormal diffusion of oxygen and carbon dioxide. Corticosteroids are used to treat this form of pneumonia. Double pneumonia refers to the illness in both lungs. Congenital aspiration pneumonia refers to the disease that develops in utero or during birth. Intrauterine pneumonia is contracted in utero. Eaton agent pneumonia is caused by the microorganism Mycobacterium pneumoniae. Eosinophilic pneumonia is a lung inflammation caused by roundworms, fungus, and substances including nickel, penicillin, and sulfonamides, and unknown causes. Hypostatic pneumonia stems from inadequate aeration of the lungs, capillary pooling, and alveolar fluid congestion caused by inactivity, usually in elderly or debilitated patients who stay in the same position for long periods of time. This may be prevented by helping a patient shift positions or ambulate as often as possible. Pneumocystitis carinii pneumonia occurs when the organism P. carinii infects interstitial plasma cells in the lung, trachea, or bronchus, typically in marasmic or debilitated children or in immunocompromised patients. Fever, rapid and/or difficulty breathing, and a nonproductive cough appear as symptoms, and sulfamethoxasole-trimethoprim administered intravenously and inhalation of pentamidine are treatments of choice. Tuberculous pneumonia is caused by the tubercle bacilli. Varicella and tularemic pneumonias are complications of chickenpox (from the varicella virus) and tularemia (Francisella tularensis). Lobar, or central, pneumonia refers to pneumonia, often a result of Streptococcus pneumoniae, that affects a lobe or more than one lobe of the lung. In migratory pneumonia, the infection shifts from one portion of the lung to another, and secondary pneumonia refers to the disease that develops in people with other systemic diseases or conditions such as diphtheria, rheumatic fever, syphilis, typhus, Rocky Mountain fever, typhoid, Q fever, trichiniasis, AIDS, Legionnaire’s disease, rickettsial diseases, infectious mononucleosis, brucellosis, psittacosis, tularemia, plague, and acute viral respiratory disease. Embolic pneu-

monia develops after an embolization of a pulmonary blood vessel. Secondary pneumonia may also be lethal. Microbial causes of pneumonia are adenoviruses, influenza, rhinoviruses, Coxsackie viruses, coronaviruses, respiratory synctitial viruses, mycoplasmas (Mycoplasma pneumoniae), cocci (Pneumococcus, Staphylococcus, and hemolytic Streptococcus), protozoan (Pneumocystitis carinii), bacilli (Haemophilus influenzae, Mycobacterium tuberculosis, Klebsiella pneumoniae, and gram-negative bacilli), chlamydiae (Chlamydia trachomatis and C. psittaci), fungi (Histoplasma capsulatum, Coccidioides immitis), and rickettsiae (Rickettsia rickettsii, R. burnetii). Pneumonia may also be caused by oil aspiration, radiation, chemicals, vegetable dusts, and silo filler’s disease. See also PNEUMOCOCCAL VACCINE POLYVALENT.

pneumonia, eosinophilic

See

PNEUMONIA; PRO-

TEINOSIS; PULMONARY ALVEOLAR.

pneumonic plague

See

BUBONIC PLAGUE.

pneumonitis Also known as pneumonia, an inflammation of the lung. Forms of hypersensitivity (allergic) pneumonitis include bagassosis and other disorders caused by the chronic inhalation of organic dusts. Mycoplasma pneumonitis refers to pneumonia (also known as primary atypical pneumonia) that results from infection by mycoplasma organisms. Pneumococcal pneumonitis is pneumonia caused by pneumococci infection. See also PNEUMONIA. pneumonocele

Pulmonary hernia, also called pneumatocele. See also HERNIA, PHRENIC.

pneumopathy

A general term for diseases of the

lung.

pneumopleuritis

Inflammation of the lungs and

pleura.

pneumopyothorax

The presence of air and pus in the pleural cavity. See also PNEUMOTHORAX.

160 pneumotyphus pneumorrhagia

Hemorrhage, or abnormal bleeding, in the lung caused by trauma, severe lung infection or disease (including cancer and tuberculosis), blood disease in which there is a coagulation dysfunction, congenital abnormalities, or an adverse effect of certain prescribed medication that increases blood volume for the treatment of respiratory disease. A symptom of lung hemorrhage is red, frothy blood that is coughed up by the patient. Treatment varies and may include surgery.

pneumotyphus

Either the development of pneumonia as a complication of typhoid fever, or typhoid with the presence of pneumonia at the onset of disease.

Pneumovax

See

PNEUMOCOCCAL VACCINE POLYVA-

LENT.

pneusis From the Greek word pnein, to breathe, breathing, or panting.

pneumoserothorax The presence of air, gas, and serum in the pleural cavity. See also PNEUMOTHORAX.

Pnu-Imune

pneumosilicosis

pollinosis (hay fever)

See

SILICOSIS.

pneumotaxic center

The area in the pons of the brain that rhythmically inhibits inspiration or inhalation.

pneumotherapy

Any treatment of a lung disorder, including one that involves the administration of rarefied or condensed gases.

pneumothorax

Air or gas that collects in the pleural cavity as a result of trauma or the rupture of a lung abscess (such as a tuberculous abscess) or emphysematous bleb. Symptoms include severe sharp pain in the side and difficulty breathing. Treatment may involve the insertion of chest tubes and the administration of oxygen. A spontaneous pneumothorax, characterized by the sudden influx of air into the pleural cavity, may collapse the lung. A tension, or valvular, pneumothorax refers to air that cannot exit the pleural cavity the way it entered, which causes increased pressure in and collapse of the lung. As part of the treatment of pneumonia or pulmonary tuberculosis, a pneumothorax may be artificially induced to give the diseased lung a rest. An artificial pneumothorax is also known as therapeutic pneumothorax.

pneumotomy lung.

A surgical incision made in the

See

PNEUMOCOCCAL VACCINE POLYVA-

LENT.

Seasonal allergic rhinitis requiring the presence of pollen and capable of eliciting an allergic response in an atopic or allergic subject. The term hay fever is now used regardless of season. Under most circ*mstances, only anemophilous, or wind-borne pollen present in sufficient quantity can cause hay fever. Huge quantities of pollens are generally required to produce the symptoms of hay fever. Once the symptoms are evident, much smaller amounts of pollen will continue to elicit them. The source of the pollinating plants may be up to hundreds of miles away, being transported by seasonal winds. However, highpollen–producing trees such as elms, oaks, and others can provoke intense symptoms with exposure to only a single tree. Pollen release is generally promoted by warm, dry conditions. Ragweed pollen shedding ceases or falls sharply at 10 degrees Celsius (approximately 50 degrees Fahrenheit) or when the relative humidity is above 70 percent. Many flowers store pollen until optimal conditions exist, favoring release during the daytime. Exceptions abound, however, with ragweed and some grasses also releasing pollen at night. In order to cause hay fever, a plant must meet Thommen’s five postulates: (1) the plant must be seed-bearing (spermatophyte); only seed-bearing plants produce pollen; (2) the plant must have wide distribution, or the plant must be close to the human environment; (3) the plant must produce huge quantities of pollen; (4) the pollen must be light enough to be airborne, between 15 and 50

pregnancy and rhinitis 161 microns (1 micron = 1/25,000 inch) in diameter; (5) the pollen must be allergenic. A plant species meeting all five rules is considered a primary or index species. Species meeting fewer than five are of little or no significance. Occasionally an individual will seem to have symptoms related to a plant not meeting the criteria, but that is rare, and often the wrong plant is blamed (such as goldenrod, which is blamed for symptoms probably caused by ragweed). Since pollen is hygroscopic, or able to absorb water vapor from the atmosphere, it becomes too heavy to be wind-borne. Therefore, hay fevercausing plants are rare in humid tropical climates. In these areas, pollination depends upon insects, birds, and bats.

pollutant Any particle, chemical, irritant, or other substance that contributes to or creates bad air, that is, impure air capable of causing adverse reactions when it flows in and out of the body. polyblennia

An abnormal secretion of mucus.

polymer fume fever

See

antrocoanal polyps and grow into the postnasal space. Approximately one-third of patients with nasal polyps are asthmatics, and about 8 percent also have aspirin sensitivity (referred to as a triad, or three-linked disorders). Patients with the triad may develop problems with foods containing the yellow dye tartrazine. Polyps may worsen asthma because the nose’s normal warming of the inspired air before it reaches the lungs is blocked, forcing bronchoconstricting cold air to reach the lungs through the mouth because of nasal obstruction. About half of all cases of nasal polyps respond to corticosteroid nasal sprays. Those not responding will most likely need surgery. Endoscopic resection of polyps is the procedure of choice. Many patients have recurrences. See also CYSTIC FIBROSIS.

polypnea

polysinusitis Infection involving more than one of the sinuses. See also SINUSITIS.

METAL FUME FEVER.

poppers polyp, mucous

Extremely rapid breathing or panting.

See

INHALANT ABUSE.

A soft polyp exhibiting mucoid

degeneration.

polyp, nasal Soft tissue normally found lining the ethmoid sinuses that protrudes into the nasal cavity. Most often nasal polyps occur bilaterally, are usually benign, and cause nasal obstruction. An estimated one to 20 adults per 1,000 population, males by a ratio of from two to four to one, have nasal polyps at some time during their lives. Allergic individuals are no more likely than others to develop polyps. Benign simple polyps are rarely found before age 20, and if present in children before the age of two, a serious defect in the base of the skull may be present. Nasal polyps occur in 8 percent of cystic fibrosis patients, and when seen in children over the age of two, they may be a manifestation of this serious inherited disorder. Polyps are also found in two other rare diseases, Kartagener’s syndrome and Young’s syndrome. Polyps arising from the maxillary sinuses are called

porta pulmonis

The point of entry and exit of the bronchi, nerves, and vessels in the lung.

postnasal drip Sensation of mucus in the back of the throat commonly occurring in persons with nasal allergy, sinusitis, colds, and other upper respiratory infections. postural drainage A series of techniques that take advantage of gravity to encourage mucus to move out of the lungs or bronchi. For example, one technique requires the patient to be placed on an incline or over the edge of the bed face down, with his or her head lower than the rest of the body. The health care professional or caregiver then cups his or her hands and gently claps the patient’s back over the lung area. The clapping causes productive coughing, that is, expectoration of sputum. Other techniques based on the gravity principle depend

162 preoxygenation upon which part of the lung is affected. Because postural drainage may aggravate a person’s asthma or other respiratory disorder, a trained professional should perform the initial therapy and evaluate the patient’s tolerance.

potassium chromate poisoning Toxicity resulting from the inhalation of the chemical potassium chromate, or K2CrO4, used in furniture stains, dyes, batteries, photography, and by research laboratories as a tissue preservative. Poisoning and ulcers may also occur when the chemical comes in contact with nasal passages. Treatment includes methods used in cases of toxicity from a strong acid. potassium iodide The crystals of the mineral potassium (a salt), having a slight iodine odor, that have been prepared as an expectorant. When used as a mucolytic drug, a potassium iodide solution may help alleviate mucus buildup in the lungs and bronchial passages, but it may also cause acne-like skin lesions and hypothyroidism. Pott’s disease Named for British surgeon Percivall Pott (1713–88), a tubercular condition of the vertebrae. Not a respiratory disorder, Pott’s disease is also known as tuberculous spondylitis, and may result in kyphosis that compresses the spinal cord and nerves. poultice

From the Latin word pultes, a thick paste of hot, moist mustard, linseed, or soap and oil between two pieces of muslin that is applied to the chest or other area to relieve congestion and pain. Also known as a mustard plaster, a poultice counteracts inflammation.

prednisolone prednisone

See

CORTICOSTEROIDS.

The most commonly prescribed corticosteroid drug for the treatment of allergies and asthma. See also CORTICOSTEROIDS.

pregnancy and rhinitis Rhinitis, or nasal congestion, that occurs in approximately 35 percent of pregnant women. In one study during pregnancy, the congestion worsened in 34 percent of the women, improved in 15 percent, and was unchanged in the rest. Severe rhinitis can interfere with sleep and aggravate asthma. As in nonpregnant women, runny and stuffy noses can be caused by allergies or hay fever, or by vasomotor or nonallergic rhinitis, or infections such as colds and sinusitis. Treatment should be based on the same principles for using any drug during pregnancy. The drug must be necessary and have a long record of use during pregnancy without reported adverse outcomes to the pregnancy, and its use must be monitored by a physician experienced in its use during pregnancy. preoxygenation The breathing for two to seven minutes of 100 percent oxygen by a patient before he or she is given anesthesia for surgery. This flushes the nitrogen out of the lungs and replaces it with the oxygen. Preoxygenation is also used to prevent caisson disease, or bends. See also BENDS. preparation, heart-lung The use of devices that take over heart and lung function during openheart and thoracic surgical procedures. preventive medicine

Any techniques, modalities, or measures that promote wellness, including methods or regimens followed to stabilize or improve a patient’s well-being despite an existing disease. Preventive measures may be considered allopathic, or traditional Western health practices, or alternative, which may involve Eastern medical practices and a variety of other philosophies and modalities. Immunization is also a type of preventive medicine. See also PNEUMOCOCCAL VACCINE POLYVALENT; VACCINES.

primary pulmonary hypertension

A condition stemming from the insidious onset of respiratory

pulmonary circulation 163 failure in which pressure increases in the blood vessels throughout the lungs. Without proper treatment, the blood vessels become too damaged to transfer oxygen, thus causing cardiac complications leading to heart failure. Pulmonary hypertension (PH) can also be caused by fibrosis of the lung, sickle cell disease, pulmonary embolic disease, mitral stenosis, atrial septal defects, and chronic hypoxemia in obstructive sleep apnea. Primary pulmonary hypertension (PPH), which also may occur without apparent cause, may possibly be linked to HIV infection, substance abuse (particularly cocaine), appetite suppressant supplements or drugs, and genetic factors. Treatment for PH includes continuous intravenous epoprostenol (Flolan) and lung transplantation. Flolan, a synthetic substance that performs as the naturally produced prostaglandin does in the body, dilates pulmonary artery vessels, reduces blood clotting, improves cardiac output, and inhibits smooth muscle cell growth. Despite side effects such as headaches and diarrhea, uninterrupted intravenous therapy required for the rest of the patient’s life, and administration of a central venous line, Flolan is considered a breakthrough therapy for PH and PPH. If the therapy is interrupted, the patient’s symptoms—dyspnea, rightsided heart failure, hepatomegaly, peripheral edema, and angina, among them—may return, and the patient may die. Emotional support is recommended for PH and PPH patients and is available through the Pulmonary Hypertension Association (PHA) at www.phassociation.org or by calling (301) 565-3004.

promethazine (Phenergan)

An antihistaminic, sedative, antimotion-sickness, antinausea, and anticholinergic drug used in the treatment of cough and allergic reactions.

ProStep

See

NICOTINE PATCHES.

proteinosis, pulmonary alveolar

A condition in which the alveoli, or air sacs, of the lungs fill with a protein-rich fluid, which prevents the lungs from transferring oxygen to the blood. The cause of this disease that typically affects people between 20 and

60 years old who do not have a history of lung disease is unknown. Some people may be asymptomatic, while others experience shortness of breath or a cough, particularly a productive cough if they smoke. Diagnosed by chest X ray and pulmonary function tests, proteinosis may be treated by antibiotics and bronchopulmonary lavage. If proteinosis is untreated, pulmonary insufficiency may occur and progress into respiratory failure and death. Approximately 25 percent of proteinosis cases clear up spontaneously. The cause of the disease is largely unknown; however, it may be a result of drugs, chemical fumes, or infections by fungi or parasites. Eosinophils, a type of white blood cell that aids the lungs’ immune defenses, may increase by 10 to 15 times the normal number in the event of asthma, allergic reaction, or inflammatory process in the body and contribute to eosinophilic pneumonia, also known as pulmonary eosinophilia syndrome (PIE) and Löffler’s syndrome. When eosinophils invade the alveoli, bloodstream, and blood vessel walls, airways may become narrower or, with asthma, plugged with mucus. Diagnostic testing includes microscopic examination of sputum, which would contain clumps of eosinophils, and X ray. Treatment for severe cases of eosinophilic pneumonia may include corticosteroids or other asthma treatment if asthma is present, and drugs corresponding to parasites. Some cases of the disease clear up without treatment.

Proventil

See

ALBUTEROL.

pseudocroup Another name for laryngismus stridulus, or false croup. See also LARYNGISMUS STRIDULUS. pseudoemphysema Temporary blockage of the bronchi that resembles emphysema. See also EMPHYSEMA. pseudoephedrine

The generic name for Sudafed, Afrinol, and other drugs, including many over-thecounter preparations, used alone or in combination with antihistamines in the treatment of nasal congestion caused by allergies and colds.

164 pulmonary edema pseudotuberculosis Diseases that have similar characteristics of tuberculosis but are not caused by the same bacillus. Pseudotuberculosis is often caused by the organism Yersinia pseudotuberculosis.

limeters of mercury) systolic and 8 to 12 mm Hg diastolic. Pulmonary capillary wedged pressure is also measured by the wedge-pressure method.

pulmonary circulation psittacosis (parrot fever)

A Chlamydia pssitaci infection characterized by headache, nausea, chills, and sometimes pulmonary problems. The disease, rarely fatal, can be transmitted to humans from birds—parrots, pigeons, and fowl are the main carriers—by inhalation of dust contaminated with bird droppings. Approximately 100 cases of psittacosis are reported annually in the United States, though some professionals believe many cases go unreported. Bird or poultry handlers are at the greatest risk of infection. Antibodies specific to the Chlamydia species found in human blood confirm the diagnosis. Tetracycline is the treatment of choice. Psittacosis may be confused with asthma or allergy to birds.

ptarmus

Sneezing spasms.

pulmometry

The measurement of the lungs’

capacity.

pulmonary arterial webs

Deformities resembling webs that appear in pulmonary angiograms at sites where a patient has had a pulmonary thromboembolism.

pulmonary artery The major blood vessel that leads from the right ventricle of the heart directly to the lungs. Pulmonary artery wedge pressure refers to the blood pressure in the capillary end of the artery as measured by the insertion of a catheter that inflates a balloon with air. The catheter floats in a “wedged” position until the air in the balloon is deflated and the catheter goes back into the main pulmonary artery. Normal pulmonary artery pressure is 20 to 30 mm Hg (mil-

The process of blood flow from the heart (from the right cardiac vessel) to the lungs. In the lungs, blood becomes oxygenated, and then returns to the heart (left cardiac atrium).

pulmonary edema Edema, or swelling, of the lung. See also

EDEMA, PULMONARY.

pulmonary fibrosis

See

FIBROSIS, PULMONARY.

pulmonary function tests Procedures used to diagnose and evaluate the severity of asthma and some other lung disorders. See also PEAK FLOW METER. pulmonary mucociliary clearance A respiratory tract defense mechanism involving ciliated cells, or cells with fine hairs in the respiratory tract, that have the ability to move mucus, inhaled particles, and other debris up and out of the tracheobronchial tree. pulmonary stenosis

See

pulmonary surfactant

STENOSIS, PULMONARY.

See

RESPIRATORY SYSTEM;

SURFACTANT, PULMONARY.

pulmonary valve Located between the right ventricle of the heart and the opening of the pulmonary artery, the membranous structure that separates the ventricle and artery and either closes off or permits the flow of blood. pulmonary vein The major blood vessel that drains the lungs and brings blood back to the heart’s left atrium.

Q See also

puna

RESPIRATORY SYSTEM.

pulmonectomy

The surgical excision of all or a portion of lung tissue, also known as pneumonectomy.

pulmonitis See also

ALTITUDE SICKNESS.

pursed-lip breathing pyohemothorax

See

BREATHING.

Blood and pus found in the

pleural cavity.

Inflammation of the lung. PNEUMONIA.

pyothorax

pulmonologist

Physician who specializes in the diagnosis and treatment of lung diseases, including asthma.

pulmotor A device for artificial respiration that forces air or oxygen into the lungs. pulse, respiratory

The pulse corresponding with a person’s breathing in and out that may be palpated in the large veins in the neck.

pulse, Riegel’s The reduction or diminution of the pulse when a person exhales. pulsus paradoxus A mercury fall of greater than 10 millimeters in the systolic blood pressure during inspiration that occurs during a severe life-threatening asthma attack. pump, air (oxygenator)

See

A device that forces air in or suctions air out of a pathway or chamber. A pump-oxygenator not only pumps blood but forces oxygen into it as well.

Pus found in the pleural cavity.

pyrilamine An antihistaminic drug of the ethylenediamine class used for the treatment of allergic disorders. See also ANTIHISTAMINE. Q fever

An infection found throughout the world caused by inhaling dust or other substance contaminated by Coxiella burnetii (Rickettsia burnetii), an organism harbored in farm animals. Ingesting infected raw milk or coming into contact with infected animals’ urine, feces, and flesh also transmits the disease. Similar to the symptoms of influenza, Q fever is characterized by fever, severe headache, chills, myalgia, weakness, chest pain, coughing, and pneumonitis. Untreated, Q fever may be fatal. Antibiotic drugs such as tetracyclines are the treatment of choice. A preventive vaccine is available for individuals who may contract the disease through occupations that involve the handling of cows, sheep, goats, and other animals that may be infected. Q fever has retained its name because its etiology had been previously unknown, and the Q stood for “query.” Besides the rickettsial organism that has been identified as a specific cause, all acute

165

R infections may include the aforementioned symptoms, and “Q fever” has been used as a generic diagnosis.

quadrangular membrane Part of the larynx, or vocal cords. The quadrangular membrane is located on the upper portion of the elastic membrane of the larynx. quanti-Pirquet

A skin test measuring sensitivity to tuberculin developed by Austrian pediatrician Clemens Peter Johann von Pirquet (1874–1929).

quarantine Derived from the Italian word quarantina, meaning 40 days, a designated time during which individuals, groups of people, or animals are not allowed to come into contact with the public, usually because of an infectious disease that may spread to others. The quarantine time begins from the exposure to an infectious disease to the end of its incubation period. Quibron

See

THEOPHYLLINE.

quinolone antibiotics A unique group of broadspectrum antibiotics that attack an enzyme, DNA gyrase, essential for the reproduction of infectioncausing bacteria. Nalidixic acid, an earlier quinolone drug, had limited usefulness, but derivatives of this drug became available for use in the early 1990s; there are four different clinically important quinolone derivatives now available in the United States: ciprofloxacin (Cipro) and norfloxacin (Noroxin, Floxin, and Maxaquin). Another antibiotic in this category, ofloxacin, was recalled shortly

after it was introduced following reports of deaths related to its use. With the exception of norfloxacin (used primarily for urinary tract infections), these antibiotics are frequently prescribed for patients with respiratory infections. However, since some of the quinolone antibiotics raise theophylline levels, which possibly causes toxicity, they must be used cautiously or avoided in patients who are also taking this asthma drug.

quotient, respiratory

See also

A severe nosebleed.

EPISTAXIS.

rhinorrhea

A thin watery discharge from the nose. Conditions causing rhinorrhea include allergies, the common cold, and cluster headaches. A watery discharge following a serious head injury may indicate the leakage of cerebrospinal fluid.

rhinoscleroma A disease caused by the bacillus Klebsiella rhinoscleromatis that results in extremely

S rhinosporidiasis

Also known as rhinosporidiosis, a fungal infection contracted from cattle and caused by Rhinosporidium seeberi in which a chronic granulomatous disease produces polyps that form on mucous membranes of the nose, larynx, eyes, penis, vagin*, and skin. Rhinosporidiasis may be seen in India, Sri Lanka, and other locations. Antifungal drugs are among the treatments.

rhinostenosis

Obstruction or constriction of the

nasal passages.

rhinotracheitis

Inflammation of the nasal passages and the windpipe, or trachea.

room, dust-free

An area or chamber designated for individuals with allergies or sensitivity to airborne microorganisms and particles that may be harmful if inhaled. Devices may be installed that filter or purify the air in the room, thus reducing the number of offending particles or allergens.

rose fever (rose cold)

Another name for hay fever occurring in the spring pollen season. Rose pollen is transferred by insects and is not an important allergen. Persons who have hay fever symptoms in the spring are allergic to tree and/or grass pollens. See also RHINITIS, ALLERGIC.

Rotacaps rhinovirus

A species of picornavirus that causes the common cold. It is estimated there are more than 100 rhinoviruses that occur throughout the world.

rhonchus Snoring, or any rattling in the windpipe or chest.

Capsules containing the dry, powdered bronchodilating asthma drug albuterol (Ventolin). The capsules are placed in a device called a Rotahaler, which is activated by puncturing the capsule and releasing the powder into a small chamber. The powder is then inhaled through the mouth into the airways. This Rotahaler method of inhalation is useful for patients lacking the coordination necessary to activate a metered-dose inhaler. See also ALBUTEROL.

rifampin

Also known by the trade names Rimactane and Rifadin, an antibiotic used to treat tuberculosis caused by the Mycobacterium tuberculosis and to treat carriers of Neisseria meningitidis. See also TUBERCULOSIS.

rima respiratoria

The space located behind the

arytenoid cartilages.

Robitussin

The trade name for guaifenesin, an

sac, alveolar See also

Air sacs found in the lungs.

ALVEOLUS; LUNG.

St. Joseph’s Cough Syrup for Children A brand of dextromethorphan hydrobromide, a derivative of a synthetic morphine used to treat coughing. It reportedly does not cause dependence, although as an antitussive, it is not as effective as codeine. See also ANTITUSSIVE.

expectorant.

174

seasonal allergy 175 salbutamol

See

ALBUTEROL.

saline solution

A combination of salt and water. A saline nasal spray contains the concentration of tears (.09 percent) and is used as a spray to irrigate the nasal passages.

salmeterol (Serevent)

A bronchodilating drug of the beta-adrenergic agonist type for the treatment of asthma. Salmeterol is also available as a metered-dose inhaler. Its effects last for 12 hours or longer without tolerance or loss of effectiveness. Studies also indicate that continued use does not result in worsening asthma symptoms. See also BETA-ADRENERGIC AGONISTS.

salpingopharyngeal

Pertaining to the pharynx, or throat, and the eustachian tube of the ear.

salt

The chemical sodium chloride (the same as table salt), an inorganic, mineral constituent of the body that is vital to cell function and life. English researchers have reported that excessive intake of dietary salt may increase asthma mortality.

Salter, Henry H.

British physician (1823–71) who practiced in London and was associated with R. B. Todd at King’s College. Salter, an asthmatic, published a respected work entitled On Asthma: Its Pathology and Treatment, in which he pointed out the dangers and questioned the effectiveness of the use of opium in treating asthma. He saw in opium a tendency to cause involuntary muscular action and induce spasms. He attributed its prescription by physicians of his day to their unthinking acceptance of its routine use and their failure to monitor closely their own patients’ responses. Salter also wrote articles on the pancreas and tongue for Todd’s Cyclopedia. In 1854, he became a lecturer in physiology and in medicine at Charing Cross Hospital in London.

salts, smelling

Aromatized ammonium carbonate, used to revive a person who has fainted.

saltwater sprays

See

SALINE SOLUTION.

Samuelsson, Bengt I. Swedish physician and scientist, born in 1934, who shared the Nobel Prize for physiology or medicine in 1982 with Sune Bergstrom and John Vane. Samuelsson identified and described leukotrienes and their role in asthma, allergy, and inflammation. At the Karolinska Institute in Stockholm, Sweden, since 1972, he has served as professor of medical and physiologic chemistry, chairman of the Department of Chemistry, dean of the medical faculty, and rector. See also LEUKOTRIENES. sanatorium A facility, also called a sanatarium, dedicated to the prevention and treatment of chronic illness, particularly tuberculosis, and the promotion of health. sandfly fever

A tropical and subtropical viral disease caused by arboviruses carried by the sandfly Phlebotomus papatasi. Sandfly (or pappataci or phlebotomus) fever resembles influenza but does not include respiratory distress. Sandflies of the order Diptera and the genus Phlebotomus, however, may transmit sandfly fever, Oroya fever, and forms of leishmaniasis. See also LEISHMANIASIS.

sanitizer

Any substance or agent that disinfects an area or reduces bacteria to make the materials or area that is sanitized safe according to standards for public health.

sarcoidosis A chronic, often asymptomatic, disease that can affect the skin, lungs, lymph nodes, spleen, eyes, and the small bones of the hands and feet. Although the cause of sarcoid (formerly known as Boeck’s sarcoid) is unknown, it is characterized by granulomatous lesions in body tissue. A routine chest X ray often reveals the presence of the disease, but symptoms may occur and include fever, fatigue, malaise, arthritis, cough, shortness of breath on minimal exertion, nervous system disturbances, painful red bumps on the shins, abnormal heart rhythm, and elevated blood calcium.

176 segment, bronchopulmonary Steroids are the treatment of choice, although in some patients, the disease resolves spontaneously.

spread to the cervical lymph nodes. Treatment involves antituberculosis drug therapy.

saturation, oxygen The ratio of the amount of oxygen in a certain amount of blood to the amount of oxygen the blood could optimally carry.

scuba

scaleniotomy

Referring to the three scalenus muscles on each side of the neck, a surgical incision into one of the muscles to check expansion of the lung’s apex in patients with tuberculosis.

scarlatina anginosa A type of scarlet fever (an acute, contagious disease caused by more than 40 strains of streptococci) that involves ulceration and severe necrosis of the throat and abscess of the tonsils and surrounding areas.

See

SELF-CONTAINED UNDERWATER BREATH-

ING APPARATUS.

seal, velopharyngeal The closed area between the mouth, nose, and throat cavities. seasonal allergy (seasonal hay fever)

Nasal and eye allergies and asthma that occur in the spring and fall upon exposure to pollinating trees, grasses, and weeds in susceptible persons. Many who suffer from perennial, or year-round, allergies also have seasonal allergies and tend to suffer more in the spring and fall. See also ALLERGIC RHINITIS; ASTHMA; HAY FEVER; POLLINOSIS.

schneiderian membrane The nasal mucosa, named after the German anatomist Conrad Viktor Schneider (1614–80) who identified it.

segment, bronchopulmonary A subdivision of the lobes of the lung, usually a small section.

scleroderma

Seldane

scoliosis, empyemic A lateral curvature of the spine as a result of empyema (pus in a body cavity, usually the lungs) and retraction of one side of the chest.

self-contained underwater breathing apparatus (SCUBA) A watertight device connected to a

A chronic disease of unknown etiology that causes sclerosis or hardening of skin and other organs, including the lungs. Scleroderma is not considered a respiratory disorder per se because it affects several major organs after the skin becomes tough and leathery, a primary manifestation. There is no special therapy, but various drugs are prescribed according to pathological changes.

screening Diagnostic testing, including chest X ray and tuberculin tests, to identify either risk factors or the presence of disease in large groups of people. Screening plays an important role in public health and prevention of disease. scrofula

A type of tuberculosis adenitis, considered a complication of a pulmonary lesion that has

A brand name for terfenadine, a secondgeneration or nonsedating antihistaminic drug used to treat allergic rhinitis and urticaria. There have been rare but life-threatening cardiac arrhythmias (irregular heartbeat) associated with the use of terfenadine given simultaneously with other drugs, including the antibiotic erythromycin, the antifungal drug ketoconazole, and with grapefruit juice. A risk is also associated with the use of this drug in persons with liver disorders.

tank of compressed air worn by swimmers and divers. See also BENDS.

self-treatment risks

The danger of underestimating the severity of asthma or allergic reactions until they become more difficult to treat, cause serious irreparable damage to the lungs, or provoke a lifethreatening situation. A person with asthma may have gradually become accustomed to his or her

singultation 177 shortness of breath and have an unrealistic perception of its severity. See also ASTHMA.

sequestration, pulmonary A nonfunctioning part of the lung that is supplied with blood from systemic circulation.

Semprex-D (Prolert)

Serevent

A brand name for acrivistine, a nonsedating antihistamine. In clinical trials subjects did not develop tolerance (loss of effectiveness of a drug with continued use) after several weeks of use. Onset of the drug effect starts within one to two hours of the first dose, but the drug must be taken three or four times a day. See also ANTIHISTAMINE.

sense of smell, loss (anosmia)

Inability to detect odors, either permanently by destruction of the olfactory (or first) cranial nerve, or temporarily by nasal obstruction or allergies.

sensitivity A person’s level of susceptibility to allergens, also known as antigens, which may produce a varied number of symptoms. Sensitogens are all the allergens of the body that can possibly produce an allergic reaction. Sensitogens include anaphylactogen and sensibilisinogen. septicemia, bronchopulmonary

A potentially life-threatening condition characterized by pathogenic bacteria that have entered the bronchi and lungs through the blood. An abscess, a preexisting disease such as cancer, diabetes mellitus or an immunodeficiency disorder, or an infection such as pneumonia may contribute to the onset of septicemia. Symptoms of septicemia, or blood poisoning, include chills, fever, rapid respirations, and shock. If treated with antibiotic drugs, usually administered by intravenous infusion, septicemia can be arrested before septic shock or damage to lung and other tissue occurs. Oxygen therapy may be employed, and surgery may be required to remove the site of the infection.

septotomy

A surgical incision made in the nasal

septum.

septum, nasal

See

NASAL SEPTUM.

See

SALMETEROL.

sexual activity and asthma

The physical exertion of intercourse that in asthmatic persons may result in wheezing or shortness of breath and should be treated as exercise-induced asthma. See also ASTHMA.

Shen-Nung The legendary founder of Chinese medicine and agriculture and the “Fire Emperor” of China from 2838 to 2698 B.C. who devised the Pen-Ts’ao, or the Divine Husbandman’s Materia Medica. This reference described how drugs and plants could be used to treat diseases. Shen-Nung’s work was continued by other investigators long after his death. His original reference to Ma-Huang, the plant source of the drug epinephrine, has been studied pharmacologically up through today. According to Shen-Nung, Ma-Huang, or ephedra, redirects a reversed flow of ch’i (in Eastern medicine, ch’i refers to the air, or essential spirit, of the human body), which causes coughing and difficulty in breathing. Today, ephedrine is an effective drug in the treatment of hay fever and asthma. See also EPHEDRINE. shock

A set of symptoms indicating great physical and/or emotional trauma, including inadequate peripheral blood flow to the heart, infection, hemorrhage, trauma, myocardial infarction (heart attack), poisoning, dehydration, excess or lack of insulin, allergic reaction, anesthetic overdose, acidosis, electric current, toxins from gram-negative bacteria, insufficient amount of blood in the circulatory system, mental or psychic trauma, protein administered parenterally, injection of certain serum, adverse surgical effects, and other causes. Shock is considered a medical emergency and requires immediate treatment, depending upon type and severity.

178 sinobronchitis sick building syndrome (tight building syndrome)

silicotuberculosis Pulmonary tuberculosis concurrent with silicosis. See also SILICOSIS; TUBERCULOSIS.

Symptoms suggestive of allergy occurring in groups of office workers. Since the energy crisis of the 1970s, changes in construction were designed to improve heating and air-conditioning efficiency. These changes frequently resulted in poor ventilation, which leads to respiratory irritation and the possible retention of allergens in the air. Symptoms range from itching and burning of the mucous membranes of the respiratory system to rashes and central nervous system complaints. In more than 450 evaluations made by the National Institute of Occupational Safety and Health (NIOSH), there have rarely been severe or permanent illnesses as a result of these symptoms. The exceptions have been cases of hypersensitivity pneumonitis, an allergic lung disease caused by repeated exposure to organic dusts or other offending agents, or infectious pneumonias such as Legionnaire’s disease. See also LEGIONNAIRE’S DISEASE; PNEUMONITIS.

silo filler’s disease An occupational, lung-damaging irritation of nitrogen oxide (NO2), a poisonous gas produced by fermenting material in silos. Silo workers may experience eye and throat irritation, but the condition may be as severe as to cause unconsciousness and injury to the lungs. Among preventive measures are forbidding entrance to the silo for seven to 10 days after it has been filled, adequate ventilation above the silo’s base for that seven- to 10-day period, a blower fan installed in the silo that can be turned on upon entering, and constructing a fence around the area of the silo to prevent children and animals from possible toxicity exposure.

sickness, mountain

hiccup.

See

ALTITUDE SICKNESS.

Singulair

Brand name of montelukast.

singultation

From the Latin word singultus, a

siderosis A chronic, pneumonia-like lung disease, also known as arc welder’s disease or hemosiderosis, caused by the inhalation of iron particles in dust or fumes.

sinobronchitis Bronchitis occurring simultaneously with paranasal sinusitis. See also BRONCHITIS; SINUSITIS.

sigh

sinopulmonary infections and immunoglobulin A (IgA) deficiency A higher incidence of respira-

A deep breath and exhalation that may be accompanied by a sound.

signs, vital Temperature, respiration rate, blood pressure, and pulse rate monitored regularly as functions that are essential to life.

tory infections in the sinuses and lungs in persons with a deficiency in antibodies of the IgA class. See also IMMUNE COMPLEX DISORDERS.

sinuses, accessory nasal silicosiderosis silicosis

See

SIDEROSIS.

A chronic, pneumonia-like lung disease caused by the chronic occupational inhalation of quartz dust, or silica, stone dust, sand dust, or flint dust that contains silicon dioxide. Silicosis is also called grinder’s disease, or pneumoconiosis. See also GRINDER’S DISEASE; PNEUMOCONIOSIS.

Hollow air-filled cavities in the bones of the skull located over the eyes (frontal), behind the eyes (ethmoidal), behind the nose (sphenoid), and behind the cheeks (maxillary). The frontal sinus is not present at birth and usually develops fully by the late teens (or it may never develop in some persons). The function of the sinuses is unknown; however, infection in one or more of the sinus cavities is a source of frequent disability that can be severe. See also SINUSITIS.

smoking, passive 179 sinuses, pleural Open regions or spaces in the pleural sac located in the lower and inferior portions of the lung. sinuses, sphenoidal

See

SINUSES,

ACCESSORY

NASAL.

sinusitis

An inflammation of the mucous membrane lining in one or more of the sinus cavities in the head, caused by inadequate drainage characteristic of allergy, infection, or physical obstruction. Sinusitis may be acute, lasting for a few days to weeks, or chronic, lasting for many months to years. It has a tendency to recur. During an attack of sinusitis, tiny hairs that keep the sinuses clear lose their effectiveness, and the sinus cavities become blocked. The blockage results in the symptoms of pressure or pain characteristic of sinusitis. Headache and facial pain caused by migraine, trigeminal neuralgia, or from a dental problem are often erroneously called “sinus headache” but must be distinguished from sinusitis. Fever and a thick yellow-green mucus discharge are often associated with sinus infection. The diagnosis of a sinus condition is usually suggested by a history of the typical symptoms described above. However, the diagnosis may be unclear at times. As many as 10 percent of sinus infections are related to dental problems. Diagnostic procedures to confirm the presence of sinusitis include transillumination of the frontal and maxillary sinuses in a completely darkened room. A bright light source is placed over the orbital area of the face, and the hard palate is observed for the absence of transmission of light indicative of sinusitis. The light source is then placed against the hard palate to observe light transmission over the cheekbones behind which the maxillary sinuses are located. Transillumination is of lesser value for the frontal sinuses and of no use to diagnose disease in the ethmoid and sphenoid sinuses. Ultrasound is a technique in which inaudible sound waves in the frequency of approximately 20,000 to 10 billion cycles per second are passed through body tissues. Differences in the velocity with which sound passes through various tissues are used to outline their shape and aid in the diag-

nosis of disorders. Despite early promises of being a safe, noninvasive means to diagnose sinus conditions, unfortunately it lacks the sensitivity to be a reliable diagnostic method. X rays are the mainstay for accurate diagnosis of sinus disease. Plain films are useful for detecting thickness suggestive of chronic sinus disease or airfluid levels correlating with acute infection. However, X rays have limited ability to view the deeper ethmoid and sphenoid sinuses. Computerized tomography (CT or CAT scan) is the most sensitive means for the diagnosis of sinus disorders. Magnetic resonance imaging (MRI) is capable of detecting minute changes in tissues, but it is two or three times more expensive than a CT scan. Allergies are probably the most common cause of sinus symptoms, and skin and blood tests are helpful in making that diagnosis. Although bacterial infections frequently complicate sinusitis, cultures of material obtained from nasal secretions are unreliable in determining the cause. Streptococcus pneumoniae and Haemophilus influenzae are responsible for approximately 50 percent of proven sinus infection, but Branhamella catarrhalis (formerly called Neisseria catarrhalis) and other bacteria are important causes of infected sinuses. Less frequently, fungal infections occur in the sinuses. Many sinus infections are preceded by viral upper respiratory infections or colds. Most sinus conditions respond to decongestant drugs, antihistamines for allergic individuals, and antibiotics. Antibiotics should be taken for a minimum of 10 to 14 days but may be needed for up to six weeks in persistent cases. Anti-inflammatory, corticosteroid nasal sprays may be helpful in controlling sinus symptoms and preventing recurrences. Sinus irrigation, the mainstay of treatment prior to the introduction of antibiotics, is still useful in stubborn cases. If adequate antibiotic therapy and sinus drainage are unsuccessful, surgical procedures by otolaryngologists (ENT doctors) skilled in various procedures may be necessary. Unfortunately, sinus surgery has a high rate of failure in preventing recurrences of sinusitis.

skier’s nose Also known as cold-induced rhinorrhea, a runny nose that occurs upon exposure to

180 sneeze cold air. It is not an allergy and does not respond to antihistamines, but it may be prevented by using a mixture of atropine sulfate and saline solution as a nasal spray.

Skoda’s rales

Named for Austrian physician Josef Skoda (1805–81), crackling noises heard on auscultation in the bronchial tubes of pneumonia patients. See also SKODA’S RESONANCE.

Skoda’s resonance

Sounds heard above the presence of fluid in the case of pleuritic effusion or pneumonia.

sleep apnea Slo-Bid

See

Slo-Phyllin

See

APNEA.

THEOPHYLLINE.

See

THEOPHYLLINE.

slow-reacting substance of anaphylaxis (SRS-A) Also known as slow-releasing substance (SRS), leukotriene C and D, a potent biochemical substance produced and released by mast cells of the immune system during anaphylaxis (severe allergic reaction). SRS causes smooth-muscle contraction especially in the bronchial tubes and increased permeability of blood vessels. See also LEUKOTRIENES.

smog A type of air pollution caused by a combination of smoke and fog. smoke inhalation smokeless tobacco

See

SMOKE POISONING.

See

TOBACCO.

smoke poisoning Deleterious effects of inhaling gases, usually carbon monoxide, and smoke that is the result of burning. Affected most is the respiratory system, namely injured mucosa, which may lead to pulmonary edema, shock, and death. Therapy includes oxygen, corticosteroids, and other measures specific to pulmonary edema.

smoker’s cancer smoking

See

LUNG CANCER.

smoking, passive The exposure of nonsmokers to the same gases and particulate matter as smokers except to a somewhat lesser degree. Cigarette smoke contains slightly different compositions from each end of the cigarette. Smoke from the lighted end produces “sidestream” smoke; the smoker’s end is called “mainstream” smoke. Sidestream smoke constitutes about 85 percent of the smoke in a smoke-filled room and contains a much greater concentration of potential carcinogens; therefore, it is a great risk to nonsmokers present in any smoking environment. Healthy children exposed to passive smoke, especially during the first year of life, suffer from an increased number of upper respiratory infections, including ear infections and tonsillitis, and lower respiratory infections, such as bronchitis, bronchiolitis, and pneumonia. There is also diminished resistance to viral infections and a small but statistically significant decrease in lung function or breathing capacity in otherwise healthy children. In allergic and asthmatic children and adults, there is also a worsening of their usual symptoms. However, there is no evidence that exposure to passive smoking increases allergic tendencies in newborn or older children. Passive smoking was the most important environmental factor occurring in 62 percent of children younger than three, hospitalized for asthma in a New York innercity hospital. sneeze From the Anglo-Saxon word fneosan, meaning to pant, a forcible expulsion of air through the nose and/or mouth caused by a spasm in the expiratory muscles or an irritant to nasal membranes. Also known as sternutation, a sneeze may have many or unknown causes, the presence of allergens or infection among them. sneeze reflex, solar

A sneeze of unknown mechanism occurring upon exposure to bright sunlight, which may be normal or associated with rhinitis.

Spinhaler 181 sniffing snore

See See

INHALANT ABUSE.

STERTOR.

snoring rale

A low-pitched, sonorous rale, similar to the sound of snoring.

snuff

Pulverized tobacco that can be inhaled, chewed, or put next to the gums. The word is derived from the Dutch word snuftabak. Snuff is also a medicinal powder that can be inhaled through the nose. Anatomical snuffbox refers to the dorsal base of the thumb on which a small quantity of snuff could be placed and inhaled through the nose.

snuffles

The condition of nasal discharge and obstructed breathing, usually seen in infants as a result of the mother’s congenital syphilis.

S.O.B. The medical abbreviation for short (or shortness) of breath. sob

Crying that involves heaving or convulsive moving of the chest due to sudden inspiration of air and the subsequent glottal spasm.

sonorous rale A sound produced in a bronchus that is low-pitched and dry, indicating the presence of mucous secretion. soot

A black substance that produces fine particles on combustion. The particles create a carbon powder that sticks to pipes, chimneys, smoke, and other substances. Considered a major pollutant, soot in the air has been linked with illness that causes thousands of premature deaths each year, according to the Environmental Protection Agency (EPA). In an April 21, 2001, article in the New York Times, the EPA’s study on fine soot and its effects noted that in 1999, “the latest year with comprehensive data, New York City, Los Angeles, Atlanta, Chicago, and several other cities had annual aver-

age levels of 2.5 micron particles that would—if seen for three years in a row—violate the proposed rule” to cut levels of soot and other smog ingredients produced mainly by power plants and vehicles. Before her appointment to the Bush administration as EPA administrator, former New Jersey governor Christie Whitman endorsed a Clinton administration ruling that would “sharply curtail emissions of soot and other emissions from diesel engines.” Soot particles, composed of metals, carbons, and other ingredients, have the ability to be breathed into the lungs and go easily into the bloodstream, putting people susceptible to or already suffering from respiratory problems at risk. The Harvard School of Public Health and the American Cancer Society reported that they found that high levels of small particles in the air corresponded with a rise in death rates. Other studies indicate that more than 50,000 people die prematurely each year from illness resulting from inhaling fine soot, and that sooty air corresponded with a rise in hospital admissions of children having asthma attacks. A 632-page research review was posted on the EPA website, www.epa.gov/ncea/. A paper recommending how to interpret information from the studies and cut the level of fine soot is currently being drafted by the EPA’s Clean Air Science Advisory Committee. Industry representatives are questioning the validity of the studies and the EPA’s proposed course of action, which is basically that a standard would be established to limit the concentrations of soot particles smaller than 2.5 microns to an average of 15 micrograms per cubic meter measured over three consecutive years.

sore throat

Pain accompanying an inflammation of the pharynx (throat), tonsils, or larynx. The inflammation may be the result of an infection, such as in streptococcal, quinsy, diphtheritic or septic sore throat.

soroche A type of mountain sickness that is prevalent in the Andes. See also MOUNTAIN SICKNESS. sounds, breath

See

SOUNDS, RESPIRATORY.

182 spirit of glyceryl trinitrate sounds, respiratory

Any sound arising from the trachea, larynx, bronchi, or lungs that can be heard with or without the use of a stethoscope. Various sounds, such as rales or rhonchi, may indicate the presence of infection or obstruction in the airways or respiratory structures. Bronchial sound may indicate pulmonary disease involving infiltration and solidification of the lung. Cracked pot sound can be heard over the pulmonary cavities. When two inflamed mucous surfaces rub together, they produce a friction sound. Breath sounds heard through a stethoscope over a normal chest are categorized as vesicular, tracheal, and bronchovesicular. Vesicular sound is that produced by the lung during inhalation, which causes the alveoli to expand. Bronchovesicular refers to the sound made by both the bronchi and lungs. Normal tracheal sounds are heard over both the trachea (windpipe) and larynx (voice box). Tubular sounds may be heard over the large bronchi or the trachea.

space, retropharyngeal The region located behind the pharynx (throat) that can serve as a pathway for an infection to spread from the mouth to organs of the trunk of the body. See also RETROPHARYNGITIS. spacer

A drug-delivery device in various shapes and sizes for metered-dose inhalers that affords the user, including small children or poorly coordinated individuals, the full benefits of an aerosol asthma medication. Spacers allow small particles of active medication to enter the airways, and trap large inactive particles that could irritate the mouth and throat. The spacer is especially helpful with the corticosteroid metered-dose inhalers and lessens the likelihood of oral yeast infections.

spasm, bronchial A sudden contraction of the bronchial tube muscles that occurs during an asthma attack. See also ASTHMA. spasmatic asthma

Symptoms of asthma triggered by spasm in the bronchioles.

See also

ASTHMA.

spasmatic croup

Another term for laryngismus stridulus, or spasm of the larynx. See also LARYNGITIS STRIDULUS; LARYNX.

speech The act of speaking, making words, or sounds that range from the simplest expressions to a highly complex pattern of communication. The physical ability to speak involves the coordination of the mouth, lips, larynx, chest, and abdominal muscles and the manipulation of air flowing in and out of the body. Speech abnormalities may occur in conjunction with certain respiratory disorders. Spinhaler

A drug-delivery device formerly used with cromolyn sodium (Intal) capsules. The powder-containing capsules were placed inside a whistlelike plastic tube and activated by twisting the device and inhaling the released drug. The Spinhaler has been replaced by the metered-dose inhaler. See also AEROSOLS; INHALER.

spirit of glyceryl trinitrate An alcoholic liquid once used as a relaxant for the treatment of asthma and angina pectoris (chest pain related to heart disease). spirogram

A printout made by a spirometer that records breathing function. See also SPIROMETER.

spirometer

An instrument that measures the air capacity of the lungs. It is used to make treatment decisions for patients with asthma and other lung disorders. It is also used to determine the severity of lung disease and to help determine disability or if a specific job should be precluded. Spirometry equipment must meet rigid specifications as recommended by the American Thoracic Society in an official policy statement published in the American Review of Respiratory Diseases in 1987.

subcrepitant 183 spore Derived from the Greek word meaning seed, a reproductive cell of certain plants, especially fungi and protozoans (the simplest, mostly unicellular, animal form). Spores are usually asexual (able to reproduce by fission), but certain sexual forms are associated with molds, such as oospores, zygospores, and ascospores. Fungal or mold spores are a significant source of allergic symptoms. sputum

A combination of mucus, pus, blood, cellular debris, infectious microorganisms, and caseous material expelled by individuals with pneumonia and other pulmonary diseases when they cough or clear their throats. Types of sputum vary according to the diagnosis. In bronchial asthma, sputum is often purulent (containing pus), grayish, and possibly frothy and contains CharcotLeyden crystals (hard formations from salts and other substances). In bronchitis, sputum contains thick mucus and pus that is greenish yellow. In bronchopneumonia, mucus may look like prune juice in color and can be frothy, thin, mucoid, purulent, and bloody.

squatting in asthmatic children The crouching position assumed by some children with asthma, heart disease, or other disorders affecting normal breathing during play or physically strenuous activity. This characteristic squatting helps relieve chronic oxygen deprivation, especially after exertion, by facilitating use of accessory muscles of respiration and thus making breathing easier. staircase breaths A technique involving the administration of several small breaths as opposed to a single large-volume breath during cardiopulmonary resuscitation. See also CARDIOPULMONARY RESUSCITATION. staphylitis See also

Inflammation of the uvula. RESPIRATORY SYSTEM.

status asthmaticus

The condition of intractable asthma, a diagnosis that indicates that a patient is so debilitated that emergency management in a hospital is required.

steam tent An enclosure devised to facilitate the inhalation of steam or vapors to relieve respiratory distress. Although benzoin, menthol, camphor, and other ingredients may be added to the boiling water, the real therapeutic value is the water vapor itself. stenosis, pulmonary From the Greek word stenos, meaning narrow, a narrowing of the opening into the pulmonary artery from the right ventricle of the heart. stenothorax The condition of having an unusually narrow chest cavity. sternutation The medical term for sneezing. A sternutator refers to any agent that causes sneezing, and convulsive sternutation refers to paroxysmal or spasmodic sneezing accompanied by extremely watery eyes. See also SNEEZE. steroid Any substance in a large group of sterolrelated chemicals, including compounds containing a 17-carbon, 4-ring system (the perhydrocyclopentanophenanthrene ring). See also CORTICOSTEROIDS. stertor

The medical term for snoring. Stertorous breathing also refers to loud breathing that sometimes sounds like a hen’s clucking. Hen cluck stertor is often found in patients with postpharyngeal abscess. Stertorous breathing may also occur in persons with asthma or respiratory allergy symptoms. Snoring is actually the vibrating sound made by inhaled air passing through the mouth and then the soft tissues in the throat, including the roof of the mouth, tonsils, adenoids, and uvula. As the body ages, the soft tissues stretch and further restrict the passage of inhaled air. Overweight men over 40 are most likely to snore and experience sleep apnea, and women who are pregnant or postmenopausal may also snore because they produce less progesterone, a hormone that, among other properties, helps stabilize respiratory muscles. The use of alcohol and tranquilizers and

184 suction, post-tussive sleeping on one’s back may also contribute to snoring. (Sewing golf balls or marbles on pajamas has been suggested as a way to prevent sleeping on one’s back.) The FDA has approved nasal strips designed to be worn across the bridge of the nose to help keep nasal passages open for optimal breathing through the nose during sleep. Another breathing device is the Continuous Positive Airway Pressure mask, which pushes air through the nose, down the throat, and into the lungs. Surgical procedures, such as tonsillectomy and/or adenoidectomy, and radio frequency ablation that uses microwaves to adjust soft tissues in the throat, may be effective in treating severe snoring and breathing problems.

stethoscope An instrument consisting of two rubber tubes connected to a bell at one end and ear pieces at the other. It is used to listen to respiratory, cardiac, pleural, arterial, venous, uterine, fetal, intestinal, and other body sounds for diagnostic purposes. stillicidium lacrimarum

The medical term for

of this treatment, including irritation from the cigarette smoke, eventually outweighed any possible benefit. Atropine-like drugs, however, are now prescribed mainly for the treatment of chronic bronchitis and occasionally asthma. See also ATROPINE.

Streptococcus pneumoniae A species of grampositive, nonmotile bacteria that causes lobar and other types of pneumonia and is associated with infections including endocarditis, septicemia, meningitis, and conjunctivitis. See also PNEUMONIA. stress Physical or emotional tension that may be well-tolerated by the body for efficient function or ill-tolerated, which often results in some form of debilitation. Negative stress, or distress, is considered a trigger for asthma. stridor

A shrill or harsh sound, like wind whistling through pipes, created during respiration by individuals with severe asthma or acute obstruction of the larynx.

watery eyes.

subcrepitant stillicidium narium The medical term for watery mucus discharged from the nose and associated with allergies or the common cold. stimulant, respiratory Any increases breathing function.

substance

that

A rale that makes a partially crackling or crepitant sound.

suction, post-tussive The sucking sound heard through a stethoscope over the lung after a patient has coughed. suffocation

stonecutter’s phthisis

A wasting form of bronchopneumonia as a result of irritation of the lung by inhaled stone dust. See also PHTHISIS.

stramonium

An antispasmodic drug derived from the dried leaves of Datura stramonium and related to the drug atropine. Atropine blocks the constricting action of the vagus nerve on the bronchial tubes. Stramonium was the active ingredient in Asthmador cigarettes, inhaled by asthma patients to relax smooth muscles in the bronchial tubes in a now-obsolete treatment of asthma. Adverse effects

The state of being smothered, choked, gassed, drowned, or otherwise having one’s breathing impaired to the point of unconsciousness or death.

sulfating agents Food additives used to prevent discoloration of food and to inhibit growth of certain microorganisms in the fermentation process during the manufacture of wine. Sulfur dioxide gas, or powdered or liquid potassium metabisulfite, and other sulfating agents have been used for hundreds of years and are the most important additives that can cause serious adverse reactions. Ingestion of sulfites has no apparent effects on normal per-

system, respiratory 185 sons, but approximately 5 percent of asthmatic individuals are sulfite-sensitive, with symptoms ranging from mild wheezing to death. The average diet in the United States contains about 2 to 3 milligrams of sulfites daily. Each ounce of beer or wine contains 5 to 10 milligrams. Prior to a Food and Drug Administration ban in 1986 on the use of sulfites in restaurants, a meal contained from 25 to 200 milligrams of sulfites. As little as 5 milligrams of ingested sulfite can provoke an asthmatic response in susceptible persons, and there are at least 12 documented asthma deaths from sulfating agents. Allergic symptoms including urticaria (hives), angioedema (tissue swelling), and anaphylaxis (allergic shock) may be caused by sulfites, but only a few individuals who react to these additives have positive skin tests to them. The cause of sulfite reactions may be related to a deficiency of the enzyme sulfite oxidase, which is required to inactivate sulfite in the body. Highest levels of sulfites are found in dried fruits, potatoes, seafoods, and wine. Sulfite use is

prohibited in any food served fresh in restaurants. Since January 1988, packaged foods and bottled wines must be labeled if they contain more than 10 parts per million of sulfur dioxide (SO2). Some medications used as solutions in the emergency treatment of asthma contain sulfites. Isoetharine (Bronkosol) solution contains sodium bisulfite as a preservative, and isoproterenol (Isuprel) contains sodium metabisulfite, also as a preservative. Although these medications are rarely used since the introduction of albuterol and metaproterenol, asthma patients and their physicians should be aware that these solutions for aerosol treatment of asthma may actually worsen asthma in some individuals. The most common foods that may contain sulfites are processed potatoes (chips, fries, dehydrated); dried and packaged fruits and beverages; shrimp and other seafood; beer and wine; salads and all ingredients in salad bars in countries outside the United States (sulfite use is banned in restaurant salad bars in the United States); precut

T fruit outside the United States; avocado, guacamole, and other dips; cider and wine vinegars; pickled vegetables; white grapes; Maraschino cherries; fresh mushrooms; beet sugar; wet-milled corn; and conditioned dough.

supplemental air

See

in light of available medications and adequate monitoring.

Sus-Phrine

The brand name for epinephrine hydrochloride. See also EPINEPHRINE.

RESERVE AIR.

surfactant, pulmonary

A natural, fatty substance that lubricates the lungs and prevents them from collapsing during expiration, and reduces or controls surface tension of air-liquid emulsion found in the lungs. In cases of pulmonary edema, prematurity, and hyaline membrane disease, the surfactant is inadequate or abnormal.

surgery, related to allergic and asthmatic persons Individuals with asthma and/or allergies to drugs including anesthesia need to consider certain factors when they require an elective surgical procedure. (1) Do not schedule surgery when a viral infection or exacerbation of asthma is present. (2) Have the physician evaluate breathing status, blood oxygenation, and lung function one or two days before the surgery. (3) Review all medications and blood levels of medications with the physician and surgical team before the surgery. (4) Use local anesthesia, which does not interfere with breathing mechanisms, if possible. (5) Avoid nitrous oxide (laughing gas) as dental anesthesia; a local anesthetic and a mild tranquilizer are recommended. (6) Ensure that the patient will be assisted in bringing up mucus and secretions after the surgery, if necessary. In the event of emergency surgery and the use of general anesthesia, most often there is minimal increased risk for the allergic or asthmatic patient

suspiration From the Latin word suspirare, sighing, or a sigh. The word suspirious also refers to sighing, or breathing with emphasis or effort. sweat chloride test A diagnostic test used to determine the presence of cystic fibrosis. The test, which measures the salt content in the sweat, is performed on children who are wheezing or who have a family history of cystic fibrosis, failure to thrive, recurrent pneumonia, or other pulmonary disorder that involves gastrointestinal disturbances. See also CYSTIC FIBROSIS. sympathomimetic drugs

See

AGONIST.

symptoms of allergy

From the Greek word meaning occurrence, a symptom is a change or ill effect experienced by an individual and potentially indicating a disease process. Specific symptoms of allergy include sneezing, itching, wheezing, runny nose, nasal congestion, shortness of breath, tightness in the chest, rashes, swelling of body tissues, discharge from the eyes, and other discomforts. See also RHINITIS.

Syngamus laryngeus A species of parasitic worm that thrives in the respiratory tract of birds, mammals, and sometimes humans.

186

theophylline 187 system, respiratory

See

RESPIRATORY SYSTEM.

tabacosis

Tobacco poisoning, especially from the inhalation of tobacco dust by tobacco handlers. Exposure to tobacco dust is a cause of occupational asthma. See also OCCUPATIONAL ASTHMA.

tachypnea See also

Abnormally rapid breathing. BREATHING.

talcosis A condition resulting from the inhalation or implantation of talc, powdered soapstone, or hydrous magnesium silicate, in the body. Talc, also called talcum, is commonly used as a dusting powder, as a counterirritant for prickly heat, diaper rash, and other skin eruptions, and for industrial products. It is also an irritant that can trigger asthma. See also OCCUPATIONAL ASTHMA; PNEUMOCONIOSIS. tampon, nasal A nostril plug made of a rubber bulb inflated with compressed air that is designed to stop nasal hemorrhaging. Tapia syndrome

Named for Spanish physician Antonio Garcia Tapia (1875–1950), a lesion affecting the vagus and hypoglossal cranial nerves and resulting in pharyngeal (throat) and laryngeal (voice box) paralysis on one side and atrophy of the tongue on the other side.

Tavist

A brand of clemastine fumarate, an antihistamine drug.

technician, respiratory therapy An individual trained to treat noncritical respiratory care patients. A technician may also respond to emergency calls for respiratory care. tent, oxygen

See

OXYGEN TENT.

terbutaline sulfate (Brethaire, Brethine, Bricanyl) A selective beta2 bronchodilating drug used to treat

asthma. As an oral or inhaled medication, its effectiveness and safety are similar to those of albuterol. It can be administered by subcutaneous injection for asthma emergencies and has an action similar to that of epinephrine, but it takes up to 15 minutes to become effective (epinephrine usually works within one minute). See also BETA-ADRENERGIC AGONISTS.

terfenadine (Seldane)

A second-generation of nonsedating antihistaminic drug used to treat allergic rhinitis (hay fever) and urticaria (hives). There have been rare but life-threatening cardiac arrythmias (irregular heartbeat) associated with the use of terfenadine given simultaneously with certain other drugs, including the antibiotic erythromycin, the antifungal drug ketaconazole, and with grapefruit juice. A risk is also associated with the use of terfenadine in persons with liver disorders.

terpin hydrate An over-the-counter expectorant, which helps rid the body of excess bronchial secretions. test, tuberculin tetracyclines

See

MANTOUX TEST.

A group of broad-spectrum antibiotics first discovered as a result of systemic screening of soil samples collected from around the world in a search for microorganisms that could produce antibiotics. The first of these drugs produced was chlortetracycline in 1948. Since then three other naturally occurring antibiotics have been produced from species of the bacteria Streptomyces, tetracycline (Achromycin, Sumycin, Panmycin, Robitet), oxytetracycline (Terramycin), and demeclocycline (Declomycin). Methacycline (Rondomycin), doxycycline (Vibramycin, Doryx), and minocycline (Minocin) are semisynthetically derived by manipulation of the natural tetracyclines. The antibiotic affect of tetracyclines is due to their ability to interfere with protein synthesis in bacteria. However, by some other mechanism, the drugs are effective against Rickettsia and Chlamydia infections. Although tetracyclines are frequently used for the treatment of respiratory infections such as sinusitis, bronchitis, and pneumonia in

188 therapist, respiratory patients with asthma or allergic rhinitis, many microorganisms have developed a resistance to them. Adverse effects of the tetracyclines include rare cases of anaphylaxis, and all drugs in this class should be avoided in persons with a history of serious allergic reaction to any of them. More commonly, rashes occur, especially with sun exposure. Demeclocycline causes the most severe and frequent photosensitivity reactions; doxycycline reactions are less severe. Most of the photosensitivity rashes resemble severe sunburn and occur on exposed skin areas. Paresthesias (tingling of the hands, feet, and nose) may be the first sign of adverse reactions to tetracyclines and the sun. Tetracyclines also cause numerous other adverse effects, most often gastrointestinal upset, which are usually mild and self-limiting. Rarely, neurologic disturbances are exhibited, such as pseudotumor cerebri (increased pressure in the brain that gives symptoms suggestive of a brain tumor). Tetracyclines are absorbed by bones and teeth and depress bone growth and tooth development. Therefore they should probably not be given to pregnant women or to children before the age of eight or nine. In rare instances with life-threatening infections such as Rocky Mountain spotted fever, their use may be necessary.

theophylline Derived from the Latin word thea, or tea, and the Greek word phyllon, or plant, a spasmolytic drug that relaxes smooth muscle in the respiratory system. Theophylline, a white crystalline powder with action like caffeine and theobromine, is used to treat bronchial asthma, bronchospasm that accompanies chronic obstructive lung disease (COLD), and chronic bronchitis. Trade names include Accurbron, Aerolate Slo-Phyllin, Aquaphyllin, Bronkodyl, Elixomin, Slo-Phyllin, Respbid, Theophylline Oral, Theospan-SR, Theovent, T-Phyls and Uniphyl. Theophylline was first isolated from tea leaves in 1888. At first, it was used as a diuretic for cases of congestive heart failure, and for a brief period in the 1950s it was used to treat angina. A modified version of the drug, aminophylline, became popular in the 1940s to treat asthma, but it was not until the late 1970s and 1980s that its popularity peaked with the introduction of long-acting formulas.

The basis of theophylline’s activity has not been well defined but is thought to be complex. Theophylline is known to block the action of adenosine, which causes constriction of the bronchioles in asthma. The drug strengthens the contractability of the diaphragmatic muscle and diminishes fatigue. Theophylline seems to stimulate the respiratory center; in patients with both chronic bronchitis or emphysema and heart failure (cor pulmonale), theophylline strengthens cardiac output. The drug also may inhibit the release of inflammatory mediators. There is considerable disagreement among physicians about the role of theophylline in the treatment of asthma. Some researchers feel theophylline is more effective than beta2-agonists and should be a primary drug, whereas others have relegated theophylline to a backup role to be added to a regimen of other asthma drugs. Despite its reputation for causing many side effects, the only major drawback of theophylline is overdose, which can be avoided by monitoring serum levels. Tachyphylaxis (tolerance) does not occur, and it is the only bronchodilator drug for which there is a fixed dose that is independent of the severity of the disease. The use of theophylline in children is also controversial. The drug has been blamed for causing both learning disabilities and hyperactivity. Studies have demonstrated normal school performance in students with asthma taking theophylline on a daily basis when compared with nonasthmatic children. Guidelines for the safe use of theophylline are 1. Serum levels from 15 to 20 micrograms/ml were considered optimal until recently. Now levels from 5 to 15 are considered adequate and safer for most patients. 2. During pregnancy, and in chronic bronchitis or emphysema, levels from 8 to 12 are advised. 3. Doses should be taken at regular intervals and in the same relationship to meals. 4. Various brand-name products and generic formulations are not interchangeable, and levels may vary greatly when switching from one formulation to another. 5. If another illness occurs while on theophylline, especially heart failure, liver disease, or upper

transplantation, lung 189 respiratory infections (including the common cold), theophylline doses may need to be adjusted downward. If unable to reach your doctor, you should skip a dose and lower subsequent doses until the physician can be consulted. 6. Many drugs affect the theophylline level by diminishing its excretion from the body, thus raising levels to a possible toxic degree. Cimetidine (Tagamet), mexiletine, ciprofloxacin, and other quinolone antibiotics, erythromycin, allopurinol, propanolol, and oral contraceptives may increase levels. Influenza vaccine also raises theophylline levels for a short time. The anticonvulsant medications phenytoin, phenobarbital, and carbamazepine, the antibiotic rifampin, and cigarette smoking may lower theophylline levels. 7. The following patient types should probably avoid theophylline except in very carefully monitored settings: (a) elderly frail patients with multiple medical problems; (b) patients susceptible to nausea and vomiting; (c) premature babies and infants under one year; (d) patients known to have sudden changes in their heart rhythm (arrhythmias); and (e) any patient who might misuse medications.

therapist, respiratory

An individual trained in the techniques and use of equipment for patients with acute and chronic respiratory disorders.

thoracentesis A diagnostic surgical procedure involving the aspiration of fluid from the thoracic cavity, or chest, with a large-bore needle. Also known as pleurocentesis, thoracentesis is usually preceded and followed by chest X rays. thoracic cavity

The area of the chest and the organs it contains, including the lungs, heart, thoracic aorta, pulmonary artery and veins, vena cava, thymus gland, lymph nodes, trachea, bronchi, esophagus, and thoracic duct. The thorax is enclosed by thoracic walls and is located above the diaphragm. The thoracic cage is the skeletal component of the chest that consists of 12 pairs of ribs, the thoracic vertebrae, and the sternum or breastbone.

thoracic outlet compression syndrome Symptoms caused by nerves or vessels becoming compressed in the neck and axilla that may be confused with cervical disk lesions, lung cancer, bursitis, and angina. thoracic squeeze A divers’ phenomenon, particularly when divers hold their breath and go approximately 80 to 100 feet in depth, in which the lungs become so compressed that alveolar capillaries rupture. Divers suffering from thoracic squeeze must be removed from the water immediately and given artificial respiration and oxygen therapy. thoracograph A device that records on paper the shape of the thorax and its movements during a patient’s respirations. thoracopneumoplasty

Plastic surgery procedures that involve the thorax and lung.

thoracostenosis

Also known as “wasp waist,” a narrowing of the chest, or thorax, due to wasting or atrophy of the muscles.

thorax The medical term for the chest cavity, organs, and other structures. throat

The pharynx and fauces of the respiratory system, which extends from the arch of the palate to the glottis and superior opening of the esophagus. Essentially, the throat is an airway.

tidal air

The air inhaled and exhaled in normal

breathing.

Tilade

inhaler An aerosol medication of nedocromil sodium used to treat severe perennial bronchial asthma and to prevent exercise-induced or environmental pollutant bronchospasm.

tobacco The dried leaves of the Nicotiana tabacum and other plant species that are used to make cigarettes, cigars, pipe tobacco, snuff, and chewing tobacco, all of which have ill effect on the

190 tree, bronchial lungs and respiratory passages. When lit and smoked, the tobacco’s nicotine is released and widely known to cause addiction and respiratory disease. See also

LUNG CANCER; SMOKING.

tonsil

From the Latin word tonsilla, meaning almond-shaped, lymphatic tissue masses in the mucous membrane of the fauces and pharynx that help form white blood cells in the event of infection and to help filter harmful bacteria from the body. Nasal tonsils are located in the lymphoid tissue on the nasal septum. Pharyngeal tonsils, also

TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Acacia

Acacia decurrens

Leguminosae

Cultivated ornamental (subtropical)

Mar.–May

Acacia, Bailey’s

A. baileyana

Leguminosae

Cultivated ornamental (subtropical)

Mar.–May

Acacia, longleaf

A. longifolia

Leguminosae

Cultivated ornamental (subtropical)

Mar.–May

Alder, red (Oregon)

Alnus rubra

Betulaceae

Pacific coast from S.W. Y.T. to So. CA, rarely more than 50 mi. from salt or over 2,500 A. elev.

Mar.–Apr.

AK So. to Olympic Mts., Cascade Mts., No. CA, E. WA, N.E. OR, Rocky Mts.

May–July

Alder,

A. sinuata (A. sitchensis)

Betulaceae

A. tenuifolia

Betulaceae

N.E. MN, ND to B.C., So. to NM

Mar.–May

Alder, tag (speckled)1

A. incana (A. rugosa)

Betulaceae

Nfld. to N.W.T. and B.C. So. to MD., No. to IN and MN, MT, ID, WA

Mar.–May

Alder, white

A. rhombifolia

Betulaceae

No. ID to E. slope Cascades, to So. OR, W. slope of Sierra Nevada, So. to Coast Range in CA

Jan.–Apr.

Alder,

Sitka1

slender1

Arborvitae, Chinese

Thuja orientalis

Cupressaceae

Cultivated ornamental

Apr.–May

Arborvitae, western (white cedar)

T. occidentalis

Cupressaceae

P.Q. and N.S. to Hudson Bay, So. to NJ, OH, No. IN and IL, WI, MN, Mts. NC and TN

Apr.–May

Ash (Arizona velvet)

Fraxinus velutina

Oleaceae

CA, AZ, So. NM, E. TX. Cultivated in these areas

Mar.–Apr.

Ash, black

F. nigra

Oleaceae

Nfld. and P.Q. to Man., So. to DE, KY, IA

Spring

Ash, green (ash, red)

F. pennsylvanica

Oleaceae

P.Q. to Man., So. to FL and TX

Spring

Ash, Mexican

F. uhdei

Oleaceae

Cultivated ornamental

Winter

Ash, Oregon

F. oregona

Oleaceae

C. CA, No. to B.C.

Mar.–May

Ash, white

F. americana

Oleaceae

N.S. to MN, So. to FL and TX

Spring

Aspen

Populus tremuloides

Salicaeae

Lab. to AK, So. to NJ, VA, TN, MO, Rocky Mts., Sierra Nevada, Cascades

Spring

Beech, American

fa*gus grandifolia

fa*gaceae

N.S. to MN, So. to FL and TX

Spring

Beefwood (Austral. pine)

Casuarina equisetifolia

Casuarinaceae

Cultivated ornamental (subtropical)

Jan.–Mar.

tree pollen allergy 191 TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Birch, cherry (black)

Bettila lenta

Betulaceae

IA, So. ME and So. W. P.Q. to DE and KY, along Appalachians to GA

Mar.–May

Birch, European (white)

B. pendula alba

Betulaceae

Cultivated ornamental

Mar.–May

Birch, paperback

B. papyrifera

Betulaceae

Lab. to AK, So. to NJ, WV, No. IN, N. E. IA, W. to MT, WA

Mar.–May

Birch, river (red)

B. nigra

NH to FL, W. to So. OH, So. MI, S.E. MN, E. KS, and TX

Feb.–June

Birch, spring

B. fontinalis

AK to CA, E. to Sask., ND, SD, Rocky Mt. States

Feb.–June

Betulaceae Betulaceae

Birch, yellow

B. lutea

Betulaceae

Nfld. to Man., So. to DE, PA, No. OH

Spring

Bottlebrush

Calistemon species

Myrtaceae

Cultivated ornamental (subtropical)

All seasons

Box elder, ash–leaved (maple)

Acer negundo

Aceraceae

So. Canada, VT to FL, W. nearly to pacific coast Man.

Mar.–May

Butternut (white walnut)

Juglans cinerea

Cultivated ornamental and native tree, N.B. to Ont., No. MI, ND, So. to VA, CA, AR, KS

Apr.–May

Juglandaceae

Carob

Ceratonia silitlua

Leguminoseae

Cultivated ornamental

Late winter, early spring

Cedar, Atlantic

Cedrus atlantica

Pinaceae

Cultivated ornamental

Winter

Cedar, deodar

C. deodara

Pinaceae

Cultivated ornamental

Winter

Cedar, giant (canoe)

Thuja plicata

Cupressaceae

AK to C. CA, W. MT

Apr.–May

Cedar, incense

Libocedrus decurrens

Cupressaceae

CA to No. OR, W. to NV

Apr.–May

Cedar, Japanese

Cryptomeria japonica

Taxodiaceae

Cultivated ornamental

Spring

Cedar, Salt

Tamarix gallica

Tamaricaceae

Introduced, common in alkali western soils, along watercourses

Mar.–Aug.

Cherry

Prunus cerasus

Rosaceae

Cultivated crop and ornamental

Mar.–May

Chestnut, American

Castanea dentata

fa*gaceae

Appalachia; rare; nearly exterminated by blight

Spring

Chestnut, horse

Aesctilus hippocastanum

Hippocastanaceae

Cultivated ornamental

May–June

Cottonwood, black

Populus trichocarpa

Salicaceae

So. CA to AK, IN, NV

Feb.–Apr.

Cottonwood (Carolina poplar)

P. deltoides (includes P. sargentii)

Salicaceae

P.Q. and New England to So. Man., MN, to eastern Rocky Mts., So. to FL and TX

Mar.–Apr.

Cottonwood, Fremont

P. fremontii

Salicaceae

C. and So. CA to NV, AZ

Mar.–Apr.

192 tree pollen allergy TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Cypress, Arizona

Cupressus arizonica

Cuppressaceae

Native to AZ and E. NM; cultivated in CO and S.W.

Mar.–Apr.

Cypress, bald

Taxodium distichum

Taxodiaceae

DE to FL, W. to IL, MO, AR, and TX

Spring

Cypress, Italian

Cupressus sempervirens

Cupressaceae

Cultivated ornamental

Feb.–Mar.

Cypress, Monterey

C. macrocapa

Cupressaceae

Monterey peninsula

Spring

Elderberry

Sambuctis glauca

Sambucaceae

So. CA. to B.C., Alta., ID

June–Sept.

Elm, American (white elm)

Ulnitis americana

Ulmaceae

Nfld. to Man., So. to FL and TX, also cultivated

Feb.–Apr.

Elm, Chinese

U. irvifolia

Ulmaceae

Cultivated ornamental

Aug.–Sept.

Elm, fall-blooming (cedar elm)

U. crassifolia

Ulmaceae

MS to AR and TX

July–Oct.

Elm, Siberian (Chinese)

Ulmus pumila

Ulmaceae

Cultivated ornamental

Mar.–Apr.

Elm, slippery (red elm)

U. fulva

Ulmaceae

P.Q. and ME to ND, So. to FL and TX

Mar.–Apr.

Fir, Douglas

Pseudotsuga menziesii

Pinaceae

S.W. B.C. to C. CA, E. to S.W., Alta., MT, WY, CO, W. TX

Apr.–May

Fir, noble (red)

Ables nobilis

Pinaceae

Cascade Mts., WA, OR, CA

June–July

Fir, white

A. concolor

Pinaceae

W. WY, So. ID to NM, AZ, CA

May–June

Gum, blue

Eucalyptus globulus

Myrtaceae

Cultivated ornamental

Dec.–May

Gum, sweet

Liquidambar styraciflua

Altingiaceae

CT to So. OH, So. IL, OK, So. to FL, TX, cultivated ornamental

May

Hackberry

Ceitis occidentalis

Ulmaceae

P.Q. to Man., So. to NC, TN, AR

Spring

Hazelnut, America

Corylus americana

Corylaceaeto

ME to Sask., So. CA and OK

Jan.–Apr.

Hazelnut, beaked

C. cornuta

Corylaceae

Nfld. to B.C., So. to No. NJ, PA, OH, MO, No. CA, W. to No. CA, OR, WA

Jan.–Apr.

Hemlock, Canada (eastern)

Tsuga canadensis

Pinaceae

N.B. to Ont. and No. MN, So. to DE, WV, E. OH, C. MI, WI

May–June

Hemlock, western

T. heterophylla

Pinaceae

AK, to No. CA, to S.E. B.C., No. ID, to N.W. MT

May–June

Hickory, shagbark

Carya ovata

Juglandaceae

P.Q. and ME to MI and S.E. MN, S. FL and TX

May–June

Hickory, shellbark

C. laciniosa

Juglandaceae

NY. to So. Ont. to IA, So. to NC, MS, OK

May–June

tree pollen allergy 193 TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Hickory, white (mockernut)

C. tomentosa

Juglandaceae

MA. to Ont., MI, IA, So. to FL and TX

May–June

Hornbeam, American

Carpinus carolineana

Carpinaceae

N.S. to MN, So. to FL and TX

Mar.–May

Hornbeam, hop (ironwood)

Ostrya virginiana

Carpinaceae

N.S. to Man., So. to FL and TX

Mar.–Apr.

Juniper, California

Juniperus californica

Cupressaceae

C. and So. CA

Jan.–Mar.

Juniper, Chinese

J. chinensis

Cupressaceae

Cultivated ornamental

Winter–spring

Juniper, mountain

J. sabinoides

Cupressaceae

W. and So. TX into Mexico

Winter

Juniper, one-seed

J. monosperma

Cupressaceae

N.W. OK, W. TX to UT, NV, S.E. AZ, and NM

Spring

Juniper, Pinchot

J. pinchotii

Cupressaceae

C. TX. to S.E. NM, W. OK

Spring

Juniper, Rocky Mountain

J. scopulorum

Cupressaceae

So. B.C. to MT, ND, SD, Rocky Mt. states

May–June

Juniper, Utah

J. utahensis

Cupressaceae

CA. to S.W. ID, S.W. WY, W. NM

Spring

Juniper, Virginia (red cedar)

J. virginiana

Cupressaceae

So. P.Q. and ME to ND, So. to AL, TX

Mar.–Apr.

Juniper, western

J. occidentalis

Cupressaceae

Mountain slopes and higher. Prairies of E. WA, W. ID, So. in mt. ranges to So. CA

May–June

So. B.C., So. to E. Cascades to OR, E. to N.W. MT, N. ID

May–June June–July

Larch (tamarack)

Larix occidentalis

Pinaceae

Linden American

Tilia americana

Tiliaceae

P.Q. to ND, So. to VA, NC, KY, MO

Locust, black

Robinia pseudoacacia

Leguminosae

PA to So. IN and OK, So. to GA, LA, cultivated ornamental

June

Maple, bigleaf (canyon, coast)

Acer macrophyllum

Aceraceae

CA to AK

Apr.–May

Maple, red

A. rubrum

Aceraceae

P.Q. to MN, So. to FL and TX

Mar.–Apr.

Maple, silver (soft map)

A. saccharinum

Aceraceae

N.B., P.Q. to MN, SD, So. to FL, TN, OK, cultivated ornamental

Mar.–Apr.

Maple, sugar

A. saccharum

P.Q. and NJ to Man., ND, So. to NJ, GA, AL, TX

Apr.–May

Aceraceae

Mesquite

Prosopis juliflora

Leguminosae

C. and So. CA to Gulf of Mexico

Apr.–June

Mock orange (syringa)

Philadelphus species

Philadelphaceae

Cultivated ornamentals and widespread native shrubs

May–June

Mulberry, black

Morus tatarica

Moraceae

Cultivated ornamental

Spring

Mulberry, paper

Broussonetia papyrifera

Moraceae

Cultivated ornamental

Winter–spring

Mulberry, red

Morus rubra

Moraceae

Cultivated ornamental

spring

194 tree pollen allergy TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Mulberry, white

M. alba

Moraceae

Cultivated ornamental

Spring

Oak, Ariz. Scrub (canyon oak)

Quercus chrysolepsis

fa*gaceae

So. CA to OR, NM

Apr.–May

Oak, Arizona (white)

Q. arizonica

fa*gaceae

W. TX to AZ

Apr.–May Spring

Oak, black Oak, black jack Oak, Blue Oak, Bur

Q.velutina

fa*gaceae

So. ME. to MI, MN, So. to FL and TX

Q. marilandica

fa*gaceae

So. NY. to So. MI, IA, So. to FL and TX

Spring

Q. douglasii

fa*gaceae

Apr.–May

Q. macrocarpa

fa*gaceae

N.B., P.Q. to Ont. and So. Man., So. to VA, AL, AR, TX. Shrub in W. MN and IA to Canada

Spring

Oak, California (Black)

Q. kelloggii

fa*gaceae

So. CA to OR

Apr.–May

Oak, California scrub

Q. dumosa

fa*gaceae

Mar.–May

Oak, chestnut

Q. prinus

fa*gaceae

Appalachian Mts., ME to No. CA to Atlantic coast as far as So. VA, W. to So. IN

Spring

Oak, coast live (Encina)1

Q. agrifolia

fa*gaceae

C. and So. CA

Mar.–Apr.

Oak, Emory

Q. emoryi

fa*gaceae

TX to AZ

Spring

Oak, Engelmann

Q. engelmannii

fa*gaceae

So. CA

Apr.–May

Oak, Gambel

Q. gambelii

fa*gaceae

So. W. TX to CO, WY, So. to AZ, abundant on dry slopes of Rockies

Spring

Oak, Garry1

Q. garryana

fa*gaceae

No. CA, W. OR, WA

Spring

Oak, holly

Q. ilex

fa*gaceae

Cultivated ornamental

Spring

Oak, interior live

Q. wislizenii

fa*gaceae

C. and No. CA

Mar.–May

Oak, Palmer

Q. palmeri

fa*gaceae

So. CA, AZ

Apr.–May

Oak, pin

Q. palustris

fa*gaceae

MA to MI, IA, E. KS, So. to NC, TN, OK

Spring

Oak, post

Q. stellata

fa*gaceae

S.E. MA, So. NY to IN, IA, So. to FL and TX

Spring

Oak, red (northern red oak)

Q. rubra (Q. borealis)

fa*gaceae

N.S. to No. MI and MN, So. to VA, AL, MS, AR

Spring

Oak, Spanish (southern red oak)

Q. falcata

fa*gaceae

NJ, PA to FL and TX, along coastal plain and No. in interior to OH, IN, MD

Spring

Oak valley (Roble)

Q. lobata

fa*gaceae

C. and So. CA

Mar.–Apr.

Oak, Virginia live

Q. virginiana

fa*gaceae

Coastal plain, S.E. VA to FL and TX

Spring

tree pollen allergy 195 TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Oak, water

Technical Name

Plant Family

Distribution

Pollination Season

Q. nigra

fa*gaceae

Coastal plain, DE to FL and S.E. TX, No. in interior to S.E. MO

spring

ME to MI and MN, So. to FL and TX

Spring

Oak, white

Q. alba

fa*gaceae

Olive

Olea europaea

Oleaceae

Cultivated crop and ornamental

Spring

Orange, Osage

Maclura pomifera

Moraceae

Cultivated hedge and native tree, AR, OK, TX

Apr.–May

Palm, Canary Island date

Phoenix canariensis

Palmae

Cultivated ornamental

Palm, date

P. dactylifera

Palmae

Cultivated crop and ornamental

Spring

Palm, dwarf

Chamaerops humilus

Palmae

Cultivated ornamental

Spring

Palm, queen

Cocos plumosa

Palmae

Cultivated ornamental

Spring

Palo Verde

Cercidium torreyana

Leguminosae

So. CA, AZ

Mar.–May

Peach

Prunus persica

Rosaceae

Cultivated crop and ornamental

Mar.–May

Pear

Pyrus communis

Rosaceae

Cultivated crop

Mar.–May

Pecan

Carya pecan

Juglandaceae

Cultivated crop and ornamental, S.W. OH to IA, So. to AL, TX

Spring

Peppertree, Brazilian

Schinus terebinthifolius

Anacardiaceae

Cultivated ornamental naturalized in So. FL

Jan.–Dec.

Peppertree, Peruvian

So. molle

Anacardiaceae

Cultivated ornamental

Winter

Pine, Australian (beefwood)

Casuarina equisetifolia

Causuarinaceae

Cultivated ornamental

Spring

Pine, bull (digger)

Pinus sabiniana

Pinaceae

C. and So. CA

Apr.–May

Pine, Canary Island

P. canariensis

Pinaceae

Cultivated ornamental

Spring

Pine, eastern white

P. strobus

Pinaceae

Nfld. to Man., So. to DE, GA, KY, IA

Spring

Pine, Japanese (black)

P. thunbergii

Pinaceae

Cultivated ornamental

Spring

Pine, loblolly

P. taeda

Pinaceae

NJ to FL, TX, No. in interior to AR and TN

Spring

Pine, lodgepole

P. contorta

Pinaceae

CA, AK, Rocky Mts.

June–July

Pine, longleaf

P. palustris (P. australis)

Pinaceae

Coastal plain, S.E. VA to FL and TX

Spring

Pine, Monterey

P. radiata

Pinaceae

Monterey peninsula and adjacent coastal counties

April

So. CA to WY, TX, AZ

Spring

Pine, Pinyon

P. edulis

Pinaceae

196 tree pollen allergy TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Pine, ponderosa (west. yellow)

P. ponderosa

Pinaceae

So. CA to B.C., Rocky Mts.

May–June

Pine, red (Norway)

P. resinosa

Pinaceae

NS. to Man., So. MA, PA, MI, MN, in mts. to WV

Spring

Pine, short-leaf (yellow)

P. echinata

So. NY to WV, So. IL, S.E. KS, So. to FL and TX

Spring

Pine, single-leaf (one-leaved)

P. monophylla

Pinaceae

C. and E. CA to UT, AZ

May

Pine, Virginia scrub (Jersey)

P. virginiana

Pinaceae

So. NY to So. IN, So. to GA, AL

Spring

Pine, western white

P. monticola

Pinaceae

So. B.C. to CA, W. NV, E. to ID, S.W. AK, W. MT

May–June

Plum

Prunus domestica

Rosaceae

Cultivated crop and ornamental

Mar.–May

Poplar, balsam

Populus balsamifera

Saliaceae

Lab. to AK, So. to CT, No. PA, No. IN, IA, N.B., OR

Mar.–Apr.

Poplar, black

P. nigra

Saliaceae

Cultivated ornamental

Mar.–Apr.

Poplar, Lombardy

P. nigra italica

Saliaceae

Cultivated ornamental

Mar.–Apr.

Poplar, white (silver)

P. alba

Saliaceae

Cultivated ornamental

Mar.–Apr.

Privet, California

Ligustrum ovalifolium

Oleaceae

Cultivated ornamental

Spring

Privet, common

L. vulgare

Oleaceae

Cultivated ornamental

Spring–summer

Privet, southern

L. lucidum

Oleaceae

Cultivated ornamental

Spring

Redwood

Sequoia sempervirens

Taxodiaceae

C. CA. to S.W. OR

Mar.

Silk tassel bush

Garrya eliptica

Garryaceae

C. CA to OR

Jan.–Mar.

Spiraea (bridal wreath)

Spiraea species

Rosaceae

Cultivated ornamentals and widespread native shrubs

Spring–summer

Spruce, Colorado blue

Picea pungens

Pinaceae

Cultivated ornamentals, native to C. CO

June–July

Spruce, red

P. rubens

Pinaceae

P.Q. and Ont. to PA, NJ, So. in mts. to NC and TN

Spring–summer

Spruce, Sitka

P. sitchensis

Pinaceae

AK to C. CA in coastal mts.

May

Sweet gale

Myrica gale

Myricaceae

Circumboreal, in North America, So. to NY, PA, NC, MI, MN, WA

Apr.–June

Pinaceae

Sycamore (London Plane)

Platanus orientalis

Platanaceae

Cultivated ornamental

Spring

Sycamore, eastern (buttonwood)

P. occidentalis

Platanaceae

S.W. ME to So. MI and S.E. MN, So. to FL, TX

Spring

trigger, asthma 197 TREES THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Sycamore, mapleleaf

P. acerifolia

Platanaceae

Cultivated ornamental

Spring

Sycamore, western

P. racemosa

Platanaceae

C. and So. CA

Feb.–Apr.

Tree of heaven

Ailanthus altissima

Simaroubaceae

Cultivated ornamentals and urban weed

June

Viburnum

Caprifoliaceae

Cultivated ornamental, widespread native shrubs

May–July

Viburnum

Walnut, Arizona

Juglans rupestris

Juglandaceae

W. OK, TX to S.E. NM, AZ

Spring

Walnut, black

J. nigra

Juglandaceae

Cultivated crop, ornamental native W. New England to MI, MN, N.B., So. to FL, TX

Apr.–May

Walnut, California

J. californica

Juglandaceae

So. CA

Apr.–May

Walnut, English

J. regia

Juglandaceae

Cultivated crop

Apr.–May

Walnut, Hinds black

J. hindsii

Juglandaceae

C. and No. CA

Apr.–May

Walnut, Japanese

J. sieboldiana

Juglandaceae

Cultivated ornamental

Apr.–May

Willow, Arroyo

Salix lasiolepis

Salicaeae

CA to WA, ID, NM

Feb.–Apr.

Willow, black

So. nigra

Salicaeae

So. N.B. to C. MN, So. to FL, TX

Spring

Willow, puss*

So. discolor

Salicaeae

Cultivated ornamental, native shrub, Nfld. to B.C., So. to DE, KY, MO, SD, MT

Spring

Willow, red

So. laevigata

Salicaeae

CA, UT, AZ

Mar.–May

Willow, yellow

So. lasiandra

Salicaeae

CA to AK, ID

Mar.–May

1Pollen

is a major source of hay fever. Adapted from Pollen Guide for Allergy, Hollister-Stier.

called Luschka’s tonsils, are on the roof of the back of the throat. The lingual tonsil lies at the root of the tongue, and palatine tonsils are located on either side of the oral pharynx.

toxic-allergic syndrome A lung disorder caused by the ingestion of grapeseed oil tainted with aniline and containing acetanilide. Symptoms include respiratory distress, fever, headache, nausea, muscle and abdominal pain, rash, enlarged spleen and liver, and eosinophilia. Treatment may involve corticosteroid drugs and mechanically assisted respiration.

trachea

A cartilaginous, membranous tube known commonly as the windpipe, the main airway between the mouth and the lungs. The inside of the trachea looks like about 20 horseshoes piled up flat against each other. These cartilage “horseshoes” maintain the tube’s shape, thus keeping it open for airflow. The trachea, part of the throat, extends from the larynx (vocal cords) to the bronchi branching into the lungs. An inflammation of the trachea, or tracheitis, may be associated with bronchitis and laryngitis. See also TRACHEITIS.

198 tripelennamine tracheitis An inflammation of the trachea, or windpipe, which may be acute or chronic. Tracheitis is usually caused by a viral respiratory infection and may also involve the larynx and bronchioles. When the trachea becomes obstructed, a surgical procedure called a tracheostomy, or tracheotomy, may be necessary: An incision is made into the skin over the throat, and a hollow tube is inserted so that patient can breathe through it. See also TRACHEA.

covering, have a very low potential for causing allergic symptoms. Each tree genus has pollen that is distinct from any other. An individual may exhibit allergy to one or many of the trees in his or her region. Pollinating seasons are brief, often intense, and usually occur before, during, or shortly after leaves develop in deciduous trees, especially in the spring.

trepopnea

Breathing that is easier when a person is in a certain position.

tracheobronchomegaly

Congenital abnormal enlargement of the trachea and bronchi.

tracheocele A herniated mucous membrane protruding through the wall of the trachea, or windpipe. tracheostomy

Also called tracheotomy, the surgical creation of an opening in the trachea, or windpipe, to allow air into the body in the event that an individual’s other airways are obstructed. In emergencies, an endotracheal tube is inserted in the opening to keep the airway patent. Tracheostomy care involves suctioning excess secretions that may impede the flow of air.

trachitis See also

Inflammation of the trachea. TRACHEITIS.

tract, respiratory

See

RESPIRATORY SYSTEM.

transpiration, pulmonary

The release of water vapor from the bloodstream to the air in the lungs.

transplantation, lung tree, bronchial

See

tree pollen allergy

See

triage A process usually during war, disaster, or other emergency in which patients are assessed for the severity of their illness or injury in order to save the most lives. The first priority treatment is given to patients whose airways are not functioning. The second priority is given to those who are bleeding and in shock, and third priority has been established for patients with possible nerve damage and injured bones and tissues. triamcinolone (Aristocort, Azmacort, Kenacort) A corticosteroid drug frequently used in the treatment of allergies and asthma. See also CORTICOSTEROIDS. trigeminal cough

A reflex cough caused by irritation of the trigeminal nerve endings in the upper respiratory passages.

trigger, asthma

Any agent, substance, or condition that brings on asthma symptoms or an asthma attack. See also ASTHMA.

LUNG.

BRONCHI.

Seasonal hay fever and/or asthma caused by the inhalation of the pollen of wind-pollinating, or anemophilous, trees. Insectpollinating, or entomophilus, trees and wind-pollinating conifers, whose pollen has a thick outer

tripelennamine (Pyribenzamine or PBZ) An antihistaminic drug of the ethylenediamine class. This drug is especially useful for the treatment of allergic disorders during pregnancy because of its long history of safe use. It has a mild sedative effect, but it may cause some gastrointestinal distress that can be minimized by taking the drug with food. Tripelennamine is available as a topical cream for the relief of itching, but it can be a cause of

tussiculation 199 allergic rashes in some individuals, worsening the skin condition for which it is prescribed. Because of this adverse effect, it is rarely prescribed.

triprolidine (Actidil)

An antihistamine of the alkylamine class with mildly sedating properties. It is usually combined with pseudoephedrine in the proprietary product Actifed. This combination drug is widely used for the treatment of the nasal congestion of colds and hay fever.

troche From the Greek word meaning a small wheel, a type of mildly medicated throat lozenge. tube, endobronchial Used in anesthesia, a tube with a double lumen. One lumen is inserted into a part of one lung for the purpose of aeration, while the other lumen is constricted so the other lung or part of it can deflate. tube, endotracheal

See

TRACHEOSTOMY.

tuberculin

From the Latin word tuberculum, meaning little swelling, a preparation of cells from the tubercle bacillus used in diagnostic testing to determine the presence of the disease tuberculosis. A solution called new tuberculin has been replaced by Tuberculin, USP. Old tuberculin refers to Koch’s cultures of Mycobacterium tuberculosis. Purified Protein Derivative tuberculin is a preparation like old tuberculin but for a synthetic broth in which the Mycobacterium tuberculosis is cultured. See also KOCH, ROBERT.

tuberculin tine test

A test in which the skin is pierced by an instrument with multiple sharp points, or tines, to which tuberculin has been applied. Redness or sign of inflammation occurring at the puncture site within two or three days after the skin is penetrated indicates the possible presence of tuberculosis in the individual.

tuberculofibrosis Another term for interstitial pneumonia, a chronic lung inflammation from which fibrous tissue forms.

See also

PNEUMONIA.

tuberculosis

A highly infectious, often lifethreatening disease caused most frequently by the Mycobacterium tuberculosis, an airborne bacterium that has a history of causing illness from ancient times to epidemics in the recent past. However, tuberculosis (TB) has been and can be controlled or cured by antibiotics, including isoniazid (INH), pyrazinamide (PZA), rifampin (RMP), streptomycin, and ethambutol, and combinations of two or more of these. Depending upon the severity of the disease, surgery may be necessary to drain accumulated pus from the lungs or other infection site or to repair a spinal deformity that was caused by the disease. TB is characterized by pulmonary lesions, inflammation, tubercle formation, abscesses, fibrosis, calcification, and other processes that manifest as respiratory symptoms, particularly productive coughing. Sputum streaked with blood, difficulty breathing, a feeling of being unwell or fatigued, and cold night sweats may also appear. TB is considered a threat to public health because it is extremely contagious and, more recently, because antibiotics that have long been used to treat the disease have become less effective due to the resistance of some tuberculosis-causing strains of bacteria. In 1995, nearly 23,000 cases of TB were reported in the United States, with 28 percent involving people age 65 and older. Others at high risk of contracting TB include persons of lower socioeconomic groups, immunosuppressed individuals (particularly those with AIDS), persons with chronic renal failure, diabetes mellitus, malignancies, silicosis, gastrectomy, and jejunoileal bypass, and infants who weigh 10 percent or more below the ideal weight. On May 6, 2001, The New York Times reported a serious tuberculosis epidemic in Russia, with one in every 1,000 Russians suffering from the disease. That is triple the rate of 10 years ago and approximately 15 times the rate in America. “The threat is heightened by the size of Russia’s prison population—at 963,000, one of the world’s largest and a major incubator of the disease. In some prisons, as many as one-fifth of all TB cases are multidrug resistant,” the article says.

200 Tussi-Organidin TB may be contracted by inhaling indoor air containing tuberculosis bacteria. The bacteria may also be coughed or sneezed into the air by an infected person. An infant may be exposed through breathing infected droplets, and a fetus may breathe in or swallow infected amniotic fluid. People who live in crowded conditions or underdeveloped countries may also be at higher risk of contamination. Active tubercular infection typically begins in the lungs, but it may spread into the bloodstream and to other parts of the body (extrapulmonary tuberculosis). Often a person who is exposed to the TB bacterium will be able to ward off the disease through his or her immune system, which accounts for approximately 90 to 95 percent of all TB infections healing without causing active symptoms of the disease. Also, other diseases caused by mycobacteria similar to Mycobacterium

tuberculosis can mimic tuberculosis, including lung and lymph node infections, and a persistent cough may be attributed erroneously to smoking or a bout with influenza. Methods of diagnosis include a tuberculin skin test and a follow-up chest X ray if the skin test is positive. An abnormal chest X ray, which may be confused with other infections or the presence of cancer, may be followed by a laboratory sputum, chest fluid or tissue (biopsy) analysis to determine the presence of the tuberculosis bacterium, and a bronchoscopy to examine the bronchial tubes and obtain mucus samples. Spinal cord fluid may also be analyzed to diagnose tuberculous meningitis, which affects the brain and spinal cord. A polymerase chain reaction (PCR) test can reveal tuberculosis meningitis as well as tuberculosis in the kidneys. Samples of uterine,

U liver, and lymph node tissue and bone marrow may also be tested. Preventive measures against TB include the prophylactic prescription of isoniazid, the use of a germicidal ultraviolet light in communal areas, tuberculin skin testing, and the BCG vaccine used in high-risk, developing countries. See also MILIARY TUBERCULOSIS; TEST, TUBERCULIN.

tularemia

Also called rabbit or deer fly fever, a bacterial infection caused by the organism Francisella tularensis. There are four types of tularemia: ulceroglandular, the most common and one that causes ulcers to form on the hands; oculoglandular,

which affects the eyes; glandular, causing swelling of lymph nodes; and typhoidal, characterized by fever, abdominal pain, and exhaustion, and can lead to pneumonia. Although people become infected with tularemia from eating or touching infected animals or being bitten by ticks and insects infected by the animals, a June 6, 2001, article in the Journal of the American Medical Association cited the F. tularensis organism as one that can be inhaled and therefore used as a biological weapon. Personto-person transmission does not occur, but the bacterium is highly infectious and has the potential to cause illness and death through environmental exposure. Treatment, usually with expectations of full recovery and subsequent immunity, includes

201

V antibiotics either injected or taken orally, and dressings and compresses for topical therapy. In cases involving severe headaches, analgesics may be prescribed. See also BIOTERRORISM.

turkey raiser’s disease Continuous exposure to an allergen in turkey droppings that may cause hypersensitivity pneumonitis, an allergic pneumonia-like lung disorder. See also PNEUMONITIS. turpentine poisoning

The toxic effect of inhaling turpentine, characterized by symptoms including a burning sensation in the esophagus, vomiting, diarrhea, weak pulse and respiration, and urinary and neurological disturbances. Gastric lavage, increased fluid intake, and other measures may be necessary for treatment.

tussiculation

include rashes, enlarged thyroid glands, and swelling of the parotid glands (acute parotitis).

tussis

The medical term for cough. Tussis convulsiva refers to whooping cough, and tussis stomachalis is a reflex cough that results from an irritation of the mucosal stomach lining.

tylophora asthmatica

An herb reported to have anti-inflammatory properties and long-term benefits in controlling asthma, particularly because it is thought to reduce congestion and mucus production.

typhoid fever, respiratory symptoms in Rapid respiratory rate, cough, and bronchial rales associated with typhoid fever and acute infectious disease. Typhoid fever is not considered a respiratory disorder per se, but certain symptoms resembling respiratory disease are present.

A brief, dry cough.

Tussi-Organidin

Mucolytic expectorant containing a mixture of several iodinated compounds formed by the reaction of iodine and glycerin. This prescription drug, also known as Iodur, Iotuss, Organidin, and Par-Glycerol, is frequently combined with the cough suppressants dextromethorphan or codeine. Iodine-containing preparations should be avoided during pregnancy, in nursing mothers, or in the newborn. These products should be avoided or used with caution in those individuals with thyroid disorders or who have experienced an adverse reaction to these or other iodine-containing foods or drugs in the past. Allergic or other adverse reactions

202

volume, residual 203 unconsciousness

Insensibility characterized by the inability to swallow, nonreactive eyes, and generally a sleeplike state, possibly caused by lack of oxygen, alcohol or drug intoxication, carbon monoxide poisoning, brain tumor, cerebral hemorrhage or thrombosis, cardiac decompensation, meningitis, pneumonia, uremia, subdural hematoma, diabetes, epilepsy, fear, fright, heat stroke, and a number of other problems. Also known as twilight sleep, coma, shock, stroke, stupor, asphyxia, and apoplexy, unconsciousness may be treated by artificial respiration or cardiopulmonary resuscitation. See also CARDIOPULMONARY RESUSCITATION.

upper airway obstruction

A blockage in the main bronchus, larynx, mouth, or nose that prevents breathing.

upper respiratory infection

An invasion of disease-causing microorganisms in the nose, throat, and bronchi.

uvulopalatopharyngoplasty A surgical procedure in which the soft palate, uvula, pillars, fauces, and a certain portion of pharyngeal mucosa are removed in order to prevent intractable snoring, sleep apnea, and other sleep disorders. vaccine Inoculation with bacteria, bacterial products, or viral products in order to immunize, or protect, an individual against a certain disease. vacuum cleaners for allergic patients Dust- and dirt-collecting devices with double bags, which offer protection to allergic persons. The ordinarytype vacuum cleaners allow small suspended particles containing most collected allergens to pass through the collection bag back into the surrounding air. An allergic person should avoid a recently vacuumed room for an hour or two following vacuuming. If possible, have a nonallergic person do the vacuuming. An alternative is for the allergic individual to wear a mask capable of trapping small particles.

Vacuum cleaners with elaborate special HEPA, or water-filtering, devices may not be more efficient than ordinary vacuums. However, vacuums with double bags may be the most effective. When possible, such as when planning a new home, install a central vacuum system with motor and collection bag in the garage.

valley fever

See

COCCIDIOMYCOSIS.

valve, pulmonary A membrane that separates the pulmonary artery and the right ventricle of the heart. Vanceril inhaler vaporizers

See

BECLOMETHASONE.

HUMIDIFIERS.

vasoconstrictor Any substance that can cause constriction, or narrowing, of blood vessels. vasodilator Any substance that dilates or increases the circumference of blood vessels. vasomotor rhinitis

Nasal congestion that cannot be attributed to any other cause, such as allergic rhinitis (hay fever) or upper respiratory infections (colds, sinusitis). Vasomotor rhinitis is thought to be caused by excessive stimulation of certain nerve endings in the nose for unknown reasons. Nasal congestion, often accompanied by large amounts of clear watery mucus, does not respond to antihistamines or allergy nasal sprays containing the drugs cromolyn or corticosteroids. Alpha-agonist (decongestant) drugs, such as pseudoephedrine (Sudafed) orally or topical nasal sprays, are sometimes helpful. Abuse of over-thecounter nasal sprays may cause a rebound effect. The worsening of nasal congestion caused by the overuse of drugs is called rhinitis medicamentosa. Treatment with oral or topical (nasal sprays or drops) decongestant drugs and anticholinergic drugs such as atropine and ipratropium may be effective. However, antihistamines are not effec-

204 volume, tidal tive, and anti-inflammatory corticosteroid nasal sprays are occasionally helpful.

vent, alveolar

Opening between adjacent alveoli, or air sacs, in the lungs.

ventilation From the Latin word ventilare, meaning to air, the air circulation in a room, the amount of air inhaled on a daily basis, and the oxygenation of the bloodstream. Ventilation is the act of drawing air into and expressing air out of the body

W through the respiratory system in order to oxygenate the blood. It also refers to heating and cooling systems in buildings. Artificial ventilation is another term for respirator. Pulmonary ventilation refers to the inhalation and exhalation of air from the lungs. Continuous positive-pressure ventilation refers to a mechanical device that administers oxygen or air to the lungs with continuous pressure;

intermittent positive-pressure ventilation is a mechanical method that assists pulmonary ventilation by inflating the lungs under positive pressure. High frequency jet ventilation provides respiration in the case of respiratory failure. This continuous ventilation is administered at 100 to 150 breathing cycles per minute.

WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA Common Name

Technical Name

Alfalfa

Medicago sativa

Allscale1

Atriplex polycarps

Aster Balsamroot

Aster species

Plant Family

Distribution

Pollination Season

Leguminosae

Cultivated crop

May–Oct.

Chenopodiaceae

Colorado and Mojave Desert, alkali flats of C. CA, So. NV, UT and AZ

July–Oct.

Cultivated ornamentals and native weeds

Fall

So. B.C. to So. CA, E. to MT, SD, CO

Apr.–July

B.C. to CA, E. to MT, ID, NV, spreading elsewhere

July–Oct.

Coastal beaches and dunes B.C. to So. CA

Mar.–Sept.

Coastal beaches and dunes B.C. to So. CA

July–Sept.

Cultivated crop (sugar and red) established locally in So. U.S.

July–Oct.

Compositae

Balsamorrhiza sagittata

Compositae

Bassia hyssopifolia

Chenopodiaceae

Franseria bipinnatifidia

Compositae

Beachbur, San Francisco

F. chamissonis

Compositae

Beet

Beta vulgaris

Bassia Beachbur

Chenopodiaceae

Bractscale1

Atriplex bracteosa

Chenopodiaceae

C. and So. CA, E. to NM, TX

July–Nov.

Brewers scale1

A. breweri

Chenopodiaceae

C. and So. CA

July–Oct.

Brittle bush (incienso)

Encelia farinosa

Compositae

C. and So. CA, to S.W. UT, AZ

Mar.–May

Broom, Scotch

Cystisus scoparius

Leguminosae

Naturalized, CA, No. to WA, B.C.

Apr.–June

205

206 weed pollen allergy WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Broomweed

Gutierrezia dracunculoides

Compositae

C. TX and OK

July–Oct.

Bulrush

Scirpus microcorpus

Cyperaceae

So. CA, No. to AK, Rocky Mts., NM

May–Aug.

Burrobrush1

Hymenoclea monogyra

Compositae

So. CO E. to TX

Aug.–Nov.

Burrobrush1

H. salsola

Compositae

So. CA, NV, S. UT, AZ

Mar.–June

Canaigre (wild rhubarb)

Rumex hymenosepalus

Polygonaceae

C. and So. CA, WY, W. TX

Jan.–May

Carelessweed1

Amaranthus palmeri

Amaranthraceae

So. CA, E. to C. U.S.

Aug.–Nov.

Castor bean1

Ricinus communis

Euphorbiaceae

Cultivated ornamental, established in So. U.S.

Jan.–Dec.

Cattail, broad-leaf

Typha latifolia

Typhaceae

Widespread weed

June–Aug.

Cattail, narrow-leaf

T. angtistifolia

Typhaceae

Widespread weed

June–Aug.

Chamise (greasewood)

Adenostoma fasciculatum

Rosaceae

Common component of California chaparral

May–June

Clover, red

Trifolium pratense

Leguminosae

Cultivated hay crop

June–Aug.

Clover, sweet

Melilotus species

Leguminosae

Cultivated hay crop, widespread weed

May–Nov.

Clover, white

Trifolium repens

Leguminosae

Cultivated lawn plant

Apr.–Sept.

co*cklebur, common1

Xanthium strumarium

Compositae

Widespread weed

Aug.–Oct.

co*cklebur, spiny

X. spinosum

Compositae

Widespread weed in warm and temperate regions

July–Oct.

Widespread weed, cultivated as Shasta daisy

June–Aug.

Daisy, ox-eye

Chrysanthemum leucantheum

Compositae

Dandelion officinale

Taraxacum

Compositae

Widespread weed

Jan.–Dec.

Dock, bitter1

Rumex obtrusifolis

Polygonaceae

Widespread weed

June–Dec.

Dock, green1

R. conglomeratus

Polygonaceae

Widespread weed

Apr.–Oct.

Dock,

white1

R. mexicanus

Polygonaceae

Widespread weed

June–Sept.

Dock, yellow (curly dock)1

R. crispis

Polygonaceae

Widespread weed

May–Oct.

Dog fennel (mayweed)

Anthemis cotula

Compositae

Widespread weed

June–Oct.

Fern, bracken

Pterdium aquilinum

Dennstaedtiaceae

Widespread weed

June–Aug.

Fern, royal

Osmunda regalis

Osmundaceae

Widespread weed

Summer

weed pollen allergy 207 WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Fern, sword Christmas fern

Polystichum munitum

Polypodiaceae

AK to So. CA, to ID and MT

Summer

Firebush, Mex. (smr. cypress)1

Kochia scoparia

Chenopodiaceae

Widespread weed

Aug.–Oct.

Fireweed

Epilobrium angustifolium

Onagraceae

Widespread weed

July–Sept.

Goldenrod

Solidago species

Compositae

Widespread weed

May–Oct.

Goosefoot, Lamb’s-quarter1

Chenopodium album

Chenopodiaceae

Widespread weed

June–Oct.

Goosefoot, nettle-leaf

Chenopodium murale

Chenopodiaceae

Widespread weed

Most of year, esp. spring

Greasewood

Sarcobatus vermiculatus

Chenopodiaceae

So. CO to E. WA, Alta., ND, TX

May–Aug.

Hemp

Cannabis sativa

Cannabidaceae

Cultivated crop and widespread weed, diminishing

July–Sept.

Cannabidaceae

Cultivated crop

Summer

Hops, cultivated

Humulus lupulus

Hop-sage

Grayia spinosa

Chenopodiaceae

CA to E. WA, WY, AZ

Mar.–June

Iodine bush

Allenrolfea occidentalis

Chenopodiaceae

CA to OR, UT

June–Aug.

Jerusalem oak

Chenopodium botrys

Chenopodiaceae

Widespread weed

June–Oct.

Lenscale1

Atriplex lentiformis

Chenopodiaceae

So. and C. CA, to UT

Aug.–Oct.

Marshelder, August

Iva augustifolia

Compositae

AR, OK, TX, LA

Late summer–fall

Marshelder, rough (poverty weed)1

I. ciliata

Compositae

IL to LA, W. to N.B., NM

Late spring–summer

Mugwort1

Artemisia douglasiana

Compositae

CA E. to W. NV, to WA, ID

June–Oct.

Mugwort1

A. heterophylla

Compositae

CA. E. to W. NV, to WA, ID

June–Oct.

Mustard (Black)

Brassica nigra

Cruciferae

Widespread weed

Apr.–July

Mustard

B. campestris

Cruciferae

Widespread weed, esp. in CA

Jan.–May

Nettle

Urtica dioica

Urticaceae

Widespread weed

July–Sept.

Pea, sweet

Lathyrus odoratus

Leguminosae

Cultivated ornamental

Jan.–Dec.

Phlox

Phlox species

Polemoniaceae

Cultivated ornamental

Spring–summer

Pickleweed (glasswort)

Salicornia ambigua

Chenopodiaceae

Atlantic and Pacific coastal, salt marshes and adjacent salt flats

Aug.–Nov.

Widespread weed

June–Nov.

Pigweed, green

Amaranthus hybridus

Amaranthaceae

208 weed pollen allergy WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Pigweed, redroot1

A. retroflex

Amaranthaceae

Widespread weed

June–Nov.

Pigweed, spiny

A. spinosus

Amaranthaceae

Advancing weed

June–Sept.

Pigweed, spreading

A. blitoides

Amaranthaceae

Widespread weed

July–Nov.

Plantain, common

Plantago major

Plantaginaceae

Widespread weed

Jan.–Dec.

Plantain, English (buck-horn)1

P. lanceolata

Plantaginaceae

Widespread weed

June–Sept.

Poppy, California

Escholzia californica

Papaveraceae

CA, cultivated ornamental elsewhere

Feb.–Sept.

Povertyweed, giant

Iva xanthifolia

Compositae

P.Q. to Alta., So. to DC, OH, MD, TX, NM, AZ

July–Sept.

Povertyweed, small

I. axilaris

Compositae

CA to No.B., Canada

May–Sept.

Rabbitbrush

Chrysothamnus nauseosus

Compositae

E. CA, No. to B.C., E. to Sask., TX

July–Oct.

Rabbitbrush1

Franseria deltoides

Compositae

So. AZ and Mexico

Spring

Ragweed, canyon1

F. ambrosiodes

Compositae

So. CA, So. AZ

Mar.–June

Ragweed, desert (burroweed)1

F. dumosa

Compositae

So. CA, S.W. UT, AZ

Mar.–May

Ragweed, false (Sandbur)1

F. acanthicarpa

Compositae

C. and So. CA to WA, Sask., TX, advancing eastward

Aug.–Nov.

Ragweed, giant (crownweed)1

Ambrosia trifida

Compositae

So. Canada and U.S. to Rocky Mts.

July–Sept.

Ragweed, short1

A. artemisifolia

Compositae

So. Canada and U.S., except W. and S.W. U.S.

Aug.–Oct.

Ragweed, silver1

Dicoria canescens

Compositae

So. CA, S.W. AZ, NV, S.W. UT

Sept.–Jan.

Ragweed, slender1

Franseria tenuifolia

Compositae

C. and So. CA, to KS, TX

May–Nov.

Ragweed, southern1

Ambrosia bidentata

Compositae

So. IL, to LA, W. to N.B. and TX

Aug.–Sept.

Ragweed, western1

A. psilostachya

Compositae

CA to WA, Sask., IL

July–Nov.

Redscale

Atriplex rosea

Chenopodiaceae

CA to WA, Atlantic coast

July–Oct.

Rose

Rosa species

Rosaceae

Cultivated ornamentals and native shrubs

Jan.–Dec.

Widespread weed

July–Sept.

Sagebrush, annual

Artemisia annua

Compositae

weed pollen allergy 209 WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Sagebrush, biennial

A. biennis

Compositae

Widespread weed

Aug.–Sept.

Sagebrush, California1

A. californica

Compositae

Coastal C., and So. CA

Aug.–Dec.

Sagebrush, carpet (pasture)1

A. frigida

Compositae

Some forms cultivated annuals

July–Sept.

Sagebrush, common (giant)1

A. tridentata

Compositae

So. CA to B.C., Rocky Mts.

Aug.–Oct.

Sagebrush, prairie1

A. ludoviciana

Compositae

CA to WA, Alta., Ont., AR, NM

July–Sept.

Sagebrush, sand dune

A. ludoviciana

Compositae

Coastal C. CA, and OR

June–Aug.

Sagebrush, Sukasdorf

A. pycnocephala

Compositae

Coastal N. CA to Vancouver Island

May–Aug.

Saltbush, annual

A. suksdorfii

Chenopodiaceae

So. AZ and So. NM

July–Sept.

Sea blite (seepweed)

Suaeda moquini

Chenopodiaceae

So. CA to Alta.

July–Oct.

Sea blite (seepweed)

S. californica

Chenopodiaceae

Coastal salt marsh, San Francisco Bay to So. CA

July–Oct.

Sea blite (seepweed)

S. suffrutescens

Chenopodiaceae

C. CA to WA, Rocky Mts.

July–Sept.

Sedge

Carex species

Cyperaceae

Widespread, largest genus of flowering plants in North America

Spring–summer

Shadscale (sheep fat)

Atriplex conifertifolia

Chenopodiaceae

So. CA to E. OR, ND

Apr.–July

Sheep sorrel1

Romex acetosella

Polygonaceae

Widespread weed

Mar.–Aug.

Silverscale

Atriplex argentea

Chenopodiaceae

So. CA to B.C., ND, NM

June–Sept.

Snapdragon

Antirrhinum majus

Scrophulariaceae

Cultivated crop

Jan.–Dec.

Spearscale

Atriplex patula

Chenopodiaceae

Widespread weed

June–Nov.

Sunflower

Helianthus species

Compositae

Cultivated crop, ornamental, native So. Canada to Mexican border

Feb.–Oct.

Tanacetum vulgare

Compositae

Cultivated ornamental, naturalized weed

July–Sept.

Tarragon (green sagebrush)

Artemisia dracunculus

Compositae

C. and So. CA, N. to B.C., WI, TX, cultivated form sterile

Aug.–Oct.

Tarweed

Hemizonia species

Compositae

30 species, all in CA

Apr.–Nov.

Tea, Mexican (wormseed)

Chenopdium ambrosiodes

Chenopodiaceae

Widespread weed

June–Dec.

Thistle, Russian1

Salsola kali

Chenopodiaceae

Widespread weed

July–Oct.

Tulip

Tulipa species

Liliaceae

Cultivated ornamentals

Spring

Tansy

210 wheeze WEEDS THAT ARE A CAUSE OF HAY FEVER IN THE UNITED STATES AND CANADA (continued) Common Name

Technical Name

Plant Family

Distribution

Pollination Season

Water hemp1

Acnida tamariscina

Amaranthaceae

E. TX, No. to So. OK, E. to IN

Aug.–Sept.

Wingscale, (shadescale)1

Atriplex canescens

Chenopodiaceae

C. and So. CA to E. WA, SD, KS, TX

June–Aug.

Winter fat

Eurotia lanata

Chenopodiaceae

C. and So. CO, WA, Rocky Mts., TX

Mar.–June

Wormwood

Artemisia absinthium

Compositae

Cultivated ornamental, naturalized weed

July–Sept.

1Pollen

is a major source of hay fever. Adopted from Pollen Guide for Allergy, Hollister-Stier.

A ventilation coefficient refers to the amount of air that must be taken in for every liter of oxygen to be absorbed into the blood.

ventilation rate

The amount of air breathed during the course of one minute.

ventilator A device that provides artificial respiration either by hand or machine. Ventolin

See

ALBUTEROL.

ventricle of larynx

Space between the true and

the false vocal cords.

Venturi mask Named after Giovanni Battista Venturi, an Italian scientist (1746–1822), a device placed over the nose and mouth that administers a controlled dose of oxygen to an individual.

viruses From the Latin word for poison, organisms that can produce disease in the host in which they thrive. There are hundreds of viruses (300 or more isolated from animals). Although some appear to be harmless to people, many viruses cause diseases including influenza, AIDS, the common cold, smallpox, yellow fever, certain lymphomas, leukemias and other forms of cancer, poliomyelitis, communicable childhood diseases such as chickenpox, and most upper respiratory infections. The respiratory syncytial virus causes many of the lower respiratory diseases in infants and young children. Some antiviral drugs have been developed, and certain viruses are susceptible to preventive vaccines. See also BIOTERRORISM. vital capacity

vestibule of nose, mouth, and larynx

The front part of the nostrils, the part of the mouth between the lips, cheeks, gums and teeth, and the part of the larynx above the vocal cords. A vestibule is a tiny space at the front or the beginning of a structure.

The volume of air that can be exhaled following a full inspiration. The timed vital capacity is the volume of air that can be forcibly exhaled in a given time. In asthma patients this important value is often expressed as the forced expiratory volume in one second, or FEV1. The FEV1 is considered by most physicians to be the most important guide to the severity of an asthma attack. See also SPIROMETRY.

vicarious respiration

vital signs

The increase of activity in a lung that makes an effort to compensate for the other lung that may be injured or diseased.

Body temperature, pulse, and number of respirations as measured or counted per minute.

woolsorter’s disease 211 vocal cords The pair of thin membranes in the larynx that vibrate when air passes between them. This creates our ability to make sounds, speak, and sing. Vollmax See also

Brand of sustained-release albuterol. ALBUTEROL.

volume, expiratory reserve The largest amount of air that can be forced out of the lungs after normal breathing out, or exhaling. volume, inspiratory reserve The largest amount of air that can be forced out of the lungs after normal breathing in. volume, residual

The amount of air remaining in the lungs after exhalation.

volume, tidal The amount of air inhaled and exhaled in a normal breathing cycle. vomer

From the Latin word for plowshare, the bone reminiscent of a plow at the lower back of the nasal septum. The vomer connects with the two palate bones, the ethmoid, sphenoid, and two upper maxillary bones.

von Pirquet’s test

See

QUANTI-PIRQUET.

war gases

Any type of chemical substance used deliberately to inflict irritation or to poison. See also BIOTERRORISM.

weed pollen allergy

Hay fever caused by exposure to the windblown, or anemophilous, pollen of plants that grow wild. Weeds often grow in areas despite minimal nutrition and water and tend to choke out more attractive plants. Most weeds are considered of little or no value and a nuisance.

However, notable exceptions include the crops alfalfa, beets, castor bean, hemp, hops, sunflower, and ornamental plants such as roses and tulips. Various species of ragweed are the most important producers of allergy-causing weed pollen. See also RAGWEED.

wheeze A breathing difficulty characterized by a high-pitched whistling or moaning sound produced when a lumen, or the space, of a respiratory passage narrows, such as in the case of asthma, hay fever, croup, or pleural effusion. Wheezing may be caused by a bronchial spasm, tumor, obstruction by a foreign body, edema, obstructive emphysema, or tuberculosis. Wheezing may be offensively loud or audible only through a stethoscope in the case of asthma, bronchitis, pulmonary edema, a foreign object inhaled into an airway, and other respiratory disorders. whiff

A brief inhalation or exhalation, or puff of air that may carry a particular odor, such as that of tobacco smoke.

whooping cough A respiratory infection caused by Bordetella pertussis that is characterized by coughing spasms that end with a high-pitched whooping sound. Also known as pertussis, whooping cough is extremely contagious and is considered a major disease in the world, although in the United States, where there had been epidemics, there is now a routine, combined immunization called DTP, or diphtheria-tetanus-pertussis, for infants and children. Pertussis is spread through droplets of moisture from an infected person’s cough. Symptoms start approximately seven to 10 days after exposure, when the bacteria attack the throat lining, trachea, and other airways and increase the production of mucus. The three stages of whooping cough, which usually lasts six weeks, are the catarrhal stage, with

X mild symptoms similar to a cold; the paroxysmal stage, with severe coughing; and the convalescent stage, when the patient begins to recover. It may be easy to confuse the catarrhal stage of whooping cough with symptoms of bronchitis, influenza, and other viral infections, or the onset of tuberculosis. A nose and throat culture determines the presence

of the pertussis bacteria most of the time. If a child develops pneumonia secondary to a pertussis infection, pneumothorax (collapse of the lung), difficulty breathing or apnea, and other complications may be fatal. Other complications of pertussis include vomiting, choking spells, otitis media, bleeding or swelling of the brain, paralysis, rectal

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Y prolapse, convulsions, and certain neurological problems. Whooping cough is often transmitted to young children by infected older children and adults with only mild symptoms. Treatment may consist of oxygen therapy, suctioning of mucus from the throat, intravenous fluids, and antibiotic therapy, particularly erythromycin.

Wilson-Mikity syndrome Named for American pediatrician Miriam G. Wilson (b. 1922) and American radiologist Victor G. Mikity (b. 1919), a pulmonary syndrome seen in premature babies. Symptoms include difficulty breathing, rapid breathing, and cyanosis during the infant’s first month of life. Known as a dysmaturity syndrome, Wilson-Mikity is also characterized by evidence of emphysema, pulmonary insufficiency, and heart failure, and approximately 25 percent of the victims die from the disease.

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Z windpipe A layman’s term for the trachea, a tube through which inhaled air goes from the larynx (voice box or vocal cords) into the lungs. The end of the trachea branches into two bronchi, each one connected to a lung. Trachealgia refers to pain in the windpipe. Tracheitis is an inflammation of the trachea that may be a symptom of bronchitis or laryngitis. A tracheostomy is the surgical creation of an opening into the trachea to relieve airway obstruction. A tracheal tickle refers to a technique to induce a reflex cough. Tracheal tugging means a pulling down of the trachea or laryngeal pulsation associated with thoracic aneurysm. wood- and coal-burning stoves

Home heating alternatives that may be excellent sources of inexpensive fuel. More than 11 million wood-burning stoves are in use in the United States since the energy crisis of the 1970s caused a significant increase in home heating costs. Wood stoves should have a catalytic converter to burn off smoke produced by burning wood. Do not store wood in the home. Always keep the doors to stoves or fireplaces closed. Once the fire has been started, use only hard wood. Soft pine, poplars, twigs, or unseasoned wood should be avoided. Coal stoves may be safe but only if they are airtight. Poorly ventilated coal stoves may result in unsafe levels of

carbon monoxide, nitrogen and sulfur dioxides, formaldehyde, and benzopyrene in the home. Kerosene heaters produce unpleasant fumes that can trigger asthma.

woolsorter’s disease A type of anthrax, caused by Bacillus anthracis, that affects the lungs of individuals who handle contaminated wool and wool products. A highly contagious disease, anthrax may be life-threatening. Woolsorter’s anthrax usually is the result of inhaling spores of the bacterium, which multiply in lymph nodes and spread to the lungs. When lymph nodes begin to deteriorate and bleed, the bacterium travels throughout the thorax, creating flulike symptoms, breathing difficulty, shock, coma, meningoencephalitis, and death. Anyone who works in textile mills that process wool, veterinarians, laboratory technicians, animal workers, certain military personnel, and others at high risk of contracting pulmonary anthrax should be vaccinated. Treatment for the infection includes intravenous penicillin, antibiotics, and corticosteroids. In the 1950s, an anthrax vaccine was developed for humans and licensed by the FDA in the 1970s. According to the U.S. Department of Defense Anthrax Vaccine Immunization Program, the vaccine manufactured by the BioPort Corporation, of

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APPENDIXES I. Progress Report of the American Lung Association, 2000 II. The Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory III. Trends in Lung Cancer Morbidity and Mortality IV. Trends in Asthma Morbidity and Mortality V. Guidelines for the Diagnosis and Management of Asthma VI. Education for a Partnership in Asthma Care VII. Stepwise Approaches for Managing Acute or Chronic Asthma Symptoms in Infants and Children under Age Five and Adults and Children over Age Five VIII. Usual Dosages for Quick-Relief Medications and Long-Term Control Medications IX. Management of Asthma Exacerbations— Emergency Department and Hospital-Based Care X. Traveling with Allergies or Asthma XI. Alternative Treatments and Remedies for Respiratory Disorders XII. Professional and Lay Organizations

APPENDIX I PROGRESS REPORT OF THE AMERICAN LUNG ASSOCIATION, 2000 In 1996, The American Lung Association’s Board of Directors voted to fund three National Asthma Research Centers, as the first step in an intensive search for the causes of asthma and ultimately for a means of prevention and cure. This joint effort of the ALA and the American Thoracic Society was named Asthmattack!, reflecting the urgent need to turn around the alarming increase in asthma’s prevalence and the rising number of deaths for which it is responsible. Since the inception of Asthmattack!, the three research centers have focussed on putting the essential building blocks of knowledge in place that will lead to better ways of treating asthma, and one day to a cure. “Basic research in the laboratory is the first step on the road to overcoming asthma,” says Spencer Koerner, M.D., an ALA board member and former chairman of the Research Coordinating Committee. “Sometimes it’s difficult to grasp just how scientists studying cells in test tubes are going to lead us to new asthma treatments, but in every area of medicine it’s been proven time and again that basic research is the only route to success at the patient’s bedside.” Scientific research is a painstaking process of linking together many studies and experiments, not a single, amazing discovery made in a vacuum. The journey to a cure is a long one, requiring collaboration among many different kinds of specialists to arrive at the final destination. “The history of medical advances abounds with examples of how basic research leads to the knowledge that allows clini-

cians to heal patients, sometimes by what may seem to be an indirect route,” Dr. Koerner points out. Asthma is no exception, and this year, Asthmattack! has begun a new phase, with the establishment of Asthma Clinical Research Centers around the country to conduct clinical research on large groups of patients. Meanwhile, work continues, thanks to the wisdom and commitment of those who recognize that steady progress is leading us to the day when asthma will no longer take its toll on millions of Americans of all ages. The first two Asthma Research Centers were initially funded in the summer of 1996. One is based at The National Jewish Medical and Research Center in Denver, Colorado, with Dr. Richard J. Martin as Principal Investigator. Dr. Martin is head of the Pulmonary Division at his institution, as well as Vice Chair of the Department of Medicine. The second center is located at The Human Molecular Biology and Genetics Institute at the University of Utah in Salt Lake City. Dr. Thomas McIntyre, Principal Investigator, is a professor of internal medicine and pathology at the University of Utah, where he has been a faculty member since 1983. The third center was funded as of January 1, 1997 and is located at the University of New Mexico in Albuquerque, with Dr. Mary Lipscomb as Principal Investigator. Dr. Lipscomb is a professor and chair of the Department of Pathology at the University of New Mexico School of Medicine.

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218 The Encyclopedia of Asthma and Respiratory Disorders While these three locations serve as home bases, the centers are not bound by bricks and mortar. Instead, they are far-flung organizations in a constantly expanding network of connections among specialists in many different fields at their base locations, at other institutions and private enterprise in this country, and at similar organizations around the world. “Our projects involve pulmonologists, immunologists, allergists and basic researchers in the areas of inflammation, corticosteroid receptors, and physiology,” comments Dr. Martin. “This year, we are joined by a leader in pulmonary epidemiology at Harvard. We also have brought prominent experts in other fields into asthma research, some for the first time. As our projects succeed, we are continually developing more national and international collaborative research. All of these investigators have an impact on our ongoing research.” Some of these scientists are as far away as Australia, while others are located in premier institutions in the United States, such as Johns Hopkins Medical School in Baltimore, and Brigham and Women’s Hospital in Boston. In New Mexico, a strong research relationship has been developed between researchers at the ALA Asthma Research Center and the Lovelace Respiratory Research Institute in Albuquerque. Scientists at the Asthma Research Center in Utah have worked with a prominent asthma center in London. Since they were initially funded, the three centers have continued to reap the benefits of collaboration on local, national and global levels.

DENVER 2000 ASTHMA RESEARCH CENTER PROGRESS REPORT At the Asthma Research Center in Denver, Dr. Richard Martin and colleagues continue to expand and clarify the concept that infection plays a key role in the origin of chronic asthma, at least in some people. During the past four years, they have firmly established that mycoplasma and chlamydia, two classes of bacteria which are very common and often cause pneumonia, are present in the airways of a large subset of asthmatics. When such individuals are treated with antibiotics to suppress the bacteria, their lung function improves and their asthma symptoms lessen.

“We have found mycoplasma or chlamydia to be present in over fifty percent of the asthmatics in the studies we have conducted,” comments Dr. Martin. “We are now confident that these bacteria are involved in the development of asthma in a significant number of people.” In the past year, an epidemiologic study has been launched and is currently investigating a group of children who had pneumonia caused by mycoplasma or chlamydia between seven and nine years ago. Another group of children who had pneumonia that was not caused by bacteria will serve as a control group. At this writing, the researchers have found that 75 percent of the children who had mycoplasma pneumonia now have asthma. “This is a very high percentage, since the incidence of asthma in the general populations is only six percent,” Dr. Martin explains. While this is a relatively small study which will eventually include 45 children in the study group and 45 controls, it will provide the preliminary data that is needed to decide whether to embark on a larger one. The results of the discovery that certain microbes play a role in the development of asthma will in due course have an impact on how physicians treat asthma all over the country, and indeed all over the world. “We’re beginning to publish our findings, and as they are disseminated others will try this approach and further evaluate it,” Dr. Martin explains. “We are already receiving queries from physicians throughout the United States about the relationship between chronic infection and chronic asthma and how that impacts on treatment. And we are getting feedback from them that corroborates our findings. While we are researchers, you might say we’re getting closer and closer to the bedside.” The Denver center has also developed a laboratory animal model of mycoplasma. These animals provide a means for studying the relationship between the presence of mycoplasma infection and the development of bronchial hyperresponsiveness that is a hallmark of asthma. Another major focus in this center is to gain a greater understanding of the cellular and immunologic mechanisms by which mycoplasma contributes to chronic asthma. These investigations

Appendix I 219 have revealed that the tiny bacteria has the capacity to act as either an antigen or a superantigen. An antigen is a substance that causes an allergic reaction by inducing the immune system to produce antibodies. Antigens require memory recall from the body’s cells: a familiar example is poison ivy infection, which does not occur the first time a person is exposed to the plant. But when exposed for a second time, cellular memory kicks in and the unpleasant symptoms appear. A superantigen, however, can induce a reaction upon initial exposure. “It’s intriguing that this organism can affect the immune system in two different manners,” Dr. Martin says. “It’s also important, because someone with an initial exposure can develop bronchial hyperresponsiveness. Then if they are reexposed to mycoplasma, the memory recall aspect may also come into play, and the combination of the two may worsen the situation.” Studies to further elucidate the precise events and interactions that take place at the cellular level will continue in the coming year. The Denver center also undertakes several pilot projects annually, consisting of innovative studies that are related to its major areas of investigation. One such project has investigated the role of surfactant proteins and how they interact with mycoplasma. Surfactants perform a variety of functions in the body, but their involvement in defending against invaders that are inhaled has not previously been well studied. “We began looking at surfactants several years ago, and the results were so promising that we have continued and expanded this pilot project,” says Dr. Martin. In 1999, it was found that mycoplasma can bind to two surfactants called SP-A and SP-D, and that this may cause an inflammatory response in the lungs. During the coming year, this pilot project will examine the biochemistry and cell biology of the interaction of SP-A and SP-D with mycoplasma, hoping to determine whether the surfactants inhibit or enhance infection with mycoplasma. Another pilot project that will be continued in the coming year has the goal of developing a noninvasive method for diagnosing mycoplasma and chlamydia in asthmatics. This is currently done by performing a bronchoscopy, which involves inserting a tube through the throat, a costly and uncom-

fortable procedure. Collecting a sample of induced sputum for laboratory analysis would be cost effective, less stressful and less risky. In the first year of this project, investigators found that the induced sputum technique is not as sensitive to the presence of mycoplasma and chlamydia as bronchoscopy. Their current efforts are aimed at increasing its sensitivity, as well as studying the inflammatory mediators that are present in the sputum of patients with mycoplasma and chlamydia, and those found in the sputum of individuals who do not harbor the bacteria. A new pilot project will take basic research into the clinical arena by investigating patients to see whether surfactant proteins differ in those who have mycoplasma and chlamydia, and in patients who do not. Another new project will examine the ways in which mycoplasma alters the tight junction between the epithelial cells that line the airways, allowing inflammatory mediators and edema fluid to move through these junctions.

UTAH 2000 ASTHMA RESEARCH CENTER PROGRESS REPORT The Asthma Research Center at the University of Utah, under the leadership of Principal Investigator Thomas Mc. McIntyre, Ph.D., is taking a reductionist approach to understanding the complex chain of events that occurs when asthma develops. “We know that a person’s genetic susceptibility to asthma depends on a fairly large number of genes, perhaps as many as twenty or thirty,” explains Dr. McIntyre. “They interact with each other, and because of their genetic background people with certain combinations of genes are more susceptible to developing asthma when they meet up with a trigger. There are many, many asthma triggers, making it even more complicated to understand precisely why some people have asthma and others do not.” By studying asthma in the laboratory, these researchers have been able to isolate and clarify certain key steps in its development. “We have shown that when one particular genetic defect is present, which we have found to produce a modest increase in susceptibility to asthma, the incidence of asthma can be further modified by a second gene mutation that by itself has little or no effect on

220 The Encyclopedia of Asthma and Respiratory Disorders asthma susceptibility,” Dr. McIntyre says. “Our studies are now focussed on substantiating the idea that asthma involves interactions among many genes, each of which has a small part to play, but that together appear to have a synergistic effect.” The symptoms of asthma wax and wane as inflammatory changes take place in the branching network of tubes that conducts air into the lungs. These changes occur when inflammatory cells enter the airway tubes, causing fluid to be retained in the lining of the airways. Fluid retention narrows the airways, while other inflammatory events trigger contractions of smooth muscle cells that also reduce the size of the airways. Over time, these inflammatory exacerbations lead to tissue remodeling and eventually to structural changes that chronically decrease the size of the airways. “Our goal is to understand the genesis of this process. We want to know how and why inflammatory cells enter the airways,” Dr. McIntyre comments. Understanding such early changes will provide tools and guidance for alleviating the symptoms of asthma, and perhaps for a means of preventing it altogether. A major difficulty for researchers studying asthma is that in humans the disease is well established before any symptoms appear. Nonetheless, scientists at this center have been able to explore in the laboratory a genetic defect in certain people that leads to an increased incidence of severe asthma. These studies have allowed them to begin unraveling the genetic basis of the disease. In 1998, they found that individuals who lack an enzyme called PAF acetylhydrolase, which stops the activity of an inflammation-inducing agent called PAF (platelet-activating factor), are missing the enzyme due to a very specific single mutation in the gene that codes for it, a change that leads to a loss of the enzyme’s activity. A person who lacks PAF-acetylhydrolase is at a small but detectable increased risk of developing severe asthma. During the past year, the researchers have identified a second mutation in humans that modifies the effect of the PAF-acetylhydrolase gene mutation, further increasing the incidence of asthma. This observation is important because it describes a common but “silent” mutation that may be present in a large number of people and thus have significant impli-

cations regarding who may be at risk for asthma. Another milestone in the past year involves defining, at a molecular level, the changes in inflammatory cells that occur in response to their environment. This type of signaling from the outside to the inside of the cell has been shown to induce a new receptor in inflammatory cells that makes them more sensitive to chemicals that had previously been invisible to them. “Some of these chemicals mimic the inflammatory mediator PAF, while others act on an intracellular receptor, and so we now know a new way that cells become sensitive to external inflammatory signals and become activated,” Dr. McIntyre comments. This finding provides another clue to how the inflammatory process is turned on, leading to the airway inflammation that is characteristic of asthma. The genetic difference between mice that lack a specific class of inflammatory cells called mast cells is also being explored as a means of understanding the genetic basis for airway sensitivity to asthma triggers. Mast cells are thought to be the sentries that rapidly react to the presence of antigens, or foreign invaders, triggering an acute asthma episode. Significant differences involving dozens of genes were identified when genes from mice lacking mast cells, who tend not to develop asthma, were compared with genes from normal animals. In the past year, genes from mast cell–deficient mice have been studied and found to code for certain proteins that may be responsible for the loss of mast cells. This information can eventually lead to identification of genes that may be involved in asthma in humans. In other studies of mice with defective inflammatory cells, a gene that controls the processing of certain destructive enzymes has been defined. Currently, the investigators are attempting to “knock out” or remove this gene to determine whether mice who lack it are less susceptible to developing asthmatic lung complications. “Once we are able to create mice that lack this enzyme and that pass this trait on to the next generation, we hope to find that they develop less severe symptoms of asthma, especially when exposed to airborne triggers,” according to Dr. McIntyre. A mutation in humans has been found with this exact condition, but it is so rare that it cannot be studied, highlighting the

Appendix I 221 importance of examining asthma in a laboratory model, such as genetically engineered mice. When will the knowledge and understanding that is being acquired in this basic research pay off with clinical applications? “Science is a slow process,” says Dr. McIntyre. “It’s been a challenge for me in my role as President of the American Lung Association of Utah to explain why this is so, and why we need to support this lengthy effort. All research takes time, because systems are complicated, and with asthma that’s especially true because it’s so complex. Even a disease caused by a single genetic event is complicated, and many genes are involved in asthma, as well as many triggers. What we and the other Asthma Research Centers are working on now is the basic knowledge we have to have before we can start designing new therapies. We need to know who all the players are to be able to influence the process, and each year we are getting closer to our goal.”

NEW MEXICO 2000 ASTHMA RESEARCH CENTER The centerpiece of the Asthma Research Center at the University of New Mexico is its Pilot Project Program, designed to foster new ideas in asthma research and to bring scientists from other disciplines to the study of asthma. In the first four years of the program, scientists from many different areas of interest and perspectives have become involved, including basic researchers, clinicians, and even anthropologists. The Pilot Project Program has also succeeded in developing significant collaborative efforts between junior and senior scientists. A total of 18 research awards have been made, many to junior faculty members and promising post-doctoral research fellows. The investigations begun thanks to this funding have resulted in a number of papers published in respected scientific journals, and in additional funding from other sources. Pilot project grantees are also integrated into other research activities that target asthma, which are largely supported by a Specialized Center of Research (SCOR) grant from the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH). This synergy has created a climate in which asthma research can grow exponentially.

As one example of this process, former pilot project grantees have made important contributions to this year’s SCOR grant renewal application. “Their asthma-related research, which was initially funded by the ALA Asthma Research Center, provided key data and new insights that were important in the growth and refinement of the SCOR research program,” comments Mary F. Lipscomb, M.D., the Center’s Principal Investigator, as well as the Principal Investigator of the SCOR grant. “If our SCOR grant is renewed, certainly the ALA’s support has helped make that possible.” In addition, a number of former and current Pilot Project awardees are active in the National Institute of Environmental Health Sciences (NIEHS) Developmental Center, which is directed by Pope Mosely, M.D., who is also director of the Asthma Research Center’s Pilot Project Program. The NIEHS Center, now in its second year of funding, focuses on asthma and lung cancer among Native American populations within New Mexico. “One key reason for this center’s success is the environment created by the combined asthma research efforts of the ALA center and the SCOR grant,” Dr. Lipscomb explains. “Each entity supports the other two, and the whole is greater than the sum of the parts.” Members of all three centers meet weekly for a discussion group or journal club, which serves as a forum for new work on asthma and related fields. They also participate in “work-in-progress” sessions where fellow investigators present their work and receive feedback from colleagues who are active in different scientific disciplines, bringing new viewpoints to bear on each project. Presentations are also made by senior members of the SCOR and NIEHS centers, who report their own research progress. Of the pilot projects funded in 1999, two were designed to develop animal models for studying asthma, and both accomplished their goals. Another project succeeded in casting new light on how antibodies could be used to suppress the activity of mast cells and basophils, two types of cells that are triggered in the lungs of people with asthma and play an important role in causing the airways to narrow. “The information this investigator developed has resulted in three papers published in scientific journals, and has given the

222 The Encyclopedia of Asthma and Respiratory Disorders researcher enough preliminary data to apply for an NIH grant that would provide major funding,” Dr. Lipscomb comments. Another 1999 project studied eosinophils, cells that are significantly involved in both acute asthma episodes and the long-term chronic effects of asthma. This investigator made important observations about how eosinophils are selectively recruited into the lungs of asthmatics, findings that are contributing to a new grant proposal for a project in the asthma SCOR program. In January of 2000, new pilot project grants were awarded to four talented young scientists who are committed to careers in pulmonary diseases with a focus on asthma. One of these projects concerns the increased risk of developing asthma among infants whose mothers have asthma. The investigator hypothesizes that the antibodies in a pregnant woman that are responsible for her asthma may cross the placenta and play a role in the development of childhood asthma in the baby. Using a laboratory animal model, the role of the mother’s response to a particular allergen in the development of an allergic response in her offspring is being studied. A second project, headed by a cardiovascular and endocrine physiologist who was attracted by the rich asthma research climate at the University of New Mexico, is concerned with airway smooth muscle. This investigator has developed a new approach to determining the factors that contribute to the propensity of the smooth muscle that surrounds the airways to constrict during asthma episodes. Another project is investigating immunoglobin E (IgE), a type of antibody that can bind to inhaled allergens, and its role in enhancing the function of dendritic cells in the lungs of people who have asthma. Dendritic cells are essential components of the immune response that occurs in asthma. Their role is to present the allergen to a type of white blood cell called T-lymphocytes, which then help to orchestrate the immune system-mediated inflammation that is characteristic of asthma. It is already known that IgE plays a role in causing mast cells to release their contents in asthmatic airways and contribute to the inflammatory process, but this project proposes new ways in which IgE antibodies participate in the development of asthma episodes. The fourth pilot project is studying the role of the respiratory syncytial virus (RSV), a common

childhood infection, in the subsequent development of asthma. “We know children infected with RSV in early childhood are at increased risk for asthma, but the reason why is unclear,” Dr. Lipscomb says. “This scientist is investigating a protein from the Clara cells that line the airways, which may help us understand why children infected with RSV tend to develop asthma.” Known as Clara cell secretory protein or CCSP, it dampens inflammatory responses in the lungs by decreasing inappropriate and excessive inflammation in lung tissue. “Asthmatics may not make enough CCSP when they need it,” speculates Dr. Lipscomb. “If a child who is genetically predisposed to asthma is infected with RSV, and is unable to make enough CCSP, the result would be prolonged inflammation, and that could set the stage for developing asthma.” This study, using genetically manipulated laboratory animals, may provide important insight into the relationship between CCSP levels, RSV infection, and asthma. Eventually, the information developed in studies like this could lead to new treatments for asthma. Much has been accomplished by the Asthma Research Centers during the past four years, and much work still lies ahead. This ambitious enterprise has been fruitful in producing new and valuable information, and in encouraging more scientists to become involved in asthma research. Their long-term efforts will pay off many times over in alleviating suffering, reducing health care costs, and improving the productivity of the national economy. The painstaking work of basic research, however, requires time, patience and perseverance as one building block after another is cemented into place. Only through the commitment of programs like the Asthma Research Centers can these scientists reach their final goal: a better life for the millions of people who are adversely affected by asthma. For more information about the American Lung Association’s research program, contact Ray M. Vento, Assistant Vice President, Scientific Programs Administration, American Lung Association, 1740 Broadway, New York, NY 10019-4374. Reprinted by permission of the American Lung Association

APPENDIX II THE ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY LUNG ASSOCIATION TERRITORY EXECUTIVE SUMMARY The Best Practices and Program Services Division has compiled this issue of The Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory to provide lung associations with lung disease morbidity data pertinent to the areas they serve. This document depicts prevalence estimates of chronic conditions and the incidence of lung cancer at the state, county, constituent, and affiliate levels. The data are based upon the 1998 National Health Interview Survey and the 1997 Surveillance, Epidemiology, and End Results (SEER) program. In previous years this document included incidence estimates of acute lung diseases such as the common cold, acute bronchitis, pneumonia, and influenza. However, the National Health Interview Survey (NHIS), a scientifically designed population sample survey that serves as the principal source of magnitude data on chronic and acute lung disease, redesigned its questionnaire in 1997. Originally, questions on these acute lung diseases were included in the survey, however the National Center for Health Statistics staff eliminated acute lung disease because of difficulties in compiling accurate data. Therefore, the most recent year of data for acute lung diseases is for 1996. The latest acute lung disease estimates by lung association are in the April 2000 Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory. In addition, the NHIS questions on chronic lung disease questions were revised as well. All questions now ask for a medical diagnosis instead of self-report. This change in definition of disease has

made it impossible to compare the estimates in this year’s estimates with those of the past. Preceding the data is a statistical methodology section, which defines the procedures used to compute local lung disease prevalence and incidence estimates. This section also delineates the limitations of these data. Please note that these numbers reflect the estimated prevalence and incidence of lung disease within each lung association area, and not the actual number. That is, the estimate is derived from national data and adjusted for the age-specific population of each area. Many other factors may affect actual prevalence. When releasing this information to the public or press, please be careful to ensure that the nature and derivation of these estimates are understood.

April 2001 STATISTICAL METHODOLOGY Introduction Presently, state and county-specific measurements of the number of persons with chronic lung disease are not available. In order to assess the magnitude of lung disease at the state and county levels, we have utilized a synthetic estimation technique originally developed by the U.S. Bureau of the Census. This method uses age-specific national estimates of diagnosed lung disease to project the prevalence and incidence of lung disease within the counties served by lung association constituents and affiliates. Table 1 summarizes these prevalence and incidence estimates.

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224 The Encyclopedia of Asthma and Respiratory Disorders Prevalence Estimates: Chronic Bronchitis, Emphysema, and Asthma With the revision of the National Health Interview Survey (NHIS) questionnaire, chronic disease estimates have changed dramatically. Questions now ask for a medical diagnosis instead of self-report, making it impossible to compare this year’s estimates with those of the past. Revisions to the chronic obstructive pulmonary disease (COPD) questions include a change in prevalence time frames (stopping the use of overall COPD estimates) and the elimination of childhood estimates. Prior to 1997 survey respondents were asked “Have you or someone in your family had chronic bronchitis or emphysema in the past year?” After 1997, the chronic bronchitis question states, “Have you been diagnosed with chronic bronchitis by a health professional in the past year?” while the emphysema question asks respondents, “Have you been diagnosed with emphysema by a health professional during your lifetime?” In addition to the change seen with chronic bronchitis and emphysema, questions asked on asthma were revised. Previously, survey respondents were asked “Have you or someone in your family had asthma?” After 1997, this question was replaced with two new asthma questions. The first measures lifetime prevalence (as in the case of emphysema): “Have you been diagnosed with asthma by a health professional within your lifetime?” The second measures point prevalence (as in the case of chronic bronchitis): “If diagnosed with asthma in your lifetime, have you had an asthma attack or episode in the past year?” For the purposes of this publication we will use data from the latter question to obtain county estimates. Information on pediatric asthma is still collected. In 1998, the NHIS estimated that 8.9 million Americans reported a physician diagnosis of chronic bronchitis within the year and that an estimated 3 million Americans had been diagnosed with emphysema sometime in their life. The NHIS estimates that 10.6 million diagnosed people (3.8 million under 18) had an asthma attack in 1998. Previous results from the NHIS showed that an estimated 16 million people (14.2 million chronic bronchitis and 1.8 million emphysema) had self-

reported COPD in the past year. During that same year an estimated 14.6 million people (4.4 million children under age 18) said they had asthma. Local area prevalence of chronic bronchitis, emphysema, and asthma are estimated by applying age-specific national prevalence rates from the 1998 NHIS to age-specific county-level resident populations. Prevalence estimates for chronic bronchitis, emphysema, and adult asthma are calculated for those 18 to 44, 45 to 64, and 65+. The prevalence estimate for pediatric asthma is calculated for those under age 18. The procedure for determining local prevalence estimates is as follows. First, the age-specific countylevel resident population for July 1, 1998, is obtained from the U.S. Bureau of the Census website. The age-specific national prevalence rate for each chronic lung disease is applied to the age-specific county-level population of each county. Thereafter, the age-specific prevalence estimates for each county within a lung association area are summed to determine its overall prevalence. An individual respondent to the NHIS can report the presence of more than one chronic lung disease, i.e., chronic bronchitis and emphysema. For this reason and the fact that prevalence estimates are over different time frames (chronic bronchitis prevalence over a year vs. emphysema over a lifetime), adding these estimates to calculate COPD prevalence should not be performed, as it would overestimate the prevalence in your community. Incidence Estimates: Lung Cancer The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute derives nationwide lung cancer incidence estimates. The SEER program was initiated in 1973 to collect cancer incidence data and includes nine population-based cancer registries, covering about 10 percent of the U.S. population. Unlike the estimates for chronic lung diseases, lung cancer estimates are for the year 1997. Data for 1998 has not been released by the time of printing. Based on the lack of current information on ageand state-specific national incidence rates derived from SEER (the most recent year for which these data are available is 1989) the following modified methodology to obtain county estimates was em-

Appendix II 225 ployed. The Data Evaluation and Publication Committee, a standing committee of the North American Association of the Central Cancer Registries (NAACR), recommended dividing the national incidence rate by the national mortality rate published by the SEER program to estimate countylevel lung cancer incidence (in 1997 - 54.4/41.7 = 1.30). This number was then applied to county-level mortality data derived from CDC Wonder to generate county-level lung cancer incidence estimates. The rationale behind this methodology stems from measured lung cancer survival rates, which relates closely to the mortality rate of lung cancer. Limitations of Estimates The National Health Interview Survey (NHIS), the principal source of magnitude data on chronic and acute lung disease, redesigned its questionnaire in 1997. Unfortunately, acute lung disease questions were excluded and chronic lung disease questions were edited, obliterating all trends. This has made it impossible to compare this year’s estimates with those in past publications. Since the statistics presented by the NHIS are based on a sample, they will differ (due to random sampling variability) from figures that would be derived from a complete census, or case registry of people in the United States with these diseases. The results are also subject to reporting, nonresponse, and processing errors. These types of errors are kept to a minimum by methods built into the survey.

Additionally, a major limitation of the survey is that the information represents physician-diagnosed data so estimates are certainly low. However, the NHIS is the best available source that depicts the magnitude of acute and chronic lung disease on the national level. Local estimates of chronic and acute lung diseases are scaled in direct proportion to the base population of the county and its age distribution. No adjustments are made for other factors that may affect local prevalence (e.g., race, socioeconomic status, income, local prevalence of cigarette smokers, or occupational exposures) since the health surveys that obtain such data are rarely conducted on the county level.

REFERENCES 1. Irwin, R. Guide to Local Area Populations U.S. Bureau of the Census Technical Paper Number 39 (1972). 2. National Center for Health Statistics. Raw Data from the National Health Interview Survey, U.S., 1998 (Analysis by the American Lung Association Best Practices Division, Using SPSS and SUDAAN software). 3. Population Estimates Branch, U.S. Bureau of the Census. County Resident Population Estimates, by Age: July 1, 1998. 4. Population Estimates Branch, U.S. Bureau of the Census. Estimates of Population of Minor Civil Divisions: Annual Time Series, July 1, 1998. 5. National Institutes of Health, National Cancer Institute (NCI). SEER Cancer Statistics Review, 1973–1997. 6. CDC Wonder. Unpublished Mortality Data, 1997.

TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 CHRONIC LUNG DISEASES Association ALABAMA CONSTITUENT: ALA OF ALABAMA Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

4,313,456

3,713

48,723

147,797

112,064

56,564

42,193 132,857 26,936 18,987 46,292 11,325 21,658 117,083

40 121 26 13 48 3 16 116

457 1,503 297 206 524 122 232 1,339

1,386 4,559 901 626 1,589 370 705 4,062

1,051 3,457 683 474 1,205 281 534 3,080

623 1,735 379 278 603 169 328 1,477

226 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF ALABAMA (cont.) Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De KalbCounty Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint ClairCounty Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County

Population 36,706 21,827 36,926 15,829 28,531 13,966 14,283 42,222 52,924 13,863 11,637 37,461 13,626 74,944 48,916 46,803 58,274 61,985 36,732 103,923 18,096 29,684 24,875 9,843 16,750 15,798 85,613 51,339 660,039 16,012 84,206 33,447 100,481 62,247 12,984 23,207 278,008 23,375 30,857 80,192 398,886 24,005 217,392 109,218 12,682 21,019 28,648 20,025 50,368 62,018 140,853 15,765 77,025 40,360 160,761

Lung

Cancer1 43 21 30 20 13 17 9 43 55 9 14 49 17 69 35 49 35 46 35 133 14 26 25 13 13 20 75 66 560 16 78 17 43 17 3 21 187 23 36 82 426 17 170 77 14 20 27 14 51 55 68 12 72 18 129

Emphysema 415 254 411 173 308 160 161 482 614 153 133 427 153 854 541 496 662 697 415 1,196 205 340 284 103 176 178 945 584 7,591 183 978 375 1,184 712 131 263 3,212 251 355 921 4,375 256 2,423 1,237 133 230 326 227 567 694 1,560 167 853 459 1,861

Chronic Bronchitis 1,258 770 1,248 524 934 486 488 1,461 1,862 464 405 1,296 463 2,590 1,641 1,504 2,009 2,115 1,259 3,627 623 1,032 862 311 534 541 2,867 1,772 23,026 555 2,967 1,138 3,592 2,159 397 799 9,742 761 1,078 2,795 13,269 778 7,350 3,752 405 698 987 687 1,721 2,105 4,731 507 2,588 1,391 5,644

Adult Asthma Pediatric Asthma 954 584 946 397 708 368 370 1,108 1,412 352 307 982 351 1,964 1,244 1,140 1,523 1,604 955 2,750 472 782 654 236 405 410 2,174 1,343 17,460 421 2,250 862 2,723 1,637 301 606 7,387 577 817 2,119 10,061 590 5,573 2,845 307 530 749 521 1,305 1,596 3,587 384 1,963 1,055 4,280

481 261 505 229 425 175 188 536 637 195 146 477 183 957 682 730 750 823 481 1,286 234 372 315 160 267 208 1,200 658 8,176 203 1,008 449 1,144 786 226 300 3,393 353 381 997 5,695 367 2,966 1,421 201 301 369 261 666 836 1,958 246 1,069 519 1,949

Appendix II 227 CHRONIC LUNG DISEASES Association Walker County Washington County Wilcox County Winston County ALASKA CONSTITUENT: ALA OF ALASKA Aleutians East Borough Aleutians West Census Area Anchorage Borough Bethel Census Area Bristol Bay Borough Denali Borough Dillingham Census Area Fairbanks North Star Borough Haines Borough Juneau Borough Kenai Peninsula Borough Ketchikan Gateway Borough Kodiak Island Borough Lake and Peninsula Borough Matanuska-Susitna Borough Nome Census Area North Slope Borough Northwest Arctic Borough Prince of Wales-Outer Ketchikan Ce Sitka Borough Skagway-Hoonah-Angoon Census Area Southeast Fairbanks Census Area Valdez-Cordova Census Area Wade Hampton Census Area Wrangell-Petersburg Census Area Yakutat Borough Yukon-Koyukuk Census Area ARIZONA/NEW MEXICO CONSTITUENT: ALA OF ARIZONA/ NEW MEXICO ARIZONA Apache County Cochise County Coconino County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

71,006 17,663 13,451 24,130

66 17 16 32

808 191 137 278

2,452 579 415 843

1,859 439 314 639

909 262 230 298

615,205

251

6,324

19,185

14,547

10,281

2,221

3,941 255,618 16,005 1,090 1,938

2 104 7 0 1

48 2,734 137 10 22

146 8,294 417 32 66

111 6,289 316 24 50

39 3,894 363 21 26

4,488

120

84,253 2,321 30,143 48,321

34 1 13 20

869 25 321 496

2,636 77 973 1,505

1,999 58 738 1,141

1,398 34 465 810

14,228 14,479

6 6

151 146

457 444

347 337

222 250

1,736

55,793 9,004 7,017

22 4 3

547 79 62

1,659 239 188

1,258 181 142

1,027 200 154

6,764

162

123

170

6,863 8,305

3 4

67 86

205 261

155 198

126 136

3,655

108

5,984

176

133

112

10,256

109

329

250

160

6,868

160

121

178

6,813 790

3 0

71 8

214 24

162 19

112 13

6,311

171

130

135

6,400,812

4,053

69,149

209,750

159,042

95,094

4,667,277 68,734 112,404 114,087

3,137 9 91 29

50,641 611 1,204 1,169

153,609 1,855 3,652 3,545

116,475 1,406 2,769 2,688

68,563 1,485 1,707 1,921

228 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

ALA OF ARIZONA/ NEW MEXICO (cont.) Gila County Graham County Greenlee County La Paz County Maricopa County Mohave County Navajo County Pima County Pinal County Santa Cruz County Yavapai County Yuma County

48,839 31,711 9,323 14,830 2,783,779 130,647 96,838 790,333 146,947 38,155 148,748 131,902

52 14 4 N/A 1,772 212 34 529 117 12 152 110

538 314 90 168 30,306 1,517 902 8,788 1,550 370 1,741 1,373

1,632 952 274 510 91,929 4,601 2,735 26,656 4,700 1,123 5,281 4,164

1,237 722 208 387 69,705 3,489 2,074 20,212 3,564 852 4,004 3,158

689 573 175 192 40,534 1,568 1,950 10,858 2,317 715 1,735 2,144

NEW MEXICO Bernalillo County Catron County Chaves County Cibola County Colfax County Curry County DeBaca County Dona Ana County Eddy County Grant County Guadalupe County Harding County Hidalgo County Lea County Lincoln County Los Alamos County Luna County McKinley County Mora County Otero County Quay County Rio Arriba County Roosevelt County Sandoval County San Juan County San Miguel County Santa Fe County Sierra County Socorro County Taos County Torrance County Union County Valencia County

1,733,535 524,686 2,812 62,618 26,506 13,586 44,873 2,362 168,967 53,446 31,628 4,041 904 6,174 56,442 16,432 18,273 23,985 67,332 4,830 54,315 10,010 37,839 17,824 88,037 106,169 28,714 122,826 10,988 16,343 26,759 16,021 3,986 63,807

916 272 0 49 N/A 12 34 3 86 43 22 1 3 4 55 17 6 13 13 3 29 14 14 14 29 38 12 48 16 14 13 4 1 34

18,508 5,866 32 655 273 147 469 27 1,775 562 337 43 10 63 575 187 209 253 626 52 575 111 387 192 904 1,031 302 1,378 132 172 289 166 44 664

56,141 17,795 96 1,988 828 447 1,424 81 5,385 1,705 1,023 130 30 190 1,744 566 634 767 1,898 157 1,745 337 1,173 583 2,742 3,127 916 4,179 402 522 877 503 132 2,015

42,567 13,493 73 1,507 628 339 1,080 61 4,083 1,293 776 99 23 144 1,322 429 480 582 1,439 119 1,323 255 889 442 2,079 2,371 694 3,169 304 396 665 382 100 1,528

26,531 7,093 37 1,005 441 200 721 31 2,688 848 485 63 12 106 962 212 231 378 1,360 73 847 138 640 266 1,475 1,989 456 1,645 115 258 398 263 58 1,037

2,538,202

2,597

28,166

85,425

64,771

35,088

20,657 24,337 36,319

23 35 65

227 264 439

687 801 1,330

521 607 1,009

295 358 376

ARKANSAS CONSTITUENT: ALA OF ARKANSAS Arkansas County Ashley County Baxter County

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Appendix II 229 CHRONIC LUNG DISEASES Association Benton County Boone County Bradley County Calhoun County Carroll County Chicot County Clark County Clay County Cleburne County Cleveland County Columbia County Conway County Craighead County Crawford County Crittenden County Cross County Dallas County Desha County Drew County Faulkner County Franklin County Fulton County Garland County Grant County Greene County Hempstead County Hot Spring County Howard County Independence County Izard County Jackson County Jefferson County Johnson County Lafayette County Lawrence County Lee County Lincoln County Little River County Logan County Lonoke County Madison County Marion County Miller County Mississippi County Monroe County Montgomery County Nevada County Newton County Ouachita County Perry County Phillips County Pike County Poinsett County Polk County Pope County Prairie County Pulaski County Randolph County St. Francis County

Population 133,875 31,797 11,408 5,684 22,438 15,021 21,586 17,122 22,890 8,421 25,109 19,828 77,199 50,267 49,794 19,414 9,051 15,075 17,475 78,238 16,825 10,946 83,661 15,843 36,010 22,035 28,874 13,682 32,908 13,108 17,720 81,588 21,456 8,942 17,207 12,912 14,326 13,154 21,099 50,004 13,242 14,860 39,526 50,515 10,125 8,648 9,981 8,163 27,779 9,629 27,302 10,546 24,634 19,653 52,041 9,344 348,813 17,788 28,127

Lung Cancer1 114 35 10 9 20 20 22 34 20 13 23 20 65 36 47 30 9 12 17 53 10 12 124 14 35 26 31 22 32 18 20 81 25 12 30 14 8 14 25 39 12 23 31 57 12 6 20 12 34 5 35 16 36 27 49 5 274 21 43

Emphysema 1,497 360 127 63 255 158 251 199 271 94 281 221 873 535 515 204 101 157 190 869 185 127 991 175 405 240 322 149 366 154 202 890 241 98 195 136 164 144 232 530 145 174 427 522 108 100 109 89 309 108 271 117 272 218 574 105 3,882 200 286

Chronic Bronchitis 4,542 1,092 386 190 772 478 762 603 821 285 852 669 2,647 1,623 1,562 620 306 475 575 2,635 560 386 3,006 530 1,227 728 978 452 1,109 468 612 2,699 732 297 593 414 499 437 703 1,608 441 527 1,294 1,583 327 304 331 269 939 327 823 356 825 663 1,741 318 11,776 606 866

Adult Asthma Pediatric Asthma 3,444 828 292 144 586 362 577 457 623 216 646 507 2,007 1,231 1,184 470 232 360 436 1,998 425 293 2,279 402 931 552 742 343 841 355 464 2,047 555 225 449 314 378 331 533 1,219 335 400 981 1,200 248 231 251 204 712 248 624 270 625 502 1,320 241 8,929 460 657

1,808 414 156 80 290 240 257 206 257 115 339 272 1,010 775 821 307 124 246 257 1,079 240 130 934 223 480 320 392 199 453 149 227 1,182 285 128 222 203 179 189 300 779 188 174 589 835 156 104 144 119 380 130 490 145 346 270 732 125 4,779 237 483

230 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF ARKANSAS (cont.) Saline County Scott County Searcy County Sebastian County Sevier County Sharp County Stone County Union County Van Buren County Washington County White County Woodruff County Yell County CALIFORNIA CONSTITUENT: ALA OF CALIFORNIA Alameda County Alpine County Amador County Butte County Calaveras County Colusa County Contra Costa County Del Norte County El Dorado County Fresno County Glenn County Humboldt County Imperial County Inyo County Kern County Kings County Lake County Lassen County Los Angeles County Madera County Marin County Mariposa County Mendocino County Merced County Modoc County Mono County Monterey County Napa County Nevada County Orange County Placer County Plumas County Riverside County Sacramento County San Benito County San Bernardino County San Diego County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

77,156 10,585 7,735 105,898 14,608 16,904 11,092 45,228 15,533 144,989 64,629 8,837 18,987

72 12 6 90 29 17 17 55 25 114 77 12 29

847 119 88 1,171 161 197 128 496 182 1,630 727 95 212

2,568 360 268 3,553 487 597 387 1,505 552 4,945 2,205 288 643

1,947 273 203 2,694 369 453 293 1,141 418 3,749 1,672 218 488

1,100 142 98 1,477 207 200 137 646 181 1,928 859 133 258

32,682,794

17,963

356,489

1,081,351

819,926

473,486

1,397,050 1,192 33,415 194,347 39,642 18,596 917,970 27,006 158,322 755,051 26,176 122,163 143,735 18,071 631,615 118,667 55,076 33,281 9,223,807 114,523 236,377 15,786 83,754 197,261 9,338 10,307 366,631 119,540 91,114 2,723,782 229,216 20,362 1,480,708 1,166,699 48,984 1,635,967 2,766,123

762 3 40 212 46 8 559 36 121 399 20 107 74 20 356 60 83 14 4,324 57 169 16 82 108 9 5 157 120 72 1,330 156 23 932 809 18 800 1,565

15,763 13 402 2,178 445 188 10,246 294 1,733 7,611 266 1,348 1,436 205 6,405 1,223 617 384 100,540 1,201 2,869 182 904 1,892 101 115 3,897 1,360 1,030 30,324 2,511 227 15,511 12,702 494 16,562 30,697

47,816 41 1,219 6,606 1,350 571 31,078 892 5,258 23,086 808 4,087 4,356 621 19,430 3,709 1,871 1,166 304,970 3,642 8,704 553 2,743 5,740 307 350 11,821 4,124 3,123 91,984 7,618 687 47,050 38,529 1,497 50,238 93,116

36,256 31 924 5,009 1,023 433 23,565 677 3,987 17,505 613 3,099 3,303 471 14,732 2,812 1,419 884 231,241 2,762 6,600 419 2,080 4,352 233 265 8,963 3,127 2,368 69,746 5,776 521 35,676 29,214 1,135 38,092 70,604

18,381 16 352 2,611 530 321 12,475 393 2,271 13,151 447 1,717 2,548 234 10,864 1,973 741 406 133,874 1,830 2,394 193 1,247 3,776 138 139 5,673 1,534 1,193 37,285 3,281 279 23,716 16,987 854 28,241 38,212

Appendix II 231 CHRONIC LUNG DISEASES Lung Cancer1

Association

Population

San Francisco County San Joaquin County San Luis Obispo County San Mateo County Santa Barbara County Santa Clara County Santa Cruz County Shasta County Sierra County Siskiyou County Solano County Sonoma County Stanislaus County Sutter County Tehama County Trinity County Tulare County Tuolumne County Ventura County Yolo County Yuba County

745,756 549,684 234,074 701,080 389,472 1,641,848 243,200 164,156 3,376 44,024 376,748 433,777 426,872 77,069 54,016 13,043 354,527 53,029 732,143 153,293 59,953

502 333 152 398 218 706 114 153 3 42 265 341 256 44 42 14 185 51 329 91 52

9,289 5,670 2,700 8,135 4,396 18,506 2,715 1,768 37 481 3,989 4,828 4,333 814 579 144 3,449 616 7,861 1,703 600

28,175 17,198 8,190 24,675 13,335 56,134 8,235 5,363 112 1,460 12,101 14,645 13,144 2,469 1,755 437 10,461 1,868 23,846 5,167 1,820

21,364 13,040 6,210 18,710 10,111 42,563 6,244 4,066 85 1,107 9,176 11,105 9,967 1,872 1,331 331 7,932 1,416 18,081 3,918 1,380

6,718 9,118 2,872 8,431 5,119 21,672 3,303 2,458 48 634 5,883 5,942 7,327 1,211 820 182 6,617 636 11,048 2,110 1,060

AFFILIATES: ALA OF CENTRAL CA Fresno County Kings County Madera County Mariposa County Merced County Tulare County

755,051 118,667 114,523 15,786 197,261 354,527

399 60 57 16 108 185

7,611 1,223 1,201 182 1,892 3,449

23,086 3,709 3,642 553 5,740 10,461

17,505 2,812 2,762 419 4,352 7,932

13,151 1,973 1,830 193 3,776 6,617

ALA OF CENTRAL COAST Monterey County San Luis Obispo County Santa Cruz County

366,631 234,074 243,200

157 152 114

3,897 2,700 2,715

11,821 8,190 8,235

8,963 6,210 6,244

5,673 2,872 3,303

ALA OF EAST BAY Alameda County Contra Costa County Solano County

1,397,050 917,970 376,748

762 559 265

15,763 10,246 3,989

47,816 31,078 12,101

36,256 23,565 9,176

18,381 12,475 5,883

ALA OF INLAND COUNTIES Inyo County Mono County Riverside County San Bernardino County

18,071 10,307 1,480,708 1,635,967

20 5 932 800

205 115 15,511 16,562

621 350 47,050 50,238

471 265 35,676 38,092

234 139 23,716 28,241

ALA OF LOS ANGELES COUNTY Los Angeles County Orange County

9,223,807 2,723,782

4,324 1,330

100,540 30,324

304,970 91,984

231,241 69,746

133,874 37,285

1,192 33,415 18,596 158,322

3 40 8 121

13 402 188 1,733

41 1,219 571 5,258

31 924 433 3,987

16 352 321 2,271

ALA OF SACRAMENTOEMIGRANT TRAILS Alpine County Amador County Colusa County El Dorado County

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

232 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

ALA OF SACRAMENTOEMIGRANT TRAILS (cont.) Nevada County Placer County Sacramento County Sierra County Yolo County

91,114 229,216 1,166,699 3,376 153,293

72 156 809 3 91

1,030 2,511 12,702 37 1,703

3,123 7,618 38,529 112 5,167

2,368 5,776 29,214 85 3,918

1,193 3,281 16,987 48 2,110

ALA OF SAN DIEGO & IMPERIAL COUNTIES Imperial County San Diego County

143,735 2,766,123

74 1,565

1,436 30,697

4,356 93,116

3,303 70,604

2,548 38,212

ALA OF SAN FRANCISCO & SAN MATEO COUNTIES San Francisco County San Mateo County

745,756 701,080

502 398

9,289 8,135

28,175 24,675

21,364 18,710

6,718 8,431

ALA OF SANTA BARBARA & VENTURA COUNTIES Santa Barbara County Ventura County

389,472 732,143

218 329

4,396 7,861

13,335 23,846

10,111 18,081

5,119 11,048

48,984 1,641,848

18 706

494 18,506

1,497 56,134

1,135 42,563

854 21,672

3,968,967

1,722

43,851

133,011

100,857

55,524

323,427 14,543 472,579 9,154 4,327 5,798 266,671 15,174 2,322 9,017 7,983 3,642 4,313 3,438 26,633 498,402 1,821 141,449 33,709 18,612 490,044 44,225 39,377

135 5 165 5 6 4 69 10 0 5 4 0 5 0 14 290 3 36 3 3 192 30 13

3,423 152 5,209 97 50 64 3,074 177 24 101 79 39 50 38 302 5,725 20 1,469 370 193 5,327 522 427

10,385 460 15,800 295 150 196 9,323 537 73 306 238 117 152 115 915 17,365 61 4,457 1,124 585 16,159 1,583 1,294

7,874 349 11,980 223 114 148 7,069 408 55 232 181 89 115 88 694 13,167 46 3,379 852 444 12,252 1,201 981

5,055 235 6,654 142 54 80 3,279 178 38 122 146 56 52 48 347 6,200 26 2,310 479 305 7,163 501 581

ALA OF SANTA CLARASAN BENITO San Benito County Santa Clara County COLORADO CONSTITUENT: ALA OF COLORADO Adams County Alamosa County Arapahoe County Archuleta County Baca County Bent County Boulder County Chaffee County Cheyenne County Clear Creek County Conejos County Costilla County Crowley County Custer County Delta County Denver County Dolores County Douglas County Eagle County Elbert County El Paso County Fremont County Garfield County

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Appendix II 233 CHRONIC LUNG DISEASES Association Gilpin County Grand County Gunnison County Hinsdale County Huerfano County Jackson County Jefferson County Kiowa County Kit Carson County Lake County La Plata County Larimer County Las Animas County Lincoln County Logan County Mesa County Mineral County Moffat County Montezuma County Montrose County Morgan County Otero County Ouray County Park County Phillips County Pitkin County Prowers County Pueblo County Rio Blanco County Rio Grande County Routt County Saguache County San Juan County San Miguel County Sedgwick County Summit County Teller County Washington County Weld County Yuma County CONNECTICUT CONSTITUENT: ALA OF CONNECTICUT Fairfield County Hartford County Litchfield County Middlesex County New Haven County New London County Tolland County Windham County DELAWARE CONSTITUENT: ALA OF DELAWARE Kent County New Castle County Sussex County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

4,184 10,099 12,425 736 6,789 1,521 500,802 1,647 7,312 6,351 40,519 231,104 14,547 5,686 17,897 112,899 703 12,564 22,365 30,790 25,088 20,665 3,318 13,403 4,301 13,345 13,704 134,919 6,263 11,473 17,490 6,050 526 5,448 2,553 18,781 20,553 4,550 159,501 9,436

1 0 3 0 6 1 220 1 3 4 20 91 10 1 8 90 1 4 18 16 9 14 3 3 4 0 13 81 3 8 6 3 0 1 4 1 3 3 64 4

47 113 146 9 75 17 5,596 18 78 68 451 2,581 161 66 199 1,246 9 129 235 337 262 219 38 147 48 167 141 1,483 67 119 196 61 5 63 29 222 221 51 1,698 101

144 343 444 28 227 52 16,975 53 237 206 1,367 7,829 488 202 603 3,780 26 392 712 1,022 793 664 115 446 145 508 428 4,497 203 362 593 184 17 191 89 674 670 153 5,152 307

109 260 337 21 172 40 12,871 40 179 156 1,037 5,937 370 153 457 2,866 20 297 540 775 602 504 87 338 110 385 325 3,410 154 275 450 139 13 145 68 511 508 116 3,906 233

54 136 141 7 95 20 6,782 25 112 96 556 3,135 203 67 247 1,583 7 210 357 443 406 322 42 191 59 116 228 1,916 96 187 237 107 9 66 31 211 310 63 2,457 143

3,272,563

2,437

36,976

112,157

85,042

42,883

837,476 827,706 181,311 150,015 792,879 246,959 131,360 104,857

594 646 131 117 593 199 84 73

9,515 9,382 2,032 1,714 8,961 2,757 1,486 1,129

28,862 28,458 6,164 5,198 27,182 8,362 4,506 3,425

21,884 21,578 4,674 3,942 20,610 6,340 3,417 2,597

10,787 10,740 2,434 1,899 10,380 3,355 1,717 1,571

744,066

634

8,461

25,666

19,460

9,557

124,311 482,562 137,193

92 365 177

1,365 5,515 1,581

4,140 16,729 4,797

3,139 12,684 3,637

1,769 6,101 1,687

234 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association DISTRICT OF COLUMBIA CONSTITUENT: ALA OF THE DISTRICT OF COLUMBIA District of Columbia FLORIDA CONSTITUENT: ALA OF FLORIDA Alachua County Baker County Bay County Bradford County Brevard County Broward County Calhoun County Charlotte County Citrus County Clay County Collier County Columbia County DeSoto County Dixie County Duval County Escambia County Flagler County Franklin County Gadsden County Gilchrist County Glades County Gulf County Hamilton County Hardee County Hendry County Hernando County Highlands County Hillsborough County Holmes County Indian River County Jackson County Jefferson County Lafayette County Lake County Lee County Leon County Levy County Liberty County Madison County Manatee County Marion County Martin County Miami-Dade County Monroe County Nassau County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

521,426

452

6,340

19,232

14,582

5,244

521,426

452

6,340

19,232

14,582

5,244

14,908,230

15,048

170,709

517,823

392,634

187,314

198,221 21,049 146,730 24,836 464,818 1,507,770 12,409 134,763 113,640 137,581 199,775 52,914 24,708 12,869 734,664 284,098 47,043 10,100 44,007 13,819 8,586 13,490 12,680 21,041 29,392 126,590 74,918 925,413 18,623 99,112 44,498 13,196 6,318 202,115 392,909 215,116 31,685 6,732 17,740 239,629 241,269 115,949 2,150,877 80,853 55,405

148 17 157 32 580 1,381 17 229 220 95 202 64 26 18 554 292 72 20 30 13 14 23 10 18 20 214 138 774 22 157 36 16 6 277 525 98 49 14 17 304 316 181 1,208 81 49

2,271 214 1,610 279 5,393 17,450 135 1,683 1,385 1,440 2,362 568 277 144 7,949 3,143 571 114 459 152 98 155 134 221 297 1,531 906 10,278 206 1,186 495 142 71 2,392 4,661 2,439 355 76 191 2,826 2,794 1,416 24,221 989 600

6,888 650 4,883 848 16,360 52,932 411 5,104 4,202 4,369 7,164 1,722 839 436 24,110 9,534 1,733 347 1,393 461 298 469 408 671 901 4,645 2,749 31,177 624 3,597 1,500 430 217 7,256 14,139 7,398 1,077 231 579 8,573 8,476 4,294 73,471 2,999 1,821

5,223 493 3,703 643 12,404 40,135 311 3,870 3,186 3,313 5,432 1,306 636 330 18,282 7,229 1,314 263 1,056 350 226 356 309 509 683 3,522 2,084 23,640 473 2,727 1,138 326 164 5,502 10,721 5,609 817 175 439 6,501 6,427 3,256 55,708 2,274 1,380

2,487 359 2,092 330 5,590 18,290 180 1,200 1,130 2,207 2,248 800 333 175 10,873 3,960 475 132 711 195 108 169 198 334 510 1,301 770 12,755 261 1,065 612 199 83 2,265 4,363 2,789 425 88 267 2,719 2,919 1,145 28,469 793 817

Appendix II 235 CHRONIC LUNG DISEASES Association

Population

Lung Cancer1

Emphysema

Okaloosa County Okeechobee County Orange County Osceola County PalmBeach County Pasco County Pinellas County Polk County Putnam County St. Johns County St. Lucie County Santa Rosa County Sarasota County Seminole County Sumter County Suwannee County Taylor County Union County Volusia County Wakulla County Walton County Washington County

168,532 31,971 804,489 145,744 1,032,872 325,129 877,273 452,649 70,305 116,065 179,360 117,678 303,341 350,489 41,524 32,496 18,873 12,548 420,668 18,613 37,422 20,239

162 47 616 101 1,206 563 1,078 506 95 114 231 103 473 242 57 42 17 14 551 20 47 29

1,840 336 8,935 1,589 12,220 3,862 10,559 5,053 774 1,330 2,044 1,263 3,784 3,848 480 352 204 141 4,970 197 423 226

5,580 1,020 27,103 4,819 37,068 11,716 32,030 15,326 2,347 4,035 6,200 3,830 11,478 11,673 1,456 1,067 618 429 15,076 598 1,284 684

4,231 773 20,551 3,654 28,107 8,884 24,287 11,621 1,780 3,059 4,701 2,904 8,703 8,851 1,104 809 469 325 11,431 453 973 519

2,436 507 11,088 2,116 11,586 3,591 9,203 6,150 994 1,454 2,288 1,779 2,712 4,988 505 480 281 166 4,743 291 489 276

AFFILIATES: ALA OF CENTRAL FLORIDA Lake County Marion County Orange County Osceola County Seminole County Sumter County

202,115 241,269 804,489 145,744 350,489 41,524

277 316 616 101 242 57

2,392 2,794 8,935 1,589 3,848 480

7,256 8,476 27,103 4,819 11,673 1,456

5,502 6,427 20,551 3,654 8,851 1,104

2,265 2,919 11,088 2,116 4,988 505

ALA OF GULF COAST FLORIDA Charlotte County Citrus County Collier County DeSoto County Hardee County Hernando County Highlands County Hillsborough County Lee County Levy County Manatee County Pasco County Pinellas County Polk County Sarasota County

134,763 113,640 199,775 24,708 21,041 126,590 74,918 925,413 392,909 31,685 239,629 325,129 877,273 452,649 303,341

229 220 202 26 18 214 138 774 525 49 304 563 1,078 506 473

1,683 1,385 2,362 277 221 1,531 906 10,278 4,661 355 2,826 3,862 10,559 5,053 3,784

5,104 4,202 7,164 839 671 4,645 2,749 31,177 14,139 1,077 8,573 11,716 32,030 15,326 11,478

3,870 3,186 5,432 636 509 3,522 2,084 23,640 10,721 817 6,501 8,884 24,287 11,621 8,703

1,200 1,130 2,248 333 334 1,301 770 12,755 4,363 425 2,719 3,591 9,203 6,150 2,712

1,507,770 8,586 29,392 2,150,877 80,853

1,381 14 20 1,208 81

17,450 98 297 24,221 989

52,932 298 901 73,471 2,999

40,135 226 683 55,708 2,274

18,290 108 510 28,469 793

ALA OF SOUTH FLORIDA Broward County Glades County Hendry County Miami-Dade County Monroe County

Chronic Bronchitis

Adult Asthma Pediatric Asthma

236 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

ALA OF SOUTHEAST FLORIDA Indian River County Martin County Okeechobee County PalmBeach County St. Lucie County

99,112 115,949 31,971 1,032,872 179,360

157 181 47 1,206 231

1,186 1,416 336 12,220 2,044

3,597 4,294 1,020 37,068 6,200

2,727 3,256 773 28,107 4,701

1,065 1,145 507 11,586 2,288

7,636,522

5,091

84,156

255,274

193,563

107,578

16,547 7,158 10,364 3,627 41,883 12,821 40,438 71,937 17,471 16,317 155,946 11,157 13,528 15,914 23,395 50,554 22,825 17,822 5,002 47,322 9,099 82,904 50,709 9,433 225,297 16,408 22,748 134,352 90,516 3,493 208,997 6,649 566,060 34,230 40,229 90,854 14,988 85,118 10,655 20,693 15,057 14,898 27,021 592,870 18,120

20 12 8 1 31 10 29 48 9 21 140 8 17 17 17 22 10 12 1 18 9 51 46 12 203 3 39 56 48 3 116 3 259 27 34 58 14 42 3 30 10 5 17 290 22

177 74 109 39 484 142 435 785 182 177 1,728 124 143 167 238 578 229 198 53 493 99 911 568 98 2,495 175 256 1,452 1,074 38 2,266 70 6,369 360 429 963 160 913 115 218 169 163 285 6,771 202

536 226 330 117 1,468 430 1,319 2,381 552 537 5,241 376 434 507 723 1,753 694 602 161 1,495 299 2,764 1,723 297 7,567 531 777 4,404 3,258 114 6,873 212 19,318 1,091 1,302 2,921 486 2,769 349 661 514 493 863 20,539 613

407 171 251 89 1,113 326 1,000 1,805 419 407 3,974 285 329 384 548 1,329 527 456 122 1,133 227 2,096 1,307 225 5,738 403 589 3,339 2,470 86 5,212 161 14,648 827 987 2,215 369 2,099 265 501 389 374 654 15,574 464

253 116 165 55 510 179 608 1,041 283 240 2,165 154 212 253 399 639 402 244 77 768 134 1,176 682 154 3,132 252 301 1,995 1,005 53 3,076 106 7,513 545 617 1,416 228 1,289 158 327 200 215 428 7,511 247

GEORGIA CONSTITUENT: ALA OF GEORGIA Appling County Atkinson County Bacon County Baker County Baldwin County Banks County Barrow County Bartow County Ben Hill County Berrien County Bibb County Bleckley County Brantley County Brooks County Bryan County Bulloch County Burke County Butts County Calhoun County Camden County Candler County Carroll County Catoosa County Charlton County Chatham County Chattahoochee County Chattooga County Cherokee County Clarke County Clay County Clayton County Clinch County Cobb County Coffee County Colquitt County Columbia County Cook County Coweta County Crawford County Crisp County Dade County Dawson County Decatur County DeKalb County Dodge County

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Appendix II 237 CHRONIC LUNG DISEASES Association Dooly County Dougherty County Douglas County Early County Echols County Effingham County Elbert County Emanuel County Evans County Fannin County Fayette County Floyd County Forsyth County Franklin County Fulton County Gilmer County Glasco*ck County Glynn County Gordon County Grady County Greene County Gwinnett County Habersham County Hall County Hanco*ck County Haralson County Harris County Hart County Heard County Henry County Houston County Irwin County Jackson County Jasper County Jeff Davis County Jefferson County Jenkins County Johnson County Jones County Lamar County Lanier County Laurens County Lee County Liberty County Lincoln County Long County Lowndes County Lumpkin County McDuffie County McIntosh County Macon County Madison County Marion County Meriwether County Miller County Mitchell County Monroe County Montgomery County Morgan County

Population 10,409 95,019 89,398 12,171 2,361 36,565 19,322 21,017 9,923 18,575 88,733 85,138 86,409 19,061 737,222 18,747 2,514 67,187 41,078 21,416 13,663 522,666 31,734 119,334 9,139 24,590 22,297 21,793 10,088 104,925 105,638 9,048 37,711 10,166 12,707 17,829 8,446 8,293 22,997 14,700 6,988 43,687 22,767 59,081 8,226 8,576 85,049 19,003 21,697 10,018 13,207 24,426 6,703 23,078 6,360 21,198 19,625 7,725 15,092

Lung Cancer1 6 87 42 10 4 26 23 25 8 22 40 78 34 20 445 17 0 57 27 16 5 164 26 74 6 34 18 20 9 55 75 9 36 9 17 16 9 9 14 14 9 46 10 17 6 10 56 13 22 6 8 22 4 26 5 26 16 1 12

Emphysema 109 1,004 967 128 25 380 214 220 105 217 960 975 960 219 8,370 213 29 752 453 231 143 5,670 365 1,325 96 272 251 247 108 1,144 1,148 97 416 110 138 188 90 88 251 164 74 472 232 603 91 88 917 215 232 109 137 270 72 247 69 218 217 85 165

Chronic Bronchitis 330 3,045 2,934 388 75 1,154 648 667 319 658 2,913 2,956 2,913 666 25,390 647 88 2,282 1,373 701 433 17,199 1,109 4,020 291 825 763 750 329 3,470 3,483 294 1,263 334 418 569 274 268 762 497 224 1,431 702 1,828 277 268 2,780 651 703 330 414 820 217 749 211 661 658 259 499

Adult Asthma Pediatric Asthma 250 2,309 2,225 294 57 875 491 506 242 499 2,208 2,242 2,209 505 19,252 491 67 1,730 1,041 532 328 13,041 841 3,048 220 626 578 568 249 2,631 2,641 223 958 253 317 432 208 203 578 376 170 1,085 532 1,386 210 203 2,108 494 533 251 314 622 165 568 160 501 499 196 379

167 1,492 1,323 194 38 595 270 337 154 218 1,313 1,071 1,189 235 9,515 240 31 904 579 319 220 7,682 391 1,645 146 343 294 282 152 1,521 1,545 138 528 150 187 282 129 127 332 201 110 650 389 1,004 114 142 1,272 249 332 146 218 340 102 352 92 354 274 108 218

238 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF GEORGIA (cont.) Murray County Muscogee County Newton County Oconee County Oglethorpe County Paulding County Peach County Pickens County Pierce County Pike County Polk County Pulaski County Putnam County Quitman County Rabun County Randolph County Richmond County Rockdale County Schley County Screven County Seminole County Spalding County Stephens County Stewart County Sumter County Talbot County Taliaferro County Tattnall County Taylor County Telfair County Terrell County Thomas County Tift County Toombs County Towns County Treutlen County Troup County Turner County Twiggs County Union County Upson County Walker County Walton County Ware County Warren County Washington County Wayne County Webster County Wheeler County White County Whitfield County Wilcox County Wilkes County Wilkinson County Worth County

Population 32,714 182,414 57,862 23,707 11,437 73,888 24,475 19,733 15,763 12,667 36,280 8,412 17,561 2,488 13,380 7,954 191,374 68,278 3,953 14,451 9,762 57,603 25,358 5,410 31,288 6,977 1,917 19,039 8,228 11,537 11,142 42,891 36,787 25,822 8,477 5,966 58,574 9,188 10,116 16,506 27,061 62,690 54,629 35,414 6,070 20,055 25,360 2,200 4,900 17,485 82,042 7,361 10,606 10,863 22,446

Lung

Cancer1 26 125 38 16 9 35 23 13 12 12 43 3 18 3 14 6 161 49 3 13 9 34 25 6 23 8 0 23 8 12 18 36 31 17 6 9 60 8 5 14 17 79 34 32 5 21 29 1 5 13 58 13 12 6 20

Emphysema 352 2,006 626 255 127 781 269 223 171 139 401 93 197 28 158 84 2,111 743 42 155 107 623 291 59 332 77 21 215 89 125 118 461 393 271 107 64 634 95 107 195 304 705 593 392 66 214 272 24 52 204 908 79 118 116 235

Chronic Bronchitis 1,068 6,085 1,899 774 385 2,369 816 675 518 423 1,217 281 599 84 480 255 6,404 2,254 127 469 326 1,891 884 180 1,008 234 63 652 271 378 357 1,399 1,192 823 324 195 1,924 288 325 591 921 2,137 1,798 1,189 200 650 824 74 159 618 2,754 240 359 351 713

Adult Asthma Pediatric Asthma 810 4,614 1,440 587 292 1,796 619 512 393 321 923 213 454 64 364 194 4,856 1,709 97 356 247 1,434 670 137 765 177 48 494 205 286 271 1,061 904 624 245 148 1,459 218 246 448 698 1,621 1,364 901 152 493 625 56 120 469 2,088 182 272 266 541

490 2,584 856 355 158 1,159 347 260 233 179 506 119 234 34 150 124 2,688 995 61 220 138 852 315 77 485 97 28 250 121 172 175 645 562 410 72 90 865 152 158 186 362 835 802 493 88 306 385 31 75 207 1,143 110 144 168 359

Appendix II 239 CHRONIC LUNG DISEASES Association HAWAII CONSTITUENT: ALA OF HAWAII Hawaii County Honolulu County Kalawao County Kauai County Maui County IDAHO/NEVADA CONSTITUENT: ALA OF IDAHO/ NEVADA IDAHO Ada County Adams County Bannock County Bear Lake County Benewah County Bingham County Blaine County Boise County Bonner County Bonneville County Boundary County Butte County Camas County Canyon County Caribou County Cassia County Clark County Clearwater County Custer County Elmore County Franklin County Fremont County Gem County Gooding County Idaho County Jefferson County Jerome County Kootenai County Latah County Lemhi County Lewis County Lincoln County Madison County Minidoka County Nez Perce County Oneida County Owyhee County Payette County Power County Shoshone County Teton County Twin Falls County Valley County Washington County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

1,190,472

631

13,424

40,717

30,873

15,696

141,805 871,768 67 56,208 120,624

98 452 N/A 26 55

1,529 9,956 1 613 1,325

4,638 30,199 2 1,859 4,019

3,517 22,898 2 1,409 3,047

2,117 11,048 1 815 1,715

2,974,695

2,012

32,321

98,030

74,330

43,550

1,230,923 275,623 3,785 74,272 6,511 9,088 41,825 17,203 5,121 35,338 80,699 9,820 3,041 841 120,385 7,403 21,324 889 9,347 4,091 25,359 11,113 11,933 14,849 13,658 15,007 19,534 17,957 101,305 32,667 8,041 3,995 3,778 25,125 20,205 36,842 4,030 10,254 20,450 8,412 13,863 5,490 62,222 8,010 10,218

667 114 0 40 6 9 14 6 3 29 32 9 1 0 66 4 10 0 5 1 14 1 3 9 5 12 9 6 99 9 1 3 0 3 6 38 1 8 22 4 20 0 35 4 6

13,185 3,037 42 779 64 99 400 195 57 389 819 103 31 9 1,262 73 209 10 108 45 267 104 117 164 146 167 181 186 1,137 386 89 44 40 268 202 429 39 105 217 84 158 55 669 90 110

39,988 9,211 128 2,364 193 300 1,213 591 172 1,181 2,483 314 93 27 3,828 220 634 29 327 135 810 315 354 496 443 508 550 564 3,449 1,172 271 134 121 813 612 1,301 120 317 658 254 480 168 2,029 272 334

30,321 6,984 97 1,792 147 228 920 448 130 895 1,883 238 71 20 2,902 167 481 22 248 102 614 239 268 376 336 385 417 428 2,615 889 206 102 92 617 464 986 91 241 499 192 364 128 1,538 206 253

18,693 3,886 52 1,185 120 132 805 224 72 499 1,387 156 53 13 1,926 136 393 13 115 60 401 222 220 209 208 204 395 295 1,355 367 111 55 60 385 358 438 74 174 317 151 176 95 936 108 152

240 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

Lung Cancer1

Emphysema

NEVADA Churchill County Clark County Douglas County Elko County Esmeralda County Eureka County Humboldt County Lander County Lincoln County Lyon County Mineral County Nye County Pershing County Storey County Washoe County White Pine County Carson City(2)

1,743,772 23,147 1,161,259 36,815 46,021 1,150 1,990 18,083 6,972 4,178 30,131 5,332 28,657 4,834 2,951 313,008 10,081 49,163

1,345 13 910 31 14 0 1 6 3 4 30 3 42 1 5 237 5 40

19,136 241 12,764 407 444 13 21 179 66 41 320 57 327 48 33 3,503 109 563

58,042 730 38,717 1,234 1,346 39 64 544 200 124 970 172 991 146 100 10,626 330 1,709

44,009 554 29,357 935 1,021 30 49 412 151 94 735 131 751 110 76 8,057 250 1,296

24,857 377 16,479 515 873 15 31 326 137 77 468 82 365 87 39 4,220 150 616

12,069,774

8,691

133,349

404,487

306,704

168,852

5,192,396

3,689

57,647

174,862

132,587

71,647

67,324 10,057 17,287 38,748 6,882 35,477 4,903 16,897 13,270 169,835 35,800 16,516 14,479 35,674 51,960 20,950 11,118 85,896 16,737 19,885 880,996 19,780 6,950 33,536 22,125 14,068 40,456 38,712 6,627

69 14 8 16 10 26 3 17 18 98 36 18 14 30 42 16 9 42 16 13 406 27 5 20 20 13 53 43 9

749 107 201 416 83 391 56 190 148 1,980 405 186 161 393 616 239 120 1,004 186 215 9,729 221 79 352 249 156 459 441 76

2,273 326 609 1,263 251 1,187 169 576 447 6,006 1,230 564 490 1,192 1,870 726 363 3,045 565 651 29,513 669 239 1,068 755 474 1,391 1,339 230

1,724 247 461 958 190 900 128 437 339 4,554 932 428 371 904 1,418 551 276 2,309 428 494 22,378 508 181 810 572 360 1,055 1,015 175

922 154 208 583 72 498 63 225 182 2,009 466 219 197 503 577 265 166 1,007 229 296 12,339 269 91 534 294 193 525 493 83

ILLINOIS CONSTITUENTS: ALA OF METROPOLITAN CHICAGO Cook County ALA OF ILLINOIS Adams County Alexander County Bond County Boone County Brown County Bureau County Calhoun County Carroll County Cass County Champaign County Christian County Clark County Clay County Clinton County Coles County Crawford County Cumberland County DeKalb County De Witt County Douglas County DuPage County Edgar County Edwards County Effingham County Fayette County Ford County Franklin County Fulton County Gallatin County

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Appendix II 241 CHRONIC LUNG DISEASES Association Greene County Grundy County Hamilton County Hanco*ck County Hardin County Henderson County Henry County Iroquois County Jackson County Jasper County Jefferson County Jersey County Jo Daviess County Johnson County Kane County Kankakee County Kendall County Knox County Lake County La Salle County Lawrence County Lee County Livingston County Logan County McDonough County McHenry County McLean County Macon County Macoupin County Madison County Marion County Marshall County Mason County Massac County Menard County Mercer County Monroe County Montgomery County Morgan County Moultrie County Ogle County Peoria County Perry County Piatt County Pike County Pope County Pulaski County Putnam County Randolph County Richland County Rock Island County St. Clair County Saline County Sangamon County Schuyler County Scott County Shelby County Stark County Stephenson County

Population 15,735 36,748 8,616 21,153 4,932 8,621 51,542 31,274 60,851 10,635 39,040 21,515 21,502 13,546 391,686 102,318 51,793 55,606 608,348 110,193 15,325 35,973 39,641 31,892 35,480 241,046 143,366 113,675 48,753 259,185 41,932 12,895 16,833 15,528 12,525 17,622 26,640 31,440 35,412 14,455 50,522 181,505 21,261 16,430 17,278 4,777 7,286 5,804 33,675 16,782 147,920 261,792 26,184 191,487 7,569 5,616 22,686 6,315 48,868

Lung Cancer1 9 31 13 23 10 8 48 35 36 6 47 20 20 10 194 87 27 46 303 108 23 29 25 25 29 133 87 134 43 265 55 8 14 18 6 9 14 31 48 8 34 139 22 16 20 4 13 8 40 14 143 182 40 155 9 10 10 5 31

Emphysema 173 398 98 236 57 96 566 348 732 114 433 236 240 164 4,063 1,094 546 638 6,582 1,229 174 401 443 370 434 2,555 1,637 1,268 541 2,891 461 145 187 176 136 194 293 353 404 159 549 2,009 236 184 194 55 77 65 382 186 1,651 2,795 297 2,135 85 62 252 71 544

Chronic Bronchitis 526 1,206 296 715 172 292 1,717 1,056 2,219 345 1,313 716 729 497 12,325 3,320 1,655 1,936 19,964 3,727 529 1,215 1,344 1,122 1,315 7,750 4,966 3,845 1,641 8,768 1,397 440 566 535 412 589 889 1,071 1,226 482 1,664 6,094 717 558 588 166 233 196 1,159 565 5,008 8,480 900 6,476 258 188 764 214 1,651

Adult Asthma Pediatric Asthma 399 915 225 543 131 221 1,302 801 1,683 261 996 543 553 377 9,345 2,517 1,255 1,468 15,138 2,826 401 922 1,019 850 997 5,876 3,765 2,916 1,244 6,648 1,059 334 429 406 313 446 674 812 929 366 1,262 4,621 544 423 446 126 177 149 879 428 3,798 6,430 682 4,910 196 142 579 163 1,252

222 544 112 288 61 117 733 428 641 163 541 306 291 139 6,415 1,559 818 693 9,004 1,502 196 492 536 385 349 3,756 1,817 1,549 674 3,530 596 171 233 200 184 249 378 419 450 205 741 2,526 292 221 231 59 115 79 436 232 2,010 4,005 341 2,610 101 79 313 85 668

242 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF ILLINOIS (cont.) Tazewell County Union County Vermilion County Wabash County Warren County Washington County Wayne County White County Whiteside County Will County Williamson County Winnebago County Woodford County INDIANA CONSTITUENT: ALA OF INDIANA Adams County Allen County Bartholomew County Benton County Blackford County Boone County Brown County Carroll County Cass County Clark County Clay County Clinton County Crawford County Daviess County Dearborn County Decatur County De Kalb County Delaware County Dubois County Elkhart County Fayette County Floyd County Fountain County Franklin County Fulton County Gibson County Grant County Greene County Hamilton County Hanco*ck County Harrison County Hendricks County Henry County Howard County Huntington County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

129,324 18,003 84,469 12,567 18,919 15,301 16,958 15,603 59,829 460,225 61,348 267,665 35,193

105 20 100 12 16 18 13 17 65 248 62 212 23

1,444 206 940 140 211 168 192 179 658 4,830 699 2,956 377

4,381 625 2,852 425 641 511 582 543 1,995 14,650 2,121 8,968 1,143

3,321 474 2,162 322 486 388 441 412 1,513 11,108 1,608 6,800 867

1,755 227 1,157 172 256 216 221 195 848 7,341 783 3,748 534

5,907,617

4,861

65,818

199,648

151,379

80,699

33,019 314,422

9 235

340 3,436

1,032 10,423

783 7,903

548 4,532

69,432 9,756 13,946 43,851 15,948 20,004 38,830 93,991 26,725 33,192 10,589 28,945 47,169 25,558 39,308 116,334 39,651 172,718 26,025 71,819 18,328 21,819 20,665 32,161 72,652 33,328 162,772 54,495 34,618 95,533 48,690 83,410 37,291

43 10 6 36 12 20 31 101 30 30 14 30 29 16 32 98 25 95 22 75 27 21 16 25 81 20 64 47 21 69 51 91 32

781 106 158 482 182 222 432 1,059 297 362 116 310 509 275 422 1,371 431 1,869 290 798 205 233 229 362 835 375 1,755 602 377 1,052 557 931 407

2,368 321 478 1,463 552 674 1,311 3,213 899 1,098 352 939 1,543 833 1,280 4,158 1,308 5,670 880 2,422 623 708 693 1,097 2,532 1,137 5,322 1,826 1,143 3,191 1,689 2,824 1,236

1,796 243 363 1,109 419 511 994 2,436 682 832 267 712 1,170 632 970 3,152 992 4,299 667 1,837 472 537 526 832 1,920 862 4,035 1,385 866 2,420 1,281 2,141 937

923 144 182 621 202 276 532 1,242 369 481 151 441 704 385 594 1,325 579 2,555 355 987 246 333 288 428 903 443 2,432 763 505 1,349 614 1,133 538

Appendix II 243 CHRONIC LUNG DISEASES Association Jackson County 29,070 Jay County Jefferson County Jennings County Johnson County Knox County Kosciusko County Lagrange County Lake County La Porte County Lawrence County Madison County Marion County Marshall County Martin County Miami County Monroe County Montgomery County Morgan County Newton County Noble County Ohio County Orange County Owen County Parke County Perry County Pike County Porter County Posey County Pulaski County Putnam County Randolph County Ripley County Rush County St. Joseph County Scott County Shelby County Spencer County Starke County Steuben County Sullivan County Switzerland County Tippecanoe County Tipton County Union County Vanderburgh County Vermillion County Vigo County Wabash County Warren County Warrick County Washington County Wayne County Wells County White County Whitley County

Population 41,044 22 21,715 31,452 27,754 109,390 39,261 71,151 33,393 480,969 109,844 45,695 131,236 812,662 45,568 10,470 33,510 116,569 36,464 65,560 14,798 42,607 5,447 19,592 20,431 16,852 19,308 12,899 146,253 26,454 13,431 34,551 27,503 27,251 18,238 258,185 23,055 43,329 21,017 23,935 31,447 21,354 8,838 141,274 16,654 7,236 167,736 16,946 104,963 34,572 8,336 51,556 27,800 71,462 26,849 25,329 30,358

Lung Cancer1 31 312 23 23 23 74 52 57 12 410 78 49 146 731 31 12 32 64 31 61 12 31 12 23 29 16 13 9 95 20 9 26 25 26 22 203 21 32 18 23 13 26 6 83 12 12 155 21 113 9 8 48 20 70 29 27 18

Emphysema 452 948 242 356 305 1,209 454 769 330 5,246 1,243 515 1,498 9,119 493 116 363 1,427 412 719 158 454 61 216 227 192 216 147 1,609 289 145 398 308 294 199 2,907 252 477 230 260 350 246 97 1,677 187 79 1,936 191 1,214 387 93 561 303 809 292 279 330

Chronic Bronchitis 1,372 719 733 1,080 925 3,666 1,377 2,332 1,000 15,912 3,772 1,563 4,545 27,660 1,495 352 1,103 4,329 1,249 2,180 480 1,378 185 656 687 583 657 447 4,881 876 440 1,208 935 890 603 8,818 763 1,447 699 789 1,061 747 294 5,086 566 240 5,872 581 3,684 1,173 282 1,703 920 2,453 885 847 1,001

Adult Asthma Pediatric Asthma 1,041 578Jasper 437 556 819 701 2,780 1,044 1,768 758 12,065 2,860 1,185 3,446 20,973 1,134 267 836 3,282 947 1,653 364 1,045 140 498 521 442 498 339 3,701 664 334 916 709 675 457 6,686 578 1,097 530 598 805 566 223 3,856 429 182 4,452 440 2,793 889 214 1,291 698 1,860 671 642 759

County 297 410 394 1,530 478 1,057 606 6,970 1,431 602 1,665 10,872 674 145 493 1,138 479 937 226 655 73 274 283 214 259 163 2,070 382 200 425 369 408 265 3,419 334 612 300 350 431 262 126 1,567 224 104 2,054 222 1,275 467 113 750 402 931 393 357 444

244 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association IOWA CONSTITUENT: ALA OF IOWA Adair County Adams County Allamakee County Appanoose County Audubon County Benton County Black Hawk County Boone County Bremer County Buchanan County Buena Vista County Butler County Calhoun County Carroll County Cass County Cedar County Cerro Gordo County Cherokee County Chickasaw County Clarke County Clay County Clayton County Clinton County Crawford County Dallas County Davis County Decatur County Delaware County Des Moines County Dickinson County Dubuque County Emmet County Fayette County Floyd County Franklin County Fremont County Greene County Grundy County Guthrie County Hamilton County Hanco*ck County Hardin County Harrison County Henry County Howard County Humboldt County Ida County Iowa County Jackson County Jasper County Jefferson County Johnson County Jones County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

2,861,025

2,249

32,082

97,300

73,776

38,367

8,103 4,386 14,052 13,568 6,806 25,399 120,918 26,113 23,343 21,152 19,412 15,631 11,373 21,616 14,642 17,957 46,073 13,190 13,425 8,303 17,474 18,711 49,924 16,462 36,865 8,462 8,241 18,541 42,069 16,209 87,879 10,850 21,794 16,369 10,865 7,771 10,075 12,234 11,506 16,010 12,044 18,350 15,336 20,038 9,680 10,327 7,917 15,513 20,139 36,541 17,043 102,556 20,138

9 3 0 9 6 26 116 23 10 14 6 10 14 21 6 12 62 10 8 6 17 12 40 12 22 1 10 9 32 10 69 12 26 18 4 10 10 5 10 18 8 23 18 20 6 14 1 9 26 36 13 36 9

92 50 155 153 77 277 1,367 297 265 222 218 175 130 231 165 200 526 147 146 93 193 204 555 181 400 93 96 196 475 188 975 121 243 184 122 87 115 138 131 181 131 209 169 227 107 117 87 174 221 416 194 1,231 226

278 153 470 463 234 839 4,146 899 805 673 662 530 393 700 501 606 1,597 445 443 282 586 620 1,685 548 1,214 282 290 594 1,440 570 2,958 368 737 558 371 263 348 418 396 548 398 633 512 688 324 354 263 527 669 1,261 589 3,735 687

210 116 357 351 178 636 3,144 682 611 510 502 402 298 531 380 459 1,211 338 336 213 445 470 1,278 415 920 213 220 450 1,092 432 2,243 279 559 423 281 199 264 317 300 415 302 480 388 521 245 268 200 400 507 956 447 2,832 521

106 55 197 180 88 370 1,582 337 300 338 258 212 145 330 193 246 583 181 196 112 243 270 685 235 541 121 99 291 554 196 1,214 147 297 218 144 106 128 162 149 211 175 236 217 261 136 136 113 208 288 469 217 1,087 268

Appendix II 245 CHRONIC LUNG DISEASES Association Keokuk County Kossuth County Lee County Linn County Louisa County Lucas County Lyon County Madison County Mahaska County Marion County Marshall County Mills County Mitchell County Monona County Monroe County Montgomery County Muscatine County O'Brien County Osceola County Page County Palo Alto County Plymouth County Pocahontas County Polk County Pottawattamie County Poweshiek County Ringgold County Sac County Scott County Shelby County Sioux County Story County Tama County Taylor County Union County Van Buren County Wapello County Warren County Washington County Wayne County Webster County Winnebago County Winneshiek County Woodbury County Worth County Wright County KANSAS CONSTITUENT: ALA OF KANSAS Allen County Anderson County Atchison County Barber County Barton County Bourbon County Brown County Butler County Chase County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

11,469 17,721 38,488 182,779 11,935 9,098 12,036 13,888 21,899 31,327 38,740 14,481 11,033 10,068 8,033 11,850 40,991 14,887 6,956 17,271 10,059 24,609 8,815 359,713 86,190 18,759 5,358 11,893 158,333 12,934 31,425 74,875 17,766 7,149 12,522 7,862 35,387 40,209 20,938 6,677 38,975 11,942 20,962 101,547 7,742 14,039

9 12 44 136 12 3 10 13 21 18 53 9 13 12 13 13 26 12 4 25 8 18 20 255 84 16 3 9 110 5 13 31 14 5 10 1 21 26 8 9 44 6 14 99 5 20

128 194 432 2,071 131 104 128 151 243 351 439 158 123 115 90 134 445 165 77 199 112 263 99 4,066 951 215 62 132 1,727 144 337 901 199 80 140 88 406 440 232 77 438 135 240 1,099 88 160

389 588 1,311 6,283 397 316 387 458 738 1,063 1,330 479 374 349 274 408 1,349 502 233 602 340 799 301 12,332 2,885 651 188 401 5,239 436 1,022 2,734 603 242 424 266 1,232 1,334 702 233 1,330 410 729 3,332 266 486

295 446 994 4,764 301 239 294 347 560 806 1,009 363 284 264 207 309 1,023 380 176 457 258 606 228 9,351 2,188 494 143 304 3,972 330 775 2,073 457 184 322 202 934 1,012 533 176 1,008 310 553 2,527 202 369

155 255 513 2,373 170 115 187 203 301 422 504 210 149 128 107 154 602 205 98 214 138 375 117 4,709 1,210 236 65 164 2,294 178 476 785 240 97 170 106 441 578 292 83 517 156 262 1,503 101 178

2,638,667

2,001

29,116

88,318

66,968

37,044

14,532 8,046 16,858 5,336 28,936 15,160 11,040 61,883 2,941

21 6 22 4 25 8 8 46 4

159 89 184 59 320 169 120 667 33

483 269 557 179 971 512 364 2,024 100

366 204 423 136 736 388 276 1,535 76

208 113 245 74 404 208 161 924 40

246 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF KANSAS (cont.) Chautauqua County Cherokee County Cheyenne County Clark County Clay County Cloud County Coffey County Comanche County Cowley County Crawford County Decatur County Dickinson County Doniphan County Douglas County Edwards County Elk County Ellis County Ellsworth County Finney County Ford County Franklin County Geary County Gove County Graham County Grant County Gray County Greeley County Greenwood County Hamilton County Harper County Harvey County Haskell County Hodgeman County Jackson County Jefferson County Jewell County Johnson County Kearny County Kingman County Kiowa County Labette County Lane County Leavenworth County Lincoln County Linn County Logan County Lyon County McPherson County Marion County Marshall County Meade County Miami County Mitchell County Montgomery County Morris County

Population 4,343 22,499 3,160 2,353 9,086 10,062 8,680 2,002 37,092 36,360 3,446 19,602 7,872 96,554 3,287 3,386 26,585 6,277 36,621 29,461 24,853 25,226 3,045 3,189 7,996 5,575 1,694 8,101 2,369 6,411 34,148 3,962 2,215 12,111 18,175 3,873 429,649 4,138 8,559 3,420 23,050 2,245 71,178 3,331 9,166 2,990 33,785 28,549 13,609 10,994 4,431 26,456 6,950 37,046 6,155

Lung

Cancer1 8 27 5 0 10 10 8 3 32 46 3 21 3 29 8 5 16 6 16 16 21 18 6 6 4 3 3 18 5 9 22 4 0 13 17 4 230 1 5 1 13 0 56 1 6 1 25 10 16 10 1 17 3 39 9

Emphysema 50 248 36 26 101 117 94 23 411 418 39 218 88 1,149 37 39 299 73 359 310 268 273 34 36 78 57 18 92 27 73 380 40 24 131 199 45 4,760 42 93 38 255 25 783 38 102 33 370 319 157 122 48 287 77 415 69

Chronic Bronchitis 152 752 109 80 307 355 286 69 1,246 1,267 118 662 267 3,486 112 120 906 221 1,088 941 813 827 103 109 238 173 54 279 81 220 1,153 122 73 398 603 135 14,438 126 284 116 773 75 2,376 115 309 101 1,121 967 475 369 146 872 233 1,258 210

Adult Asthma Pediatric Asthma 115 570 83 61 233 269 217 53 945 961 89 502 203 2,643 85 91 687 167 825 713 616 627 78 83 180 131 41 212 61 167 874 93 55 302 457 102 10,948 96 215 88 586 57 1,802 87 234 77 850 733 360 280 111 661 177 954 159

54 317 40 31 124 120 127 25 515 452 45 268 106 1,059 43 40 354 76 675 466 371 374 42 42 147 94 27 105 32 83 467 68 32 179 262 48 5,964 73 124 46 321 32 1,006 43 127 41 485 388 168 153 64 388 97 500 82

Appendix II 247 CHRONIC LUNG DISEASES Association Morton County Nemaha County Neosho County Ness County Norton County Osage County Osborne County Ottawa County Pawnee County Phillips County Pottawatomie County Pratt County Rawlins County Reno County Republic County Rice County Riley County Rooks County Rush County Russell County Saline County Scott County Sedgwick County Seward County Shawnee County Sheridan County Sherman County Smith County Stafford County Stanton County Stevens County Sumner County Thomas County Trego County Wabaunsee County Wallace County Washington County Wichita County Wilson County Woodson County Wyandotte County KENTUCKY CONSTITUENT: ALA OF KENTUCKY Adair County Allen County Anderson County Ballard County Barren County Bath County Bell County Boone County Bourbon County Boyd County Boyle County Bracken County Breathitt County Breckinridge County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

3,428 10,205 16,706 3,628 5,735 17,158 4,680 5,881 7,245 6,036 18,638 9,682 3,130 63,241 6,098 10,427 63,940 5,688 3,405 7,535 51,399 5,023 447,819 20,072 170,349 2,721 6,556 4,594 5,049 2,244 5,415 27,197 8,030 3,293 6,613 1,812 6,512 2,646 10,266 3,946 152,521

1 9 26 8 4 8 1 0 13 4 22 10 4 44 6 8 20 3 10 4 46 5 318 21 148 3 1 4 5 0 5 22 3 8 5 3 9 1 20 6 150

36 110 187 41 67 187 53 65 82 68 197 108 35 712 70 116 751 63 40 88 571 52 4,868 204 1,904 30 73 54 56 23 56 289 87 37 73 19 73 27 114 45 1,642

109 333 566 123 204 568 162 198 247 207 598 328 107 2,160 214 352 2,278 191 121 266 1,732 159 14,767 619 5,776 90 221 163 170 70 170 878 263 111 221 59 223 83 347 136 4,980

83 253 429 93 154 431 123 150 188 157 453 249 81 1,637 162 267 1,727 144 92 202 1,314 120 11,197 470 4,380 68 167 124 129 53 129 666 200 84 167 45 169 63 263 103 3,776

55 153 227 49 67 248 60 81 96 79 292 131 42 838 74 143 737 80 39 89 707 82 6,546 343 2,305 40 90 54 70 38 89 419 119 45 93 27 86 44 140 51 2,287

3,934,310

4,019

44,392

134,655

102,097

51,766

16,451 16,567 18,501 8,489 36,971 10,586 29,155 79,761 19,337 49,514 27,102 8,419 15,728 17,455

20 25 18 14 35 8 46 51 14 69 30 14 38 25

189 185 206 99 422 120 324 861 218 580 313 94 171 196

572 561 626 299 1,281 365 984 2,611 660 1,759 949 286 519 596

434 425 475 227 972 277 746 1,980 500 1,334 719 217 393 452

206 225 252 102 468 136 400 1,188 257 576 332 113 230 232

248 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF KENTUCKY (cont.) Bullitt County Butler County Caldwell County Calloway County Campbell County Carlisle County Carroll County Carter County Casey County Christian County Clark County Clay County Clinton County Crittenden County Cumberland County Daviess County Edmonson County Elliott County Estill County Fayette County Fleming County Floyd County Franklin County Fulton County Gallatin County Garrard County Grant County Graves County Grayson County Green County Greenup County Hanco*ck County Hardin County Harlan County Harrison County Hart County Henderson County Henry County Hickman County Hopkins County Jackson County Jefferson County Jessamine County Johnson County Kenton County Knott County Knox County Larue County Laurel County Lawrence County Lee County Leslie County Letcher County Lewis County

Population

59,344 11,932 13,335 33,422 87,301 5,337 9,624 26,900 14,788 72,436 31,941 22,760 9,347 9,587 6,848 90,973 11,347 6,593 15,581 241,697 13,478 43,324 46,501 7,548 7,182 13,920 20,314 35,966 23,736 10,565 36,970 8,963 90,576 34,820 17,542 16,723 44,482 14,774 5,197 46,380 12,931 671,595 36,577 23,986 146,731 17,948 31,890 13,067 50,847 15,606 8,029 13,589 26,237 13,513

Lung

Cancer1

40 21 12 43 78 6 12 25 25 60 35 25 12 13 13 101 6 12 9 185 12 49 39 9 10 9 16 46 23 10 49 10 74 43 22 20 30 12 6 55 10 719 22 17 140 23 53 14 38 14 12 22 29 5

Emphysema

643 133 154 406 972 62 107 301 166 805 362 242 107 109 80 1,014 128 71 174 2,844 153 470 539 86 78 160 219 413 267 123 423 97 989 379 195 188 499 167 60 523 140 7,743 405 266 1,615 194 347 149 561 170 90 145 286 149

Chronic Bronchitis

1,951 405 469 1,231 2,950 187 324 912 503 2,441 1,098 733 325 331 241 3,077 388 216 529 8,627 463 1,425 1,635 260 237 486 666 1,253 809 375 1,284 293 3,001 1,149 593 570 1,513 507 183 1,586 424 23,487 1,229 808 4,899 588 1,051 452 1,700 517 273 440 867 451

Adult Asthma Pediatric Asthma

1,479 307 355 933 2,237 141 245 691 382 1,851 833 556 246 251 183 2,333 294 164 401 6,542 351 1,081 1,239 197 180 368 505 950 613 284 974 222 2,275 871 449 432 1,147 384 139 1,203 322 17,809 932 613 3,715 446 797 343 1,289 392 207 334 657 342

874 161 161 338 1,193 66 133 364 198 997 414 353 117 123 82 1,240 150 98 210 2,766 175 637 562 98 105 172 302 447 316 124 464 134 1,308 508 240 223 596 193 62 612 191 8,252 508 331 2,074 267 467 166 715 225 108 208 382 191

Appendix II 249 CHRONIC LUNG DISEASES Association Lincoln County Livingston County Logan County Lyon County McCracken County McCreary County McLean County Madison County Magoffin County Marion County Marshall County Martin County Mason County Meade County Menifee County Mercer County Metcalfe County Monroe County Montgomery County Morgan County Muhlenberg County Nelson County Nicholas County Ohio County Oldham County Owen County Owsley County Pendleton County Perry County Pike County Powell County Pulaski County Robertson County Rockcastle County Rowan County Russell County Scott County Shelby County Simpson County Spencer County Taylor County Todd County Henderson County Trigg County Trimble County Union County Warren County Washington County Wayne County Webster County Whitley County Wolfe County Woodford County LOUISIANA CONSTITUENT: ALA OF LOUISIANA Acadia Parish Allen Parish

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

22,403 9,440 26,195 8,009 64,405 16,634 9,841 66,454 13,846 17,038 30,174 12,083 16,913 28,732 5,774 20,664 9,573 11,143 21,006 13,575 32,060 35,929 7,007 22,013 44,436 10,350 5,398 13,735 30,995 72,020 12,913 56,313 2,206 15,923 22,118 16,182 30,782 29,640 16,467 9,665 22,981 11,263 44,482 12,409 7,685 16,546 87,310 10,892 19,056 13,537 35,827 7,383 22,731

36 10 29 8 87 29 18 55 8 13 51 9 21 13 4 22 8 13 30 12 52 36 8 46 22 16 8 9 35 88 10 46 3 14 16 13 26 21 12 3 25 9 30 20 4 21 56 17 23 25 30 14 13

250 111 294 102 742 176 112 780 146 188 354 127 191 292 64 237 110 128 236 154 363 388 80 244 485 115 60 148 338 796 137 648 25 178 265 188 340 336 183 107 264 126 499 146 86 180 1,007 121 212 152 398 80 256

758 337 891 308 2,250 535 341 2,365 442 571 1,073 384 579 887 193 720 333 388 716 466 1,101 1,176 241 741 1,470 349 182 449 1,026 2,415 417 1,966 77 539 804 571 1,033 1,020 556 325 801 381 1,513 442 260 546 3,055 368 643 460 1,207 242 775

575 255 676 234 1,706 406 258 1,794 335 433 814 291 439 672 146 546 252 294 543 353 835 892 183 562 1,114 264 138 341 778 1,831 316 1,491 58 409 610 433 783 773 422 246 607 289 1,147 335 197 414 2,316 279 487 349 915 183 588

305 108 351 66 794 259 125 768 220 238 350 193 222 491 81 257 120 139 280 177 417 535 90 304 644 143 74 205 448 1,006 199 696 27 216 236 193 429 384 225 134 286 153 596 144 105 242 1,071 149 262 181 494 110 302

4,362,758

3,657

47,449

143,928

109,136

63,692

57,814 24,204

46 23

605 273

1,836 829

1,392 629

928 317

250 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF LOUISIANA (cont.) Ascension Parish Assumption Parish Avoyelles Parish Beauregard Parish Bienville Parish Bossier Parish Caddo Parish Calcasieu Parish Caldwell Parish Cameron Parish Catahoula Parish Claiborne Parish Concordia Parish De Soto Parish East Baton Rouge Parish East Carroll Parish East Feliciana Parish Evangeline Parish Franklin Parish Grant Parish Iberia Parish Iberville Parish Jackson Parish Jefferson Parish Jefferson Davis Parish Lafayette Parish Lafourche Parish La Salle Parish Lincoln Parish Livingston Parish Madison Parish Morehouse Parish Natchitoches Parish Orleans Parish Ouachita Parish Plaquemines Parish Pointe Coupee Parish Rapides Parish Red River Parish Richland Parish Sabine Parish St. Bernard Parish St. Charles Parish St. Helena Parish St. James Parish St. John the Baptist Parish St. Landry Parish St. Martin Parish St. Mary Parish St. Tammany Parish Tangipahoa Parish Tensas Parish

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

71,679 23,023 40,786 31,977 15,799 92,334 242,484 180,111 10,377 9,034 11,050 17,027 20,752 24,984 393,656 8,866 20,964 34,167 22,094 18,951 72,946 31,457 15,497 449,708 31,571 186,150 89,010 13,681 41,140 88,274 12,934 31,467 37,040 464,578 146,830 26,177 23,527 126,475 9,606 21,040 23,804 65,847 48,164 9,572 21,033

46 17 36 25 9 68 213 153 20 10 10 17 20 25 238 9 16 39 22 20 70 30 12 386 38 130 65 25 25 72 14 31 42 439 124 14 12 101 5 13 30 83 35 8 23

746 242 444 348 174 1,006 2,659 1,961 113 97 118 195 222 269 4,374 88 227 359 235 203 759 342 171 5,049 335 2,026 960 151 477 930 131 334 396 5,131 1,584 277 252 1,377 101 222 260 740 508 101 222

2,262 733 1,347 1,056 527 3,053 8,066 5,948 342 294 359 590 674 816 13,267 266 690 1,088 712 615 2,303 1,038 517 15,314 1,016 6,146 2,913 459 1,447 2,822 398 1,014 1,202 15,563 4,803 841 764 4,178 307 673 790 2,244 1,540 306 674

1,715 556 1,021 800 400 2,315 6,116 4,510 260 223 272 448 511 619 10,060 202 523 825 540 467 1,746 787 392 11,612 771 4,660 2,209 348 1,097 2,139 302 769 911 11,801 3,642 638 580 3,168 233 510 599 1,701 1,168 232 511

1,167 368 594 466 224 1,340 3,463 2,622 151 137 168 215 316 374 5,420 160 308 544 342 288 1,186 459 219 6,007 490 2,712 1,327 190 495 1,395 222 487 564 6,507 2,191 408 357 1,840 152 332 342 878 761 151 330

42,195 83,781 47,448 57,232 188,727 96,943 6,599

36 69 31 43 138 81 6

431 880 494 598 2,028 1,030 68

1,307 2,670 1,500 1,814 6,150 3,123 206

991 2,024 1,137 1,375 4,663 2,368 156

716 1,333 769 923 2,844 1,503 110

Appendix II 251 CHRONIC LUNG DISEASES Association Terrebonne Parish Union Parish Vermilion Parish Vernon Parish Washington Parish Webster Parish West Baton Rouge Parish West Carroll Parish West Feliciana Parish Winn Parish MAINE CONSTITUENT: ALA OF MAINE Androscoggin County Aroostook County Cumberland County Franklin County Hanco*ck County Kennebec County Knox County Lincoln County Oxford County Penobscot County Piscataquis County Sagadahoc County Somerset County Waldo County Washington County York County MARYLAND CONSTITUENT: ALA OF MARYLAND Allegany County Anne Arundel County Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince George's County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Baltimore City(2)

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

104,725 22,037 52,056 51,380 43,127 42,724 20,617 12,152 13,661 17,693

91 26 56 27 46 40 17 14 9 18

1,095 242 554 570 472 475 222 132 165 199

3,322 735 1,680 1,730 1,430 1,442 674 401 499 603

2,519 557 1,274 1,312 1,085 1,094 511 304 379 457

1,684 313 804 709 621 585 308 177 143 236

1,247,554

1,122

14,327

43,458

32,953

15,527

101,266 76,648 254,429 28,852 49,840 115,115 37,985 31,760 53,845 144,431 18,191 35,651 52,420 36,529 35,573 175,019

105 58 195 27 55 96 32 29 64 117 21 29 51 27 40 176

1,154 881 2,977 327 580 1,321 441 367 610 1,672 207 403 584 409 406 1,988

3,500 2,671 9,032 992 1,761 4,006 1,336 1,114 1,851 5,071 627 1,223 1,771 1,240 1,233 6,030

2,654 2,026 6,848 752 1,335 3,037 1,013 845 1,404 3,845 476 927 1,343 940 935 4,573

1,293 952 2,970 374 592 1,438 458 386 698 1,751 234 466 716 492 451 2,256

5,130,072

3,709

57,572

174,642

132,420

68,593

72,130 474,682 721,556 71,757 29,519 149,690 82,348 118,060 29,584 186,621 29,275 214,569 235,118 19,002 839,158 776,907 39,692 87,645 24,252 33,154 127,477 79,441 42,771 645,664

94 347 630 46 26 90 72 78 30 108 22 127 90 20 373 395 43 51 30 23 92 116 51 755

836 5,314 8,408 763 322 1,633 884 1,235 337 2,034 318 2,326 2,593 224 9,547 8,701 445 924 290 390 1,462 886 497 7,203

2,535 16,120 25,504 2,315 976 4,954 2,683 3,747 1,023 6,171 964 7,056 7,867 679 28,960 26,394 1,350 2,802 880 1,183 4,436 2,688 1,507 21,848

1,922 12,223 19,338 1,755 740 3,756 2,034 2,841 776 4,679 731 5,350 5,965 515 21,959 20,013 1,023 2,124 668 897 3,364 2,038 1,143 16,566

872 6,393 8,550 1,108 429 2,167 1,242 1,896 377 2,708 430 3,159 3,304 217 10,762 10,451 532 1,384 260 379 1,592 1,081 512 8,788

252 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association MASSACHUSETTS CONSTITUENT: ALA OF MASSACHUSETTS Barnstable County Berkshire County Bristol County Dukes County Essex County Franklin County Hampden County Hampshire County Middlesex County Nantucket County Norfolk County Plymouth County Suffolk County Worcester County Middlesex County 1

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

6,144,407

4,717

70,330

213,337

161,759

77,300

208,477 132,839 516,975 13,852 700,370 70,626 439,336 150,344 1,422,465 7,891 642,089 467,041 641,333 730,769 1,293,020

229 122 387 13 551 56 387 96 962 6 524 361 477 546 875

2,462 1,531 5,790 159 7,899 790 4,849 1,794 16,704 93 7,551 5,108 7,443 8,157 15,183

7,467 4,643 17,563 483 23,962 2,396 14,709 5,442 50,669 281 22,906 15,495 22,578 24,743 46,011

5,662 3,521 13,317 366 18,169 1,816 11,153 4,126 38,419 213 17,368 11,749 17,119 18,761 34,659

2,356 1,635 6,955 172 9,226 955 6,163 1,633 16,400 91 7,363 6,717 7,706 9,928 15,024

ALA OF GREATER NORFOLK COUNTY Norfolk County Holliston Town Natick Town Newton City Sherborn Town

642,089 13,578 31,526 80,200 4,141

524 9 21 54 3

7,551 116 366 994 44

22,906 432 1,133 2,951 142

17,368 542 870 2,241 107

7,363 197 333 789 57

ALA OF WESTERN COUNTY Berkshire County Franklin County Hampden County Hampshire County

132,839 70,626 439,336 150,344

122 56 387 96

1,531 790 4,849 1,794

4,643 2,396 14,709 5,442

3,521 1,816 11,153 4,126

1,635 955 6,163 1,633

9,820,231

7,263

109,072

330,853

250,863

135,345

11,061 9,984 101,680 30,475 21,473 16,405 8,602 54,465 109,980 14,743 159,831 43,702 140,806 49,975 24,496 23,813 37,906

18 12 64 30 14 20 12 44 105 9 142 46 133 60 29 29 32

132 115 1,072 339 240 182 97 595 1,226 169 1,762 479 1,558 553 271 267 439

399 348 3,252 1,030 727 551 296 1,805 3,720 513 5,345 1,453 4,727 1,679 821 809 1,331

302 264 2,466 781 551 418 224 1,369 2,821 389 4,053 1,102 3,584 1,273 622 613 1,009

122 124 1,604 417 292 228 112 785 1,498 184 2,249 624 1,961 695 343 320 460

MICHIGAN CONSTITUENT: ALA OF MICHIGAN Alcona County Alger County Allegan County Alpena County Antrim County Arenac County Baraga County Barry County Bay County Benzie County Berrien County Branch County Calhoun County Cass County Charlevoix County Cheboygan County Chippewa County

Appendix II 253 CHRONIC LUNG DISEASES Association

Population

Clare County Clinton County Crawford County Delta County Dickinson County Eaton County Emmet County Genesee County Gladwin County Gogebic County Grand Traverse County Gratiot County Hillsdale County Houghton County Huron County Ingham County Ionia County Iosco County Iron County Isabella County Jackson County Kalamazoo County Kalkaska County Kent County Keweenaw County Lake County Lapeer County Leelanau County Lenawee County Livingston County Luce County Mackinac County Macomb County Manistee County Marquette County Mason County Mecosta County Menominee County Midland County Missaukee County Monroe County Montcalm County Montmorency County Muskegon County Newaygo County Oakland County Oceana County Ogemaw County Ontonagon County Osceola County Oscoda County Otsego County Ottawa County Presque Isle County Roscommon County Saginaw County St. Clair County St. Joseph County

29,514 63,407 14,128 38,936 27,062 101,022 28,633 435,691 25,341 17,243 74,224 40,145 46,572 35,617 35,273 285,874 66,710 25,715 12,882 58,394 156,130 229,627 15,554 544,781 2,099 10,424 88,229 19,142 98,609 146,317 6,791 11,041 786,866 23,485 62,585 27,896 40,156 24,393 81,562 13,887 143,365 60,602 9,999 166,849 45,769 1,175,057 24,745 21,085 7,842 22,138 8,890 22,232 225,407 14,535 23,355 210,032 159,465 61,141

Lung Cancer1 46 39 23 55 17 48 18 368 36 20 64 20 32 14 40 117 42 34 23 43 129 122 26 298 1 13 61 9 83 66 4 10 662 22 42 22 30 27 46 12 127 51 14 129 43 734 17 35 14 22 8 14 92 12 42 146 142 62

Emphysema 327 685 157 431 302 1,109 317 4,750 283 202 818 442 506 411 390 3,245 738 289 151 673 1,748 2,615 165 5,875 25 116 942 216 1,072 1,583 78 124 9,085 271 703 310 461 271 901 147 1,550 652 115 1,811 485 13,370 263 234 91 235 102 240 2,406 165 278 2,288 1,738 657

Chronic Bronchitis 992 2,078 477 1,308 916 3,364 962 14,409 858 613 2,480 1,340 1,535 1,247 1,182 9,844 2,237 877 459 2,041 5,302 7,932 501 17,819 74 352 2,858 654 3,252 4,803 236 377 27,558 823 2,133 941 1,400 823 2,734 446 4,701 1,979 350 5,492 1,470 40,557 796 710 275 713 310 728 7,298 502 842 6,939 5,273 1,994

Adult Asthma Pediatric Asthma 752 1,576 362 992 694 2,550 729 10,926 650 465 1,881 1,016 1,164 946 896 7,464 1,696 665 348 1,548 4,020 6,015 380 13,511 56 267 2,167 496 2,465 3,641 179 286 20,896 624 1,617 714 1,061 624 2,073 338 3,564 1,500 265 4,165 1,115 30,752 604 538 209 541 235 552 5,533 381 638 5,262 3,998 1,512

410 942 194 541 368 1,439 398 6,319 344 200 1,047 568 682 436 494 3,691 931 342 148 719 2,103 2,936 241 8,132 25 142 1,350 253 1,442 2,165 85 146 9,621 287 834 383 499 335 1,140 217 2,127 909 123 2,450 715 15,065 384 292 95 343 111 331 3,453 186 258 3,054 2,314 919

254 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

ALA OF MICHIGAN (cont.) Sanilac County Schoolcraft County Shiawassee County Tuscola County Van Buren County Washtenaw County Wayne County Wexford County

43,051 8,782 72,489 57,965 75,637 302,787 2,116,540 29,118

32 17 48 40 55 134 1,628 22

465 100 785 627 807 3,566 23,298 314

1,409 303 2,380 1,901 2,449 10,816 70,671 952

1,068 229 1,805 1,441 1,857 8,201 53,585 722

642 113 1,072 860 1,159 3,455 29,913 435

4,726,411

2,769

51,958

157,604

119,505

67,048

14,182 292,324 29,495 38,664 34,114 5,652 53,727 27,069 31,303 64,821 26,310 13,052 40,950 51,522 8,241 4,751 12,031 51,741 342,059 17,169 31,077 16,260 20,763 31,560 43,130 6,108 1,058,943 19,267 16,909 30,036 43,919 11,496 14,161 40,887 5,301 15,068 7,995 10,664

20 140 22 25 18 4 25 22 25 23 30 16 30 18 13 0 12 48 121 8 18 13 16 29 27 6 601 22 18 12 43 10 14 25 6 12 12 14

163 3,103 315 405 357 63 622 299 342 679 287 143 424 579 87 55 134 570 3,624 177 342 181 226 355 467 68 12,169 207 186 310 477 126 149 438 60 170 89 123

494 9,413 955 1,228 1,084 192 1,888 906 1,037 2,061 872 434 1,286 1,757 265 166 408 1,728 10,993 536 1,037 549 686 1,077 1,417 207 36,912 629 563 941 1,448 383 451 1,329 180 515 270 374

375 7,137 724 931 822 146 1,432 687 786 1,563 661 329 975 1,332 201 126 309 1,310 8,335 406 787 416 520 817 1,074 157 27,988 477 427 714 1,098 290 342 1,008 137 391 205 284

177 4,538 452 620 546 76 649 380 452 1,037 380 187 673 686 128 59 163 731 5,334 286 440 222 302 419 637 83 13,152 289 240 497 642 164 226 620 71 199 109 130

4,562 25,319 6,486

5 12 1

50 270 72

151 818 219

115 620 166

66 390 89

MINNESOTA CONSTITUENT: ALA OF MINNESOTA Aitkin County Anoka County Becker County Beltrami County Benton County Big Stone County Blue Earth County Brown County Carlton County Carver County Cass County Chippewa County Chisago County Clay County Clearwater County Cook County Cottonwood County Crow Wing County Dakota County Dodge County Douglas County Faribault County Fillmore County Freeborn County Goodhue County Grant County Hennepin County Houston County Hubbard County Isanti County Itasca County Jackson County Kanabec County Kandiyohi County Kittson County Koochiching County Lac qui Parle County Lake County Lake of the Woods County Le Sueur County Lincoln County

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Appendix II 255 CHRONIC LUNG DISEASES Association Lyon County Mc Leod County Mahnomen County Marshall County Martin County Meeker County Mille Lacs County Morrison County Mower County Murray County Nicollet County Nobles County Norman County Olmsted County Otter Tail County Pennington County Pine County Pipestone County Polk County Pope County Ramsey County Red Lake County Redwood County Renville County Rice County Rock County Roseau County St. Louis County Scott County Sherburne County Sibley County Stearns County Steele County Stevens County Swift County Todd County Traverse County Wabasha County Wadena County Waseca County Washington County Watonwan County Wilkin County Winona County Wright County Yellow Medicine County MISSISSIPPI CONSTITUENT: ALA OF MISSISSIPPI Adams County Alcorn County Amite County Attala County Benton County Bolivar County Calhoun County Carroll County Chickasaw County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

24,398 34,142 5,051 10,280 22,000 21,739 21,067 30,518 37,104 9,531 29,482 19,275 7,539 116,931 54,794 13,541 24,096 10,057 31,081 10,913 485,709 4,237 16,504 16,931 54,198 9,723 16,086 193,463 79,114 60,339 14,641 128,736 31,723 10,036 11,495 24,035 4,248 20,891 13,114 18,534 196,675 11,519 7,372 48,022 85,022 11,417

16 12 1 9 12 8 23 18 21 5 8 8 4 58 44 6 30 5 29 9 282 1 10 16 34 13 12 168 29 35 9 51 10 4 17 18 10 18 5 10 68 16 4 26 31 10

266 365 52 111 244 231 225 316 417 105 325 214 83 1,277 607 148 260 109 335 119 5,466 45 179 184 602 105 165 2,196 819 616 158 1,394 340 116 130 251 47 224 143 199 2,069 126 80 545 862 125

807 1,108 157 335 740 701 683 959 1,265 318 985 649 251 3,874 1,841 449 787 329 1,018 361 16,579 136 542 559 1,825 320 502 6,661 2,484 1,869 478 4,230 1,031 350 395 760 144 680 433 604 6,277 381 241 1,652 2,615 380

612 840 119 254 561 531 518 727 959 241 747 492 190 2,937 1,396 341 597 250 772 274 12,571 103 411 424 1,384 243 380 5,051 1,884 1,417 363 3,207 782 266 299 577 109 516 328 458 4,759 289 183 1,252 1,983 288

354 520 85 155 305 337 321 502 494 135 417 266 108 1,688 762 194 361 150 463 158 6,443 67 244 247 748 143 269 2,499 1,302 1,022 219 1,900 481 124 150 389 57 316 191 279 3,118 167 110 622 1,463 162

2,751,335

2,400

29,917

90,763

68,822

40,174

34,141 32,755 13,852 18,325 8,086 40,185 14,891 9,989 18,039

47 40 13 20 1 40 14 9 20

375 372 150 203 87 410 167 110 194

1,139 1,128 455 617 264 1,245 507 332 588

863 856 345 468 201 944 385 252 446

484 422 205 253 121 681 199 143 271

256 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF MISSISSIPPI (cont.) Choctaw County Claiborne County Clarke County Clay County Coahoma County Copiah County Covington County DeSoto County Forrest County Franklin County George County Greene County Grenada County Hanco*ck County Harrison County Hinds County Holmes County Humphreys County Issaquena County Itawamba County Jackson County Jasper County Jefferson County Jefferson Davis County Jones County Kemper County Lafayette County Lamar County Lauderdale County Lawrence County Leake County Lee County Leflore County Lincoln County Lowndes County Madison County Marion County Marshall County Monroe County Montgomery County Neshoba County Newton County Noxubee County Oktibbeha County Panola County Pearl River County Perry County Pike County Pontotoc County Prentiss County Quitman County Rankin County Scott County Sharkey County

Population

9,401 11,513 18,239 21,622 31,277 28,827 17,723 97,110 74,484 8,287 19,600 12,745 22,408 40,271 177,194 247,262 21,513 11,318 1,636 21,093 130,799 17,666 8,451 13,815 63,616 10,573 34,756 37,041 76,107 12,999 19,437 74,621 37,241 31,859 61,045 72,879 26,404 32,170 38,105 12,402 27,502 21,597 12,413 39,635 33,326 46,833 11,858 37,835 25,307 24,356 9,858 109,600 25,015 6,602

Lung

Cancer1

3 6 13 8 30 38 13 73 73 5 20 9 29 55 199 237 10 17 3 10 107 10 9 13 74 8 20 26 73 8 21 72 26 30 38 30 25 23 31 14 13 21 9 17 29 36 9 43 23 25 16 52 12 3

Emphysema

100 125 199 229 316 310 188 1,058 838 89 208 142 244 447 1,948 2,739 216 112 17 241 1,416 188 85 146 706 115 414 395 839 140 212 817 392 349 658 784 281 346 415 136 293 238 127 464 347 509 125 405 279 277 101 1,220 268 65

Chronic Bronchitis

304 380 604 696 957 942 569 3,210 2,542 270 632 432 739 1,355 5,909 8,309 656 341 51 732 4,296 571 259 444 2,141 349 1,256 1,198 2,545 424 644 2,478 1,188 1,060 1,997 2,379 853 1,050 1,257 412 888 723 385 1,409 1,052 1,544 378 1,229 847 840 305 3,701 814 196

Adult Asthma Pediatric Asthma

231 288 458 528 726 714 431 2,434 1,927 205 479 327 561 1,027 4,480 6,300 498 258 39 555 3,257 433 197 336 1,623 264 952 909 1,930 322 488 1,879 901 804 1,514 1,804 647 796 953 313 673 548 292 1,068 798 1,171 287 932 642 637 231 2,806 617 149

144 168 264 336 543 432 277 1,411 989 125 303 173 327 557 2,513 3,433 377 203 27 265 1,932 272 146 216 879 154 380 569 1,071 195 281 1,071 591 455 911 1,094 407 482 556 178 425 303 210 461 542 685 188 575 356 312 167 1,501 378 122

Appendix II 257 CHRONIC LUNG DISEASES Association Simpson County Smith County Stone County Sunflower County Tallahatchie County Tate County Tippah County Tishomingo County Tunica County Union County Walthall County Warren County Washington County Wayne County Webster County Wilkinson County Winston County Yalobusha County Yazoo County MISSOURI CONSTITUENTS: ALA OF EASTERN MISSOURI Adair County Audrain County Bollinger County Boone County Butler County Callaway County Cape Girardeau County Carter County Clark County Cole County Crawford County Dent County Dunklin County Franklin County Gasconade County Howell County Iron County Jefferson County Knox County Lewis County Lincoln County Macon County Madison County Maries County Marion County Mississippi County Monroe County Montgomery County New Madrid County Oregon County Osage County Pemiscot County Perry County Phelps County Pike County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

25,295 15,268 13,225 33,537 14,787 23,973 21,016 18,660 8,041 23,861 14,391 49,357 65,173 20,297 10,585 9,158 19,286 12,416 25,500

17 16 3 26 10 27 18 27 9 25 13 32 44 16 14 9 16 18 39

273 167 143 361 152 259 233 217 77 267 151 529 663 213 118 98 209 137 264

827 505 435 1,095 460 786 708 657 235 809 458 1,606 2,013 647 357 298 634 414 802

627 383 330 830 349 596 537 498 178 613 347 1,218 1,526 491 271 226 481 314 608

378 221 195 503 248 355 290 224 153 323 229 747 1,112 323 146 138 284 176 418

5,437,562

4,805

60,541

183,616

139,221

74,452

24,241 23,555 11,552 128,963 40,434 37,499 66,229 6,382 7,449 69,227 22,295 14,134 32,707 91,852 14,824 35,748 10,909 195,472 4,360 10,194 36,610 15,329 11,550 8,433 27,864 13,473 9,039 12,065 20,357 10,175 12,465 21,448 17,497 38,555 16,395

10 35 5 58 62 29 42 8 6 48 23 23 53 68 17 40 14 179 3 6 34 14 23 3 26 6 8 18 23 8 6 23 8 27 16

290 261 127 1,487 451 416 756 69 81 781 244 156 359 987 167 396 119 2,073 50 117 385 172 129 94 303 143 98 133 215 116 135 219 188 441 179

879 791 385 4,511 1,367 1,262 2,293 210 247 2,369 739 472 1,088 2,993 507 1,201 362 6,287 151 355 1,169 523 390 284 920 433 297 403 651 352 409 663 569 1,337 543

667 600 292 3,420 1,036 957 1,739 159 187 1,797 560 358 825 2,270 384 910 274 4,767 114 269 886 396 296 215 697 328 225 305 494 267 310 503 432 1,014 412

261 328 164 1,584 552 519 841 94 107 911 321 199 467 1,384 196 497 157 3,043 55 127 580 204 158 116 406 210 133 171 321 130 185 365 265 487 236

258 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

ALA OF EASTERN MISSOURI (cont.) Pulaski County Ralls County Randolph County Reynolds County Ripley County St. Charles County St. Francois County St. Louis County Ste. Genevieve County Schuyler County Scotland County Scott County Shannon County Shelby County Stoddard County Texas County Warren County Washington County Wayne County St. Louis City(2)

39,331 8,876 23,912 6,648 14,050 272,101 55,355 997,347 17,357 4,454 4,821 40,288 8,299 6,749 29,681 22,373 24,512 23,042 13,061 338,946

27 13 16 3 22 142 52 840 10 8 4 48 8 5 34 20 18 30 26 378

417 98 270 74 154 2,884 620 11,343 189 50 54 431 91 74 335 247 265 245 150 3,723

1,264 296 818 223 466 8,748 1,881 34,407 573 151 163 1,308 277 226 1,015 748 803 742 455 11,294

958 224 620 169 353 6,633 1,426 26,089 434 114 123 992 210 171 769 567 609 562 345 8,564

614 126 315 93 202 4,240 745 12,805 253 61 66 613 118 95 392 315 364 358 162 4,817

ALA OF WESTERN MISSOURI Andrew County Atchison County Barry County Barton County Bates County Benton County Buchanan County Caldwell County Camden County Carroll County Cass County Cedar County Chariton County Christian County Clay County Clinton County Cooper County Dade County Dallas County Daviess County DeKalb County Douglas County Gentry County Greene County Grundy County Harrison County Henry County Hickory County Holt County Howard County Jackson County

15,551 7,035 33,179 12,071 15,826 16,955 81,799 8,812 33,936 10,201 80,572 13,195 8,654 48,982 176,428 19,050 16,041 7,840 15,314 7,901 11,210 12,443 6,923 226,574 10,189 8,466 21,256 8,603 5,539 9,731 655,055

6 6 31 13 18 23 109 10 32 9 55 14 4 34 162 18 16 6 13 12 23 9 6 188 14 14 22 17 6 9 520

171 82 369 132 175 200 908 97 401 113 863 151 96 527 1,976 206 182 88 167 86 134 138 78 2,623 117 98 240 104 62 109 7,299

518 249 1,120 400 531 607 2,756 294 1,215 342 2,619 458 292 1,598 5,992 624 552 266 505 261 406 417 236 7,957 354 296 729 315 187 331 22,139

392 188 849 303 402 460 2,090 223 922 259 1,986 348 221 1,212 4,544 473 419 202 383 198 308 317 179 6,034 268 224 553 239 142 251 16,787

222 83 455 174 221 192 1,127 125 384 143 1,222 166 119 736 2,375 283 207 105 224 115 121 174 92 2,745 128 104 278 90 76 130 8,946

Appendix II 259 CHRONIC LUNG DISEASES Association Jasper County Johnson County Laclede County Lafayette County Lawrence County Linn County Livingston County McDonald County Mercer County Miller County Moniteau County Morgan County Newton County Nodaway County Ozark County Pettis County Platte County Polk County Putnam County Ray County St. Clair County Saline County Stone County Sullivan County Taney County Vernon County Webster County Worth County Wright County NEBRASKA CONSTITUENT: ALA OF NEBRASKA Adams County Antelope County Arthur County Banner County Blaine County Boone County Box Butte County Boyd County Brown County Buffalo County Burt County Butler County Cass County Cedar County Chase County Cherry County Cheyenne County Clay County Colfax County Cuming County Custer County Dakota County Dawes County Dawson County Deuel County Dixon County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

99,620 47,685 30,974 32,670 33,124 13,796 14,140 20,010 3,982 22,465 13,256 18,427 49,210 20,712 9,913 37,086 69,994 25,557 4,898 23,661 9,070 22,668 26,841 6,998 34,457 19,488 29,176 2,289 19,580

92 22 34 32 40 14 17 12 1 23 6 34 47 18 21 42 35 25 4 20 16 23 30 9 40 10 21 0 22

1,112 536 340 360 362 155 160 216 46 245 143 213 543 241 114 411 780 288 57 254 104 254 315 80 405 215 313 26 210

3,372 1,627 1,030 1,092 1,100 469 485 656 139 743 435 645 1,648 731 347 1,246 2,367 875 172 770 316 770 955 244 1,229 652 949 78 638

2,557 1,234 781 828 834 356 368 497 105 563 330 489 1,249 554 263 945 1,795 663 131 584 240 584 724 185 932 495 719 59 484

1,355 633 443 460 476 185 185 297 49 326 196 226 690 247 121 516 954 336 59 357 112 305 310 87 396 274 442 30 295

1,660,772

1,140

18,248

55,348

41,970

23,598

29,414 7,288 426 876 578 6,376 12,764 2,563 3,532 40,335 7,922 8,679 24,485 9,631 4,266 6,292 9,481 7,135 10,657 9,989 11,957 18,779 8,872 23,157 2,021 6,312

23 4 0 0 1 3 6 3 1 23 6 4 16 6 4 6 6 8 6 10 10 6 6 12 1 4

334 77 5 9 6 69 130 28 39 450 88 94 263 102 46 69 104 78 120 109 131 196 101 250 22 68

1,014 233 15 29 19 209 395 86 119 1,364 266 286 798 308 140 208 315 238 363 330 398 594 305 757 68 207

769 177 11 22 14 158 299 65 90 1,035 202 217 605 234 106 158 238 181 275 251 302 450 231 574 52 157

379 115 6 13 9 95 217 36 48 549 110 128 369 152 64 91 136 101 143 145 170 305 115 346 28 94

260 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF NEBRASKA (cont.) Dodge County Douglas County Dundy County Fillmore County Franklin County Frontier County Furnas County Gage County Garden County Garfield County Gosper County Grant County Greeley County Hall County Hamilton County Harlan County Hayes County Hitchco*ck County Holt County Hooker County Howard County Jefferson County Johnson County Kearney County Keith County Keya Paha County Kimball County Knox County Lancaster County Lincoln County Logan County Loup County Mc Pherson County Madison County Merrick County Morrill County Nance County Nemaha County Nuckolls County Otoe County Pawnee County Perkins County Phelps County Pierce County Platte County Polk County Red Willow County Richardson County Rock County Saline County Sarpy County Saunders County Scotts Bluff County Seward County

Population

35,304 443,370 2,281 6,940 3,716 3,107 5,430 22,791 2,129 2,045 2,325 745 2,861 51,730 9,454 3,701 1,059 3,440 12,018 697 6,498 8,348 4,572 6,849 8,680 973 4,074 9,186 235,537 33,477 882 672 554 34,567 8,063 5,423 4,101 7,674 5,204 14,720 3,129 3,191 9,898 7,963 30,680 5,616 11,242 9,435 1,730 12,960 120,329 19,231 36,016 16,384

Lung Cancer1

36 328 3 5 4 1 6 13 5 1 0 1 3 36 6 9 3 4 12 0 4 8 10 3 6 0 5 8 118 23 0 3 0 21 10 4 8 9 8 12 5 5 6 4 20 1 12 6 4 12 46 18 30 9

Emphysema

396 4,888 26 76 43 34 62 260 25 23 27 8 30 557 102 42 12 37 128 8 70 95 52 75 95 11 45 103 2,698 358 9 7 6 374 88 58 44 87 59 164 36 34 109 85 316 62 125 107 19 146 1,245 208 387 183

Chronic Bronchitis

1,201 14,826 78 231 130 102 188 788 76 70 81 25 92 1,689 308 128 35 113 389 24 213 287 157 228 288 33 138 312 8,183 1,087 27 22 18 1,133 266 177 134 264 178 497 110 103 330 257 959 187 379 324 57 443 3,775 631 1,174 555

Adult Asthma Pediatric Asthma

911 11,242 59 175 98 78 142 598 57 53 62 19 70 1,281 234 97 27 86 295 18 162 218 119 173 218 25 104 236 6,205 824 21 17 14 859 202 134 102 201 135 377 84 78 250 195 727 142 287 245 44 336 2,863 478 890 421

473 6,240 30 99 46 46 69 290 25 27 29 11 45 775 142 47 15 50 185 9 96 108 60 98 125 13 56 124 2,957 509 15 9 8 513 117 82 61 99 68 202 37 50 140 123 510 80 155 123 25 171 1,983 285 543 222

Appendix II 261 CHRONIC LUNG DISEASES Association Sheridan County Sherman County Sioux County Stanton County Thayer County Thomas County Thurston County Valley County Washington County Wayne County Webster County Wheeler County York County NEW HAMPSHIRE CONSTITUENT: ALA OF NEW HAMPSHIRE Belknap County Carroll County Cheshire County Coos County Grafton County Hillsborough County Merrimack County Rockingham County Strafford County Sullivan County NEW JERSEY CONSTITUENT: ALA OF NEW JERSEY Atlantic County Bergen County Burlington County Camden County Cape May County Cumberland County Essex County Gloucester County Hudson County Hunterdon County Mercer County Middlesex County Monmouth County Morris County Ocean County Passaic County Salem County Somerset County Sussex County Union County Warren County NEW YORK CONSTITUENTS: ALA OF BROOKLYN Kings County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

6,447 3,452 1,479 6,238 6,261 797 7,172 4,632 18,674 9,329 4,019 930 14,554

5 0 1 0 5 0 4 6 13 3 4 0 10

70 38 16 63 71 8 69 52 205 108 46 10 160

213 114 50 193 216 25 210 159 623 326 139 29 487

161 87 38 146 164 19 159 120 472 247 105 22 369

94 50 20 107 81 13 136 61 265 115 52 15 205

1,185,823

849

13,285

40,298

30,554

15,939

52,932 39,382 72,021 32,865 78,237 362,477 127,894 270,643 109,498 39,874

36 46 47 25 61 226 99 183 83 43

591 450 815 372 902 4,027 1,427 3,006 1,249 446

1,792 1,366 2,473 1,128 2,735 12,217 4,330 9,117 3,788 1,352

1,358 1,036 1,875 855 2,074 9,263 3,283 6,913 2,872 1,025

720 497 938 429 963 4,990 1,738 3,731 1,393 540

8,095,542

6,141

91,513

277,593

210,480

105,914

237,988 854,428 421,283 504,268 98,001 140,389 748,322 248,012 553,030 122,389 331,474 712,638 603,214 459,012 490,104 483,050 64,935 282,274 143,139 498,893 98,699

200 655 299 436 117 125 543 200 374 69 252 552 458 308 598 296 52 152 96 312 47

2,691 10,066 4,689 5,433 1,123 1,523 8,356 2,673 6,327 1,377 3,783 8,244 6,721 5,255 5,574 5,342 714 3,257 1,523 5,749 1,093

8,164 30,534 14,223 16,479 3,405 4,621 25,346 8,109 19,192 4,178 11,474 25,007 20,386 15,940 16,909 16,205 2,166 9,879 4,620 17,440 3,316

6,190 23,152 10,784 12,495 2,582 3,504 19,218 6,149 14,552 3,168 8,700 18,961 15,458 12,086 12,821 12,287 1,643 7,490 3,503 13,223 2,514

3,110 9,736 5,772 7,545 1,230 2,062 10,156 3,705 6,968 1,623 4,211 8,657 8,240 5,771 6,291 6,738 920 3,460 2,209 6,139 1,371

18,159,175

12,377

205,358

622,916

472,322

237,291

2,266,242

1,221

24,671

74,835

56,743

33,002

262 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Lung

Cancer1

Association

Population

ALA OF NEW YORK Bronx County New York County Richmond County

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

1,191,319 1,546,508 406,899

556 774 289

12,593 18,952 4,536

38,199 57,488 13,759

28,964 43,590 10,433

18,680 15,029 5,549

ALA OF QUEENS Queens County

1,993,172

1,153

23,226

70,451

53,419

23,619

ALA OF NEW YORK STATE Albany County 293,025 Allegany County 50,567 Broome County 196,531 Cattaraugus County 84,940 Cayuga County 82,164 Chautauqua County 138,310 Chemung County 92,207 Chenango County 50,985 Clinton County 79,780 Columbia County 63,102 Cortland County 48,215 Delaware County 46,388 Dutchess County 265,413 Erie County 933,702 Essex County 37,557 Franklin County 48,669 Fulton County 53,084 Genesee County 60,689 Greene County 48,145 Hamilton County 5,187 Herkimer County 64,021 Jefferson County 111,014 Lewis County 27,424 Livingston County 65,640 Madison County 70,915 Monroe County 714,936 Montgomery County 50,777 Nassau County 1,300,995 Niagara County 217,788 Oneida County 230,704 Onondaga County 457,916 Ontario County 99,526 Orange County 329,795 Orleans County 44,911 Oswego County 123,818 Otsego County 60,570 Putnam County 93,350 Rensselaer County 152,203 Rockland County 280,968 St. Lawrence County 113,147 Saratoga County 197,436 Schenectady County 145,112 Schoharie County 32,075 Schuyler County 19,194 Seneca County 31,939 Steuben County 97,966 Suffolk County 1,370,549

250 46 200 70 69 107 120 47 57 64 43 47 194 923 36 43 56 58 48 1 57 100 18 48 61 512 43 930 211 190 359 100 214 27 88 53 49 139 169 98 157 133 30 14 38 81 907

3,419 556 2,263 912 901 1,535 1,025 549 891 709 537 521 3,008 10,666 427 544 582 663 552 62 707 1,199 284 740 787 8,001 565 15,151 2,436 2,609 5,145 1,108 3,524 491 1,321 690 1,036 1,721 3,106 1,265 2,189 1,663 360 210 351 1,062 15,353

10,371 1,688 6,865 2,766 2,733 4,656 3,109 1,666 2,702 2,152 1,630 1,579 9,123 32,353 1,294 1,651 1,767 2,012 1,673 187 2,144 3,637 861 2,245 2,388 24,271 1,713 45,958 7,388 7,913 15,606 3,361 10,689 1,490 4,006 2,092 3,144 5,220 9,420 3,836 6,639 5,044 1,091 636 1,065 3,221 46,571

7,864 1,280 5,205 2,098 2,073 3,530 2,357 1,263 2,049 1,632 1,236 1,197 6,917 24,531 981 1,252 1,340 1,526 1,269 141 1,626 2,758 653 1,702 1,811 18,403 1,299 34,847 5,602 6,000 11,833 2,548 8,105 1,130 3,037 1,586 2,384 3,958 7,143 2,909 5,034 3,825 827 482 808 2,443 35,312

3,456 716 2,425 1,282 1,173 1,911 1,268 764 1,083 839 658 620 3,447 11,823 484 657 757 875 604 58 897 1,651 452 865 978 9,638 697 15,448 2,943 3,015 6,103 1,363 5,037 645 1,900 775 1,288 1,990 3,926 1,531 2,736 1,819 430 277 453 1,442 18,427

Appendix II 263 CHRONIC LUNG DISEASES Association

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

Sullivan County Tioga County Tompkins County Ulster County Warren County Washington County Wayne County Westchester County Wyoming County Yates County

69,393 52,428 97,239 166,826 61,258 60,170 95,096 900,861 44,151 24,264

56 35 35 133 61 49 46 620 23 21

772 562 1,162 1,909 684 664 1,019 10,462 485 265

2,342 1,706 3,526 5,792 2,076 2,015 3,092 31,734 1,472 803

1,776 1,293 2,673 4,391 1,574 1,528 2,345 24,062 1,116 609

952 793 1,049 2,100 830 843 1,441 10,801 626 351

AFFILIATES: ALA OF CENTRAL NEW YORK Cortland County Franklin County Jefferson County Lewis County Onondaga County Oswego County Saint Lawrence County Tompkins County

48,215 48,669 111,014 27,424 457,916 123,818 113,147 97,239

43 43 100 18 359 88 98 35

537 544 1,199 284 5,145 1,321 1,265 1,162

1,630 1,651 3,637 861 15,606 4,006 3,836 3,526

1,236 1,252 2,758 653 11,833 3,037 2,909 2,673

658 657 1,651 452 6,103 1,900 1,531 1,049

ALA OF FINGER LAKES REGION Cayuga County Chemung County Livingston County Monroe County Ontario County Orleans County Schuyler County Seneca County Steuben County Wayne County Yates County

82,164 92,207 65,640 714,936 99,526 44,911 19,194 31,939 97,966 95,096 24,264

69 120 48 512 100 27 14 38 81 46 21

901 1,025 740 8,001 1,108 491 210 351 1,062 1,019 265

2,733 3,109 2,245 24,271 3,361 1,490 636 1,065 3,221 3,092 803

2,073 2,357 1,702 18,403 2,548 1,130 482 808 2,443 2,345 609

1,173 1,268 865 9,638 1,363 645 277 453 1,442 1,441 351

ALA OF HUDSON VALLEY Greene County Orange County Putnam County Rockland County Sullivan County Ulster County Westchester County

48,145 329,795 93,350 280,968 69,393 166,826 900,861

48 214 49 169 56 133 620

552 3,524 1,036 3,106 772 1,909 10,462

1,673 10,689 3,144 9,420 2,342 5,792 31,734

1,269 8,105 2,384 7,143 1,776 4,391 24,062

604 5,037 1,288 3,926 952 2,100 10,801

1,300,995 1,370,549

930 907

15,151 15,353

45,958 46,571

34,847 35,312

15,448 18,427

50,567 84,940 138,310 933,702 60,689

46 70 107 923 58

556 912 1,535 10,666 663

1,688 2,766 4,656 32,353 2,012

1,280 2,098 3,530 24,531 1,526

716 1,282 1,911 11,823 875

ALA OF NASSAU SUFFOLK Nassau County Suffolk County ALA OF WESTERN NEW YORK Allegany County Cattaraugus County Chautauqua County Erie County Genesee County

264 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF WESTERN NEW YORK (cont.) Niagara County Wyoming County NORTH CAROLINA CONSTITUENT: ALA OF NORTH CAROLINA Alamance County Alexander County Alleghany County Anson County Ashe County Avery County Beaufort County Bertie County Bladen County Brunswick County Buncombe County Burke County Cabarrus County Caldwell County Camden County Carteret County Caswell County Catawba County Chatham County Cherokee County Chowan County Clay County Cleveland County Columbus County Craven County Cumberland County Currituck County Dare County Davidson County Davie County Duplin County Durham County Edgecombe County Forsyth County Franklin County Gaston County Gates County Graham County Granville County Greene County Guilford County Halifax County Harnett County Haywood County Henderson County Hertford County Hoke County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

217,788 44,151

211 23

2,436 485

7,388 1,472

5,602 1,116

2,943 626

7,545,828

6,035

84,513

256,350

194,374

101,517

119,657 31,291 9,808 24,390 24,042 15,711 44,518 20,405 30,822 68,445 194,456 82,357 120,319 75,911 6,812 59,803 22,254 132,400 45,581 22,745 14,207 8,570 93,064 52,739 88,814 284,224 17,789 28,812 141,132 31,998 43,126 202,311 55,010 287,689 44,577 183,856 10,150 7,596 43,802 18,384 387,633 56,313 82,414 51,494 81,205 21,989 30,348

109 16 4 16 22 16 62 25 22 75 155 78 91 75 9 62 23 125 30 22 21 6 75 57 74 166 21 25 152 32 53 142 58 235 42 192 12 8 30 14 306 65 53 58 90 30 17

1,384 349 115 269 280 180 491 217 337 782 2,232 928 1,343 859 77 690 256 1,489 525 260 156 98 1,041 571 964 2,994 194 332 1,587 362 470 2,304 586 3,307 496 2,029 112 85 494 203 4,456 609 896 607 949 239 307

4,197 1,057 349 817 851 546 1,489 658 1,023 2,372 6,770 2,815 4,073 2,606 233 2,092 776 4,518 1,594 788 473 297 3,157 1,733 2,926 9,082 589 1,006 4,813 1,099 1,425 6,989 1,777 10,031 1,505 6,155 339 259 1,499 617 13,516 1,848 2,717 1,842 2,878 725 933

3,182 802 265 619 645 414 1,129 499 776 1,799 5,134 2,134 3,088 1,976 177 1,586 588 3,426 1,209 598 359 225 2,394 1,314 2,218 6,886 447 763 3,649 833 1,081 5,300 1,347 7,606 1,141 4,667 257 197 1,137 468 10,249 1,401 2,060 1,396 2,182 550 707

1,456 428 113 342 284 197 626 315 442 866 2,424 1,088 1,636 989 90 734 276 1,758 560 288 202 108 1,257 778 1,302 4,494 257 356 1,878 416 627 2,586 847 3,570 611 2,579 143 101 576 257 4,809 833 1,206 585 954 322 523

Appendix II 265 CHRONIC LUNG DISEASES Association Hyde County Iredell County Jackson County Johnston County Jones County Lee County Lenoir County Lincoln County Mc Dowell County Macon County Madison County Martin County Mecklenburg County Mitchell County Montgomery County Moore County Nash County New Hanover County Northampton County Onslow County Orange County Pamlico County Pasquotank County Pender County Perquimans County Person County Pitt County Polk County Randolph County Richmond County Robeson County Rockingham County Rowan County Rutherford County Sampson County Scotland County Stanly County Stokes County Surry County Swain County Transylvania County Tyrrell County Union County Vance County Wake County Warren County Washington County Watauga County Wayne County Wilkes County Wilson County Yadkin County Yancey County NORTH DAKOTA CONSTITUENT: ALA OF NORTH DAKOTA Adams County Barnes County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

5,854 113,522 29,967 106,559 9,363 49,199 58,877 58,046 40,058 28,281 18,776 26,157 630,813 14,794 24,124 71,349 90,879 149,837 21,330 143,376 109,905 12,310 35,589 39,367 11,194 33,609 126,630 16,731 121,375 45,985 115,675 90,056 125,057 60,917 52,367 35,712 55,836 43,275 67,251 12,265 28,453 4,005 110,188 42,058 570,353 18,768 13,527 40,904 111,853 62,755 68,242 34,892 16,590

5 86 25 81 10 48 51 48 29 43 18 22 333 21 25 73 68 135 31 82 57 16 31 34 12 34 110 18 116 35 86 83 120 73 52 27 44 34 64 14 27 4 60 32 235 20 6 32 95 65 61 16 17

66 1,272 353 1,175 103 538 648 646 454 336 216 286 7,045 172 265 821 1,012 1,714 239 1,565 1,303 141 388 442 126 375 1,407 200 1,361 498 1,189 1,017 1,404 680 570 373 621 483 767 135 331 44 1,177 456 6,451 212 146 500 1,228 711 750 399 191

201 3,859 1,070 3,565 311 1,632 1,964 1,959 1,376 1,018 656 867 21,370 522 803 2,491 3,070 5,198 725 4,746 3,953 427 1,176 1,340 383 1,137 4,269 606 4,127 1,511 3,606 3,084 4,259 2,064 1,731 1,132 1,883 1,465 2,325 410 1,005 133 3,569 1,383 19,567 643 442 1,516 3,725 2,157 2,274 1,211 580

153 2,926 811 2,703 236 1,238 1,490 1,485 1,044 772 497 658 16,203 396 609 1,889 2,328 3,941 550 3,599 2,997 323 892 1,016 290 862 3,237 459 3,129 1,146 2,734 2,338 3,229 1,565 1,312 859 1,428 1,111 1,763 311 762 101 2,706 1,048 14,836 487 335 1,149 2,824 1,635 1,724 918 440

76 1,524 343 1,497 134 708 834 796 521 314 232 377 8,557 177 344 882 1,243 1,890 286 2,074 1,223 156 517 526 148 458 1,742 181 1,628 678 1,934 1,183 1,671 826 761 575 767 589 857 173 338 57 1,686 620 7,451 247 203 403 1,592 816 970 439 204

637,808

410

7,127

21,618

16,388

8,640

2,707 11,960

1 10

31 138

94 420

71 318

34 145

266 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF NORTH DAKOTA (cont.) Benson County Billings County Bottineau County Bowman County Burke County Burleigh County Cass County Cavalier County Dickey County Divide County Dunn County Eddy County Emmons County Foster County Golden Valley County Grand Forks County Grant County Griggs County Hettinger County Kidder County LaMoure County Logan County McHenry County McIntosh County McKenzie County McLean County Mercer County Morton County Mountrail County Nelson County Oliver County Pembina County Pierce County Ramsey County Ransom County Renville County Richland County Rolette County Sargent County Sheridan County Sioux County Slope County Stark County Steele County Stutsman County Towner County Traill County Walsh County Ward County Wells County Williams County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

6,851 1,068 7,300 3,303 2,269 66,906 116,888 5,025 5,653 2,368 3,551 2,850 4,330 3,808

0 0 3 1 3 43 60 3 5 4 1 6 5 4

67 11 83 37 27 748 1,343 58 65 28 38 33 50 43

202 34 253 113 81 2,269 4,075 175 197 85 116 99 153 130

153 26 192 85 61 1,721 3,090 132 150 65 88 75 116 98

128 17 92 44 26 905 1,451 63 70 26 54 36 52 51

1,849 66,781 2,960 2,846 2,906 2,882 4,775 2,349 6,071 3,458 5,683 9,712 9,399 24,607 6,593 3,725 2,202 8,483 4,646 12,109 5,781 2,814 18,096 14,148 4,445 1,692 4,148 880 22,707 2,228 20,981 3,013 8,538 13,557 58,540 5,208 20,159

0 35 3 1 4 0 3 3 4 5 5 8 8 17 9 5 0 8 9 10 3 1 9 13 4 0 0 1 8 1 20 3 4 8 26 5 18

20 756 34 33 34 33 54 27 69 42 59 107 99 268 70 44 23 94 53 137 66 31 203 130 50 20 35 10 249 25 241 34 97 151 648 61 220

61 2,293 103 99 102 99 163 83 208 129 178 324 299 812 213 134 69 286 161 417 199 95 617 393 152 61 106 29 755 77 732 103 294 459 1,965 185 667

46 1,739 78 75 77 75 124 63 158 98 135 245 227 616 161 102 52 217 122 316 151 72 468 298 115 46 80 22 572 58 555 78 223 348 1,490 140 505

27 870 37 35 35 38 63 28 79 33 95 138 150 358 102 41 36 116 59 157 75 38 241 292 59 19 97 12 325 29 260 39 110 184 815 61 293

Appendix II 267 CHRONIC LUNG DISEASES Association NORTHERN ROCKIES (MONTANA/ WYOMING) CONSTITUENT: ALA OF NORTHERN ROCKIES MONTANA Beaverhead County Big Horn County Blaine County Broadwater County Carbon County Carter County Cascade County Chouteau County Custer County Daniels County Dawson County Deer Lodge County Fallon County Fergus County Flathead County Gallatin County Garfield County Glacier County Golden Valley County Granite County Hill County Jefferson County Judith Basin County Lake County Lewis and Clark County Liberty County Lincoln County Mc Cone County Madison County Meagher County Mineral County Missoula County Musselshell County Park County Petroleum County Phillips County Pondera County Powder River County Powell County Prairie County Ravalli County Richland County Roosevelt County Rosebud County Sanders County Sheridan County Silver Bow County Stillwater County Sweet Grass County Teton County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

1,359,578

887

15,064

45,687

34,641

18,875

879,533 8,809 12,597 7,090 4,131 9,402 1,512 78,558 5,187 12,046 1,996 8,812 9,961 2,957 12,276 71,888 62,561 1,412 12,542 1,033 2,665 17,362 10,118 2,294 25,557 53,587 2,313 18,717 1,961 6,889 1,794 3,781 88,907 4,572 15,795 509 4,797 6,350 1,804 7,004 1,352 35,114 10,161 10,997 10,010 10,185 4,244 34,540 8,076 3,391 6,349

617 14 9 4 1 9 0 73 5 10 3 9 5 1 14 46 23 0 6 1 4 13 3 1 18 34 0 17 1 3 3 3 47 4 17 0 6 5 1 5 0 27 8 5 8 17 3 29 4 3 9

9,803 99 119 71 45 105 17 879 58 135 23 99 117 32 139 798 728 15 119 11 30 185 110 26 272 601 26 206 22 79 20 42 1,018 52 181 6 51 68 21 84 16 393 109 108 97 113 49 399 89 38 69

29,730 299 362 217 138 319 52 2,666 176 409 70 301 354 98 422 2,420 2,207 46 360 34 92 560 334 80 825 1,823 78 625 67 239 61 126 3,089 158 548 17 156 206 62 254 48 1,192 329 326 295 341 148 1,210 270 116 210

22,543 227 274 164 105 242 40 2,021 133 310 53 228 268 74 320 1,835 1,673 35 273 26 69 425 253 61 626 1,382 59 474 51 182 47 96 2,343 120 415 13 118 156 47 192 36 904 250 247 224 259 112 918 205 88 159

12,006 119 247 124 58 127 19 1,060 70 163 24 117 116 43 160 994 746 21 246 15 35 268 148 28 394 718 32 265 26 86 24 53 1,116 58 199 7 72 97 23 76 16 473 155 203 187 143 53 422 113 45 92

268 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

ALA OF NORTHERN ROCKIES (cont.) Toole County Treasure County Valley County Wheatland County Wibaux County Yellowstone County

4,738 876 8,233 2,345 1,139 126,237

8 0 4 1 0 73

51 10 92 26 13 1,422

154 29 280 80 39 4,313

117 22 212 61 29 3,270

72 12 110 31 15 1,670

WYOMING Albany County Big Horn County Campbell County Carbon County Converse County Crook County Fremont County Goshen County Hot Springs County Johnson County Laramie County Lincoln County Natrona County Niobrara County Park County Platte County Sheridan County Sublette County Sweetwater County Teton County Uinta County Washakie County Weston County

480,045 29,251 11,331 32,387 15,543 12,280 5,781 36,128 12,805 4,646 6,796 78,583 13,809 63,241 2,700 25,751 8,618 25,154 5,746 39,722 14,193 20,394 8,686 6,500

270 9 12 16 8 6 4 36 10 5 9 35 6 47 1 14 3 16 0 13 4 8 5 3

5,261 356 123 326 172 129 62 388 144 53 78 885 136 705 32 289 96 287 65 410 166 192 95 72

15,957 1,080 373 988 521 393 188 1,176 437 162 237 2,684 412 2,137 96 878 292 871 196 1,243 504 583 287 219

12,098 819 283 749 395 298 142 891 331 123 179 2,035 312 1,621 73 666 221 660 149 943 382 442 218 166

6,869 293 166 567 217 194 88 546 170 57 85 1,041 252 864 31 343 117 320 76 658 166 402 126 90

11,237,752

9,360

125,868

381,801

289,496

151,149

28,564 107,246 51,634 103,242 61,616 47,042 71,860 40,808 330,892 29,088 38,349 145,266 175,786 40,135 111,407 36,127 47,184 1,380,428 54,071

18 86 30 91 48 32 88 31 248 14 42 164 139 31 84 23 44 1,256 42

306 1,181 569 1,133 734 507 838 439 3,686 320 427 1,634 1,878 440 1,240 399 526 15,772 594

929 3,584 1,725 3,436 2,227 1,539 2,541 1,331 11,182 969 1,295 4,956 5,696 1,335 3,760 1,210 1,594 47,841 1,803

704 2,717 1,308 2,605 1,688 1,167 1,927 1,010 8,479 735 982 3,758 4,319 1,012 2,851 918 1,209 36,275 1,367

433 1,513 728 1,472 673 702 850 613 4,520 413 525 1,930 2,686 573 1,527 506 645 17,469 767

OHIO CONSTITUENT: ALA OF OHIO Adams County Allen County Ashland County Ashtabula County Athens County Auglaize County Belmont County Brown County Butler County Carroll County Champaign County Clark County Clermont County Clinton County Columbiana County Coshocton County Crawford County Cuyahoga County Darke County

Appendix II 269 CHRONIC LUNG DISEASES Association

Population

Defiance County Delaware County Erie County Fairfield County Fayette County Franklin County Fulton County Gallia County Geauga County Greene County Guernsey County Hamilton County Hanco*ck County Hardin County Harrison County Henry County Highland County Hocking County Holmes County Huron County Jackson County Jefferson County Knox County Lake County Lawrence County Licking County Logan County Lorain County Lucas County Madison County Mahoning County Marion County Medina County Meigs County Mercer County Miami County Monroe County Montgomery County Morgan County Morrow County Muskingum County Noble County Ottawa County Paulding County Perry County Pickaway County Pike County Portage County Preble County Putnam County Richland County Ross County Sandusky County Scioto County Seneca County Shelby County Stark County Summit County Trumbull County

39,838 98,208 78,226 123,949 28,505 1,021,578 41,801 33,217 88,591 147,942 40,921 847,202 69,009 31,691 16,119 29,880 40,427 28,926 37,848 60,217 32,574 74,596 53,399 226,825 64,446 134,962 46,358 281,716 448,635 41,089 255,292 67,087 143,855 23,956 41,095 98,208 15,377 570,141 14,528 31,448 84,635 14,736 41,011 20,082 34,221 53,278 27,732 150,829 43,115 35,244 129,697 75,411 62,077 80,777 59,975 47,547 373,024 537,160 226,355

Lung Cancer1 16 52 83 74 36 719 21 23 57 120 46 788 39 26 22 20 36 27 20 34 31 83 34 187 65 122 39 238 387 36 276 53 90 32 30 74 17 484 14 20 78 5 30 25 27 42 16 121 29 12 112 88 39 87 55 42 315 477 204

Emphysema 431 1,077 878 1,369 317 11,560 446 368 976 1,668 451 9,442 763 356 182 322 442 322 368 645 356 867 604 2,593 713 1,507 505 3,095 4,961 469 2,911 756 1,568 264 431 1,091 174 6,481 157 338 938 168 469 213 366 613 298 1,714 474 365 1,462 856 676 890 650 505 4,230 6,112 2,577

Chronic Bronchitis 1,308 3,268 2,665 4,152 962 35,066 1,354 1,116 2,960 5,061 1,368 28,640 2,315 1,079 552 976 1,341 975 1,116 1,957 1,079 2,630 1,833 7,866 2,162 4,572 1,531 9,389 15,047 1,423 8,830 2,294 4,756 802 1,307 3,310 527 19,659 476 1,025 2,844 508 1,424 648 1,111 1,859 904 5,199 1,438 1,108 4,434 2,596 2,051 2,700 1,973 1,532 12,831 18,541 7,817

Adult Asthma Pediatric Asthma 992 2,478 2,020 3,148 730 26,588 1,027 846 2,244 3,837 1,037 21,716 1,755 818 419 740 1,017 740 846 1,484 818 1,994 1,390 5,964 1,639 3,466 1,161 7,119 11,409 1,079 6,695 1,739 3,606 608 991 2,510 400 14,906 361 777 2,156 386 1,080 491 843 1,409 685 3,942 1,090 840 3,362 1,968 1,556 2,047 1,496 1,162 9,729 14,059 5,928

589 1,401 1,044 1,736 390 13,323 640 462 1,250 1,950 576 11,562 963 424 212 447 581 398 707 914 471 892 697 2,865 899 1,831 675 4,002 6,262 521 3,252 885 2,088 337 657 1,352 201 7,332 216 473 1,175 189 516 311 520 660 418 1,942 611 579 1,712 975 902 1,138 882 737 4,833 6,885 2,896

270 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF OHIO (cont.) Tuscarawas County Union County Van Wert County Vinton County Warren County Washington County Wayne County Williams County Wood County Wyandot County OKLAHOMA CONSTITUENT: ALA OF OKLAHOMA Adair County Alfalfa County Atoka County Beaver County Beckham County Blaine County Bryan County Caddo County Canadian County Carter County Cherokee County Choctaw County Cimarron County Cleveland County Coal County Comanche County Cotton County Craig County Creek County Custer County Delaware County Dewey County Ellis County Garfield County Garvin County Grady County Grant County Greer County Harmon County Harper County Haskell County Hughes County Jackson County Jefferson County Johnston County Kay County Kingfisher County Kiowa County Latimer County Le Flore County Lincoln County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

88,543 39,883 30,080 12,165 146,027 63,314 110,156 37,858 119,574 22,819

70 29 22 9 96 44 73 42 79 10

988 440 329 132 1,621 714 1,197 412 1,361 251

2,997 1,334 999 400 4,916 2,167 3,630 1,249 4,129 760

2,272 1,011 757 303 3,728 1,643 2,753 947 3,131 577

1,204 561 432 179 2,016 833 1,613 553 1,531 324

3,339,478

3,069

36,851

111,772

84,754

46,877

20,404 6,025 13,302 6,045 19,949 10,420 34,717 30,881 85,424 44,358 39,019 15,103 2,990 200,977 6,030 108,143 6,641 14,465 67,117 25,572 34,305 4,923 4,245 56,939 26,808 45,765 5,339 6,357 3,476 3,593 11,359 14,102 28,536 6,578 10,302 46,572 13,480 10,671 10,276 46,662 31,318

21 5 21 6 13 14 38 25 57 47 44 16 4 104 4 70 6 13 72 13 53 9 6 53 35 39 10 6 4 5 17 20 23 10 14 58 5 8 12 55 14

214 71 148 65 214 113 390 335 902 486 429 164 32 2,225 66 1,149 74 167 735 281 392 54 47 631 300 492 60 76 37 40 127 163 297 74 113 516 145 116 113 508 339

649 215 450 198 648 343 1,183 1,016 2,735 1,473 1,302 497 98 6,750 201 3,486 223 506 2,230 852 1,190 165 142 1,915 909 1,493 181 230 112 122 385 493 901 225 343 1,566 438 352 342 1,541 1,027

492 163 341 150 491 260 897 771 2,074 1,117 987 377 74 5,118 153 2,643 169 384 1,691 646 902 125 108 1,452 689 1,132 137 174 85 93 292 374 683 170 260 1,188 332 267 259 1,168 779

326 69 182 90 303 153 463 454 1,344 636 553 222 44 2,794 85 1,674 92 177 961 364 433 69 59 788 363 688 73 69 54 48 154 173 464 87 147 645 204 155 147 679 465

Appendix II 271 CHRONIC LUNG DISEASES Association Logan County Love County McClain County McCurtain County McIntosh County Major County Marshall County Mayes County Murray County Muskogee County Noble County Nowata County Okfuskee County Oklahoma County Okmulgee County Osage County Ottawa County Pawnee County Payne County Pittsburg County Pontotoc County Pottawatomie County Pushmataha County Roger Mills County Rogers County Seminole County Sequoyah County Stephens County Texas County Tillman County Tulsa County Wagoner County Washington County Wash*ta County Woods County Woodward County OREGON CONSTITUENT: ALA OF OREGON Baker County Benton County Clackamas County Clatsop County Columbia County Coos County Crook County Curry County Deschutes County Douglas County Gilliam County Grant County Harney County Hood River County Jackson County Jefferson County Josephine County Klamath County Lake County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

30,087 8,550 26,206 34,779 19,006 7,804 12,251 37,635 12,329 70,091 11,362 9,980 11,392 632,865 38,666 42,896 30,891 16,392 65,274 43,022 34,631 62,291 11,474 3,581 68,013 24,756 37,546 43,527 18,540 9,524 543,417 55,223 47,523 11,842 8,300 18,624

30 10 31 38 18 1 14 38 12 81 10 13 6 559 35 40 48 17 44 57 52 68 17 4 53 48 40 52 16 10 452 43 34 9 4 16

328 94 286 369 220 86 142 418 138 768 124 113 127 7,018 424 467 353 180 771 491 390 685 129 39 746 274 407 483 196 102 6,036 584 535 129 98 201

994 286 869 1,119 668 260 430 1,267 419 2,328 377 342 385 21,289 1,287 1,418 1,070 546 2,338 1,490 1,183 2,077 390 118 2,262 830 1,234 1,466 596 308 18,308 1,772 1,622 391 296 610

753 217 659 849 507 197 326 961 317 1,765 286 260 292 16,142 976 1,075 812 414 1,773 1,130 897 1,575 296 90 1,715 630 936 1,112 452 234 13,882 1,343 1,230 296 225 463

438 120 377 541 229 111 149 520 166 1,005 163 130 156 8,760 551 623 391 233 737 545 458 884 154 52 972 345 554 600 289 146 7,489 865 630 172 95 277

3,282,055

2,629

36,889

111,899

84,846

43,688

16,411 77,823 334,773 35,364 44,513 62,156 17,295 21,071 105,731 101,839 2,020 8,037 7,201 19,595 173,243 16,747 74,166 63,160 7,157

25 42 208 34 40 103 14 40 56 127 1 6 4 16 160 14 91 53 10

184 910 3,732 397 481 711 191 257 1,186 1,142 22 90 80 212 1,964 177 849 702 79

560 2,762 11,320 1,204 1,460 2,157 578 778 3,596 3,465 68 272 242 644 5,958 538 2,576 2,128 239

424 2,094 8,583 913 1,107 1,636 438 590 2,727 2,627 52 206 183 489 4,517 408 1,953 1,614 181

218 909 4,565 473 660 783 244 211 1,417 1,364 28 109 100 289 2,247 262 932 870 101

272 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF OREGON (cont.) Lane County Lincoln County Linn County Malheur County Marion County Morrow County Multnomah County Polk County Sherman County Tillamook County Umatilla County Union County Wallowa County Wasco County Washington County Wheeler County Yamhill County PENNSYLVANIA CONSTITUENT: ALA OF PENNSYLVANIA Adams County Allegheny County Armstrong County Beaver County Bedford County Berks County Blair County Bradford County Bucks County Butler County Cambria County Cameron County Carbon County Centre County Chester County Clarion County Clearfield County Clinton County Columbia County Crawford County Cumberland County Dauphin County Delaware County Elk County Erie County Fayette County Forest County Franklin County Fulton County Greene County Huntingdon County Indiana County Jefferson County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

313,344 45,282 104,461 28,549 268,910 9,953 630,573 61,403 1,795 24,283 65,591 24,874 7,334 23,101 400,715 1,570 82,015

273 49 86 20 207 10 506 40 3 21 58 21 10 23 200 1 57

3,587 526 1,159 297 2,947 105 7,276 686 20 281 709 274 82 255 4,419 19 881

10,881 1,596 3,515 899 8,940 318 22,072 2,082 60 854 2,150 830 249 773 13,405 56 2,674

8,251 1,210 2,665 682 6,779 241 16,736 1,579 46 647 1,630 629 189 586 10,164 43 2,027

3,940 542 1,445 466 3,846 158 7,725 831 25 293 974 352 99 324 5,634 17 1,235

12,002,329

10,688

137,136

415,982

315,416

151,857

86,660 1,267,963 73,313 184,287 49,405 355,761 130,547 62,386 587,863 170,799 155,587 5,612 58,690 131,997 421,873 41,723 80,722 36,937 63,906 89,266 209,611 245,456 542,592 34,614 278,114 144,362 4,947 128,255 14,528 42,228 44,755 88,389 46,184

62 1,451 48 216 42 312 126 49 434 131 131 5 64 58 266 26 61 34 57 84 134 203 507 30 230 125 9 87 10 39 22 65 34

972 14,950 834 2,121 556 4,062 1,479 683 6,581 1,922 1,794 63 678 1,610 4,749 479 911 424 749 992 2,464 2,793 6,232 387 3,082 1,636 56 1,456 160 474 515 1,012 516

2,948 45,349 2,530 6,434 1,686 12,322 4,486 2,071 19,962 5,830 5,443 192 2,056 4,883 14,406 1,454 2,764 1,287 2,273 3,010 7,474 8,473 18,905 1,173 9,348 4,963 170 4,416 486 1,439 1,562 3,071 1,564

2,235 34,385 1,918 4,878 1,279 9,343 3,401 1,570 15,136 4,421 4,127 145 1,559 3,703 10,923 1,103 2,095 976 1,723 2,283 5,667 6,425 14,335 890 7,088 3,763 129 3,349 368 1,091 1,185 2,329 1,186

1,162 14,405 941 2,277 655 4,510 1,697 896 7,919 2,266 1,909 74 717 1,310 5,589 519 1,061 459 741 1,227 2,407 3,146 6,749 469 3,858 1,874 64 1,656 205 563 553 1,109 627

Appendix II 273 CHRONIC LUNG DISEASES Association Juniata County Lackawanna County Lancaster County Lawrence County Lebanon County Lehigh County Luzerne County Lycoming County McKean County Mercer County Mifflin County Monroe County Montgomery County Montour County Northampton County Northumberland County Perry County Philadelphia County Pike County Potter County Schuylkill County Snyder County Somerset County Sullivan County Susquehanna County Tioga County Union County Venango County Warren County Washington County Wayne County Westmoreland County Wyoming County York County RHODE ISLAND CONSTITUENT: ALA OF RHODE ISLAND Bristol County Kent County Newport County Providence County Washington County SOUTH CAROLINA CONSTITUENT: ALA OF SOUTH CAROLINA Abbeville County Aiken County Allendale County Anderson County Bamberg County Barnwell County Beaufort County Berkeley County Calhoun County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

22,119 208,390 456,679 94,904 117,631 298,792 314,609 117,408 46,319 121,760 46,965 125,407 719,569 17,585 258,568

14 240 309 101 103 217 272 86 53 105 51 107 528 18 183

246 2,435 5,023 1,088 1,336 3,460 3,704 1,321 522 1,399 530 1,402 8,374 199 2,964

745 7,385 15,238 3,299 4,052 10,495 11,235 4,007 1,583 4,245 1,606 4,252 25,401 602 8,990

565 5,600 11,554 2,502 3,073 7,958 8,519 3,038 1,200 3,219 1,218 3,224 19,260 457 6,816

305 2,447 6,467 1,189 1,517 3,618 3,594 1,558 612 1,512 619 1,697 8,565 231 3,239

93,950 44,273 1,434,968 40,149 17,134 150,066 37,965 80,192 6,074 42,082 41,522 40,270 57,795 43,793 205,339 45,431 372,389 29,212 373,688

64 25 1,664 20 16 164 23 53 5 35 34 25 55 35 233 51 348 25 274

1,087 485 16,035 448 186 1,759 425 911 70 462 465 476 644 493 2,382 515 4,345 319 4,234

3,298 1,472 48,639 1,360 565 5,335 1,290 2,763 212 1,401 1,410 1,444 1,952 1,494 7,227 1,562 13,180 969 12,844

2,501 1,116 36,880 1,031 428 4,045 978 2,095 161 1,062 1,069 1,095 1,480 1,133 5,480 1,184 9,993 735 9,739

1,140 633 19,433 545 250 1,743 510 1,033 75 600 559 453 791 582 2,469 590 4,393 421 4,853

987,704

951

11,258

34,151

25,896

12,591

49,194 161,418 82,586 573,701 120,805

43 172 87 546 103

572 1,853 942 6,522 1,369

1,736 5,621 2,856 19,785 4,153

1,317 4,262 2,166 15,002 3,149

586 2,011 1,052 7,374 1,568

3,839,578

2,968

43,255

131,198

99,482

50,763

24,641 134,008 11,406 160,711 16,446 21,821 110,089 137,591 14,074

9 104 10 110 13 23 88 79 13

280 1,493 125 1,839 181 233 1,263 1,434 157

849 4,528 380 5,577 548 707 3,832 4,351 477

644 3,433 288 4,229 415 536 2,906 3,299 362

317 1,831 162 2,025 234 333 1,374 2,229 191

274 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF SOUTH CAROLINA (cont.) Charleston County Cherokee County Chester County Chesterfield County Clarendon County Colleton County Darlington County Dillon County Dorchester County Edgefield County Fairfield County Florence County Georgetown County Greenville County Greenwood County Hampton County Horry County Jasper County Kershaw County Lancaster County Laurens County Lee County Lexington County Mc Cormick County Marion County Marlboro County Newberry County Oconee County Orangeburg County Pickens County Richland County Saluda County Spartanburg County Sumter County Union County Williamsburg County York County SOUTH DAKOTA CONSTITUENT: ALA OF SOUTH DAKOTA Aurora County Beadle County Bennett County Bon Homme County Brookings County Brown County Brule County Buffalo County Butte County Campbell County Charles Mix County Clark County Clay County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

316,606 49,223 34,355 41,069 30,767 37,350 66,334 29,705 88,035 20,006 22,415 124,682 53,695 353,986 63,594 19,147 174,555 17,055 48,613 58,873 63,155 20,302 205,044 9,533 34,546 29,593 34,433 64,138 87,710 107,042 304,891 17,036 247,206 112,325 30,523 36,980 154,269

216 36 26 40 23 30 64 23 66 14 20 120 52 273 52 9 187 14 42 49 60 14 159 4 18 26 35 48 60 65 208 10 202 75 23 36 120

3,608 553 380 456 340 406 731 312 950 221 248 1,371 590 4,059 727 203 2,031 182 544 659 717 224 2,297 112 368 326 393 741 975 1,259 3,528 192 2,838 1,231 351 388 1,739

10,943 1,676 1,151 1,382 1,031 1,231 2,217 948 2,882 671 751 4,158 1,789 12,313 2,204 615 6,160 551 1,649 1,999 2,175 680 6,969 341 1,116 989 1,191 2,248 2,956 3,818 10,701 584 8,608 3,733 1,065 1,178 5,276

8,297 1,271 873 1,048 782 934 1,681 718 2,186 509 569 3,153 1,356 9,337 1,672 466 4,671 418 1,250 1,515 1,649 516 5,284 259 846 750 903 1,704 2,242 2,895 8,114 443 6,527 2,830 808 893 4,001

4,041 657 481 568 430 546 935 472 1,311 279 314 1,768 763 4,426 804 299 2,080 263 657 794 815 284 2,755 108 532 417 438 782 1,207 1,229 3,701 223 3,081 1,608 377 588 2,034

730,789

502

7,958

24,136

18,298

10,640

3,018 17,134 3,385 7,257 25,956 35,399 5,530 1,755 8,923 1,877 9,305 4,336 13,192

5 16 0 4 8 26 1 0 5 1 8 1 5

33 193 32 84 305 403 57 14 96 22 95 47 159

99 585 96 254 924 1,221 172 44 292 68 289 144 481

75 443 73 193 701 926 130 33 221 51 219 109 365

45 228 67 89 300 454 93 42 133 21 157 62 139

Appendix II 275 CHRONIC LUNG DISEASES Association Codington County Corson County Custer County Davison County Day County Deuel County Dewey County Douglas County Edmunds County Fall River County Faulk County Grant County Gregory County Haakon County Hamlin County Hand County Hanson County Harding County Hughes County Hutchinson County Hyde County Jackson County Jerauld County Jones County Kingsbury County Lake County Lawrence County Lincoln County Lyman County McCook County McPherson County Marshall County Meade County Mellette County Miner County Minnehaha County Moody County Pennington County Perkins County Potter County Roberts County Sanborn County Shannon County Spink County Stanley County Sully County Todd County Tripp County Turner County Union County Walworth County Yankton County Ziebach County TENNESSEE CONSTITUENT: ALA OF TENNESSEE Anderson County Bedford County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

25,433 4,181 6,945 17,732 6,398 4,502 5,870 3,517 4,217 6,868 2,518 8,051 4,954 2,359 5,323 4,161 2,955 1,495 15,348 8,049 1,618 2,907 2,209 1,227 5,761 10,679 21,913 20,448 3,775 5,612 2,734 4,556 21,614 2,040 2,808 140,397 6,496 87,323 3,492 2,866 9,863 2,719 12,198 7,548 2,924 1,477 9,295 6,723 8,620 12,260 5,595 20,989 2,160

18 4 8 16 9 0 4 9 8 6 0 1 6 0 3 5 3 0 9 13 3 0 1 4 3 6 13 8 3 5 4 4 13 3 1 91 5 57 1 0 9 1 12 5 3 0 3 8 5 6 6 17 0

276 40 77 196 71 50 51 38 48 80 29 87 54 24 58 46 31 16 166 92 18 28 25 14 65 120 244 214 37 61 32 51 224 19 31 1,565 68 949 40 32 103 30 97 84 31 16 74 72 96 132 62 236 18

838 120 234 596 214 153 155 115 144 242 87 263 165 72 175 140 95 47 502 279 55 84 76 41 197 363 741 648 113 187 96 155 681 59 95 4,748 206 2,878 120 98 312 91 295 256 93 50 226 217 292 400 188 715 55

635 91 177 452 163 116 118 87 109 183 66 200 125 54 133 106 72 36 381 211 42 63 58 31 149 275 562 492 86 141 73 118 516 44 72 3,600 156 2,182 91 74 236 69 224 194 70 38 171 165 222 304 142 542 42

373 82 96 246 90 60 130 52 56 83 32 120 71 42 78 58 46 24 229 102 22 57 28 17 76 144 299 329 68 80 33 61 353 40 38 1,914 104 1,279 45 38 160 39 303 102 47 21 230 104 117 184 78 280 50

5,432,679

4,957

61,466

186,452

141,378

70,880

70,893 34,528

84 29

818 387

2,480 1,175

1,881 891

870 463

276 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF TENNESSEE (cont.) Benton County Bledsoe County Blount County Bradley County Campbell County Cannon County Carroll County Carter County Cheatham County Chester County Claiborne County Clay County co*cke County Coffee County Crockett County Cumberland County Davidson County Decatur County DeKalb County Dickson County Dyer County Fayette County Fentress County Franklin County Gibson County Giles County Grainger County Greene County Grundy County Hamblen County Hamilton County Hanco*ck County Hardeman County Hardin County Hawkins County Haywood County Henderson County Henry County Hickman County Houston County Humphreys County Jackson County Jefferson County Johnson County Knox County Lake County Lauderdale County Lawrence County Lewis County Lincoln County Loudon County McMinn County McNairy County Macon County

Population

16,291 10,762 101,211 83,370 38,163 12,146 29,184 53,321 35,257 14,677 29,504 7,273 31,953 45,815 14,017 44,144 533,258 10,760 16,007 42,283 36,577 30,406 16,153 37,606 48,016 28,905 19,801 60,257 14,048 53,959 294,494 6,808 24,285 24,905 49,524 19,534 24,418 29,971 20,662 7,841 17,029 9,616 43,609 16,709 374,693 8,205 24,172 39,318 10,881 29,678 39,023 46,210 23,987 18,066

Lung Cancer1

18 12 95 53 69 18 26 46 26 17 42 8 42 48 18 47 478 16 21 31 31 25 21 30 69 31 20 57 14 65 272 16 36 26 44 20 30 35 13 13 13 14 39 14 355 6 25 56 13 35 38 44 29 17

Emphysema

190 123 1,175 955 430 137 336 629 383 168 332 84 368 516 159 516 6,187 125 183 462 409 321 181 431 551 326 227 705 153 623 3,381 77 262 283 573 208 277 349 237 90 194 112 514 198 4,376 101 263 439 120 337 454 528 275 203

Chronic Bronchitis

576 374 3,564 2,896 1,303 417 1,018 1,907 1,163 510 1,008 255 1,116 1,564 482 1,565 18,767 381 555 1,403 1,240 973 549 1,308 1,671 990 687 2,140 466 1,890 10,254 233 795 859 1,738 630 840 1,058 719 272 587 340 1,560 601 13,273 306 799 1,331 363 1,023 1,378 1,602 833 616

Adult Asthma Pediatric Asthma

437 283 2,702 2,196 988 316 772 1,446 882 386 764 194 846 1,186 365 1,187 14,230 289 421 1,064 940 738 417 992 1,267 751 521 1,622 353 1,433 7,775 177 603 652 1,318 478 637 802 545 207 445 257 1,183 456 10,064 232 606 1,009 275 776 1,045 1,214 631 467

193 135 1,215 1,048 506 159 361 606 515 185 391 88 394 607 182 518 6,414 127 202 608 495 479 217 470 600 380 249 703 203 659 3,670 90 361 320 602 302 316 357 258 98 219 114 495 186 4,406 78 351 534 155 382 463 585 302 240

Appendix II 277 CHRONIC LUNG DISEASES Association Madison County Mario County Marshall County Maury County Meigs County Monroe County Montgomery County Moore County Morgan County Obion County Overton County Perry County Pickett County Polk County Putnam County Rhea County Roane County Robertson County Rutherford County Scott County Sequatchie County Sevier County Shelby County Smith County Stewart County Sullivan County Sumner County Tipton County Trousdale County Unicoi County Union County Van Buren County Warren County Washington County Wayne County Weakley County White County Williamson County Wilson County TEXAS CONSTITUENT: ALA OF TEXAS Anderson County Andrews County Angelina County Aransas County Archer County Armstrong County Atascosa County Austin County Bailey County Bandera County Bastrop County Baylor County Bee County Bell County Bexar County Blanco County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

85,825 26,677 26,261 69,590 9,969 34,846 127,156 5,155 18,675 32,165 19,519 7,529 4,648 14,931 59,050 27,825 49,945 53,192 166,086 20,075 10,473 64,371 867,804 16,354 11,521 150,348 123,942 47,300 6,861 17,209 16,192 5,026 36,137 102,192 16,439 32,907 22,708 117,685 83,908

58 23 25 58 9 36 110 3 25 36 29 13 5 20 55 43 62 43 101 14 5 60 611 17 10 162 86 42 9 29 20 4 18 112 18 38 22 65 51

953 298 294 772 113 393 1,384 58 210 365 224 86 53 172 691 315 582 581 1,814 214 118 743 9,480 185 135 1,772 1,363 496 78 204 179 56 409 1,204 190 386 261 1,272 922

2,892 905 891 2,343 343 1,192 4,198 177 636 1,109 679 260 161 521 2,097 954 1,765 1,763 5,502 651 357 2,255 28,756 560 409 5,376 4,135 1,503 236 619 544 171 1,240 3,653 577 1,170 792 3,859 2,798

2,193 686 676 1,777 260 904 3,183 134 482 841 515 197 122 395 1,590 723 1,339 1,337 4,172 493 271 1,710 21,804 425 310 4,076 3,135 1,140 179 470 412 130 940 2,770 438 887 600 2,926 2,122

1,182 360 354 961 129 460 1,853 67 249 414 244 97 59 184 688 364 592 767 2,399 307 140 787 12,521 215 134 1,709 1,756 757 89 191 225 67 472 1,163 199 382 282 1,745 1,190

19,712,389

12,294

210,848

639,570

484,947

300,326

52,121 14,047 77,290 22,819 8,282 2,156 36,389 23,401 6,846 15,816 50,438 4,157 27,739 223,167 1,354,837 8,338

51 9 64 39 12 1 21 12 3 8 46 5 13 142 684 3

602 138 828 256 90 23 365 255 70 182 533 48 298 2,370 14,324 97

1,825 418 2,511 775 272 70 1,107 773 212 553 1,618 146 903 7,189 43,448 293

1,383 317 1,904 588 206 53 839 586 161 419 1,227 111 684 5,451 32,944 222

638 258 1,174 307 122 33 641 341 116 195 790 50 420 3,460 21,237 101

278 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association

Population

Lung Cancer1

Emphysema

ALA OF TEXAS (cont.) Borden County Bosque County Bowie County Brazoria County Brazos County Brewster County Briscoe County Brooks County Brown County Burleson County Burnet County Caldwell County Calhoun County Callahan County Cameron County Camp County Carson County Cass County Castro County Chambers County Cherokee County Childress County Clay County Cochran County co*ke County Coleman County Collin County Collingsworth County Colorado County Comal County Comanche County Concho County Cooke County Coryell County Cottle County Crane County Crockett County Crosby County Culberson County Dallam County Dallas County Dawson County Deaf Smith County Delta County Denton County De Witt County Dickens County Dimmit County Donley County Duval County Eastland County Ector County Edwards County Ellis County El Paso County

766 16,548 83,287 228,859 132,919 8,830 1,887 8,427 36,834 15,560 32,272 32,023 20,590 12,796 324,046 10,933 6,707 30,745 8,314 23,791 43,306 7,586 10,534 3,918 3,375 9,514 428,345 3,267 18,909 73,519 13,530 3,098 32,919 73,822 1,917 4,445 4,503 7,225 3,006 6,553 2,045,309 14,630 19,071 4,946 383,369 19,574 2,236 10,410 3,833 13,624 17,628 124,794 3,657 103,734 694,603

1 20 72 187 51 3 3 1 27 13 36 30 16 13 127 18 5 42 4 18 48 6 8 4 6 9 117 3 14 77 16 3 31 35 1 3 3 4 4 10 1,188 12 8 3 138 18 3 9 5 13 32 88 6 66 225

8 187 915 2,424 1,545 101 20 85 403 169 357 335 219 139 3,139 121 70 337 80 251 480 88 116 39 38 107 4,553 35 208 820 153 35 355 798 21 43 47 74 30 68 22,378 155 183 55 4,154 219 25 101 45 140 201 1,273 45 1,072 7,026

Chronic Bronchitis 25 567 2,777 7,352 4,686 306 61 259 1,224 512 1,083 1,015 663 423 9,521 367 213 1,023 241 763 1,456 267 352 119 116 326 13,810 108 632 2,486 465 106 1,075 2,422 65 131 142 224 91 205 67,880 471 556 168 12,600 664 76 306 136 426 610 3,860 137 3,253 21,312

Adult Asthma Pediatric Asthma 19 430 2,106 5,575 3,553 232 46 196 928 389 821 770 503 321 7,219 278 161 776 183 578 1,104 202 267 91 88 247 10,471 82 479 1,885 352 81 815 1,836 49 99 108 170 69 155 51,469 357 422 127 9,554 503 58 232 103 323 463 2,927 104 2,466 16,160

11 217 1,182 3,572 1,590 112 29 145 528 228 450 515 319 186 6,095 153 108 438 160 373 600 92 148 69 43 125 6,629 48 267 1,002 176 41 493 1,094 26 84 73 122 53 109 29,388 227 364 67 5,652 265 29 196 45 227 224 2,122 34 1,712 12,011

Appendix II 279 CHRONIC LUNG DISEASES Association

Population

Erath County Falls County Fannin County Fayette County Fisher County Floyd County Foard County Fort Bend County Franklin County Freestone County Frio County Gaines County Galveston County Garza County Gillespie County Glassco*ck County Goliad County Gonzales County Gray County Grayson County Gregg County Grimes County Guadalupe County Hale County Hall County Hamilton County Hansford County Hardeman County Hardin County Harris County Harrison County Hartley County Haskell County Hays County Hemphill County Henderson County Hidalgo County Hill County Hockley County Hood County Hopkins County Houston County Howard County Hudspeth County Hunt County Hutchinson County Irion County Jack County Jackson County Jasper County Jeff Davis County Jefferson County Jim Hogg County Jim Wells County Johnson County Jones County Karnes County Kaufman County Kendall County

31,367 17,500 28,366 21,276 4,273 8,201 1,676 336,822 9,736 17,646 15,837 14,871 244,993 4,602 19,994 1,382 6,989 17,485 23,593 102,019 112,948 23,336 80,453 36,702 3,630 7,651 5,349 4,565 49,147 3,202,021 59,781 5,142 6,125 89,304 3,527 68,988 519,661 30,559 23,705 37,259 30,350 22,033 32,076 3,192 70,239 24,041 1,724 7,440 13,671 33,438 2,364 241,219 5,011 40,055 118,200 18,625 15,188 65,535 21,190

Lung

Cancer1

21 18 29 9 9 1 0 124 9 17 12 8 199 4 16 0 4 12 25 109 87 16 56 21 4 9 3 5 32 1,699 51 0 5 43 1 116 162 40 20 47 39 39 25 3 58 22 1 6 8 40 1 256 0 32 86 16 9 47 17

Emphysema

Chronic Bronchitis

354 193 324 241 47 83 19 3,410 109 197 162 141 2,671 47 230 13 76 186 265 1,137 1,233 255 858 373 41 86 55 50 521 34,248 643 60 69 996 36 789 4,936 340 240 423 334 248 351 33 775 257 19 81 147 361 26 2,674 51 409 1,260 212 169 694 234

1,074 587 982 732 144 252 57 10,344 330 599 490 429 8,102 143 698 41 230 563 803 3,450 3,739 774 2,601 1,131 124 262 168 152 1,582 103,886 1,949 183 208 3,022 110 2,393 14,974 1,032 728 1,284 1,012 752 1,063 99 2,350 780 57 246 447 1,095 79 8,110 155 1,239 3,823 643 512 2,105 711

Adult Asthma Pediatric Asthma 814 445 744 555 109 191 43 7,843 250 454 372 325 6,143 108 529 31 174 427 609 2,616 2,835 587 1,973 857 94 199 128 115 1,199 78,771 1,478 139 158 2,292 84 1,814 11,354 783 552 974 768 570 806 75 1,782 591 43 187 339 830 60 6,149 118 940 2,898 488 389 1,596 539

412 244 361 275 59 142 23 5,813 132 238 269 289 3,554 78 247 26 103 271 316 1,391 1,634 335 1,236 629 48 100 88 66 764 48,789 900 60 82 1,215 58 871 10,119 418 409 480 430 293 462 54 988 366 26 108 204 497 34 3,344 85 681 1,815 238 209 1,024 296

280 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF TEXAS (cont.) Kenedy County Kent County Kerr County Kimble County King County Kinney County Kleberg County Knox County Lamar County Lamb County Lampasas County La Salle County Lavaca County Lee County Leon County Liberty County Limestone County Lipscomb County Live Oak County Llano County Loving County Lubbock County Lynn County McCulloch County McLennan County McMullen County Madison County Marion County Martin County Mason County Matagorda County Maverick County Medina County Menard County Midland County Milam County Mills County Mitchell County Montague County Montgomery County Moore County Morris County Motley County Nacogdoches County Navarro County Newton County Nolan County Nueces County Ochiltree County Oldham County Orange County Palo Pinto County Panola County Parker County Parmer County

Population 452 879 42,667 4,141 359 3,474 30,103 4,225 45,880 14,762 17,738 6,036 18,838 14,885 14,481 65,154 20,747 2,962 10,149 13,449 116 228,220 6,714 8,715 203,214 795 11,852 10,894 5,019 3,673 37,987 47,660 36,910 2,323 119,120 24,197 4,748 8,832 18,573 271,801 19,582 13,360 1,330 56,243 41,600 14,258 16,433 315,723 8,791 2,158 84,769 25,889 23,047 82,266 10,299

Lung Cancer1 0 1 53 8 0 4 21 5 46 12 22 4 23 12 26 70 23 1 20 23 0 148 4 9 164 1 9 16 4 0 29 10 29 4 94 27 6 5 20 194 13 16 3 46 46 21 12 178 9 3 94 32 25 57 5

Emphysema 5 10 492 46 4 40 320 45 509 154 191 63 211 156 162 707 227 32 110 169 1 2,502 69 94 2,240 9 139 123 50 42 391 448 395 26 1,229 260 54 100 209 2,875 194 147 15 642 454 153 177 3,293 91 19 917 285 250 894 102

Chronic Bronchitis 14 30 1,491 140 11 120 971 138 1,544 467 579 192 641 473 490 2,143 690 96 335 512 4 7,590 209 284 6,793 27 420 374 150 126 1,186 1,360 1,198 79 3,727 789 163 305 633 8,720 590 445 46 1,947 1,378 463 536 9,988 276 58 2,783 866 759 2,711 311

Adult Asthma Pediatric Asthma 11 23 1,131 106 8 91 736 104 1,170 354 439 146 486 359 372 1,625 523 73 254 388 3 5,755 159 216 5,151 21 319 284 114 96 899 1,031 909 60 2,826 598 124 231 480 6,612 447 337 35 1,477 1,045 351 406 7,573 209 44 2,110 657 576 2,056 236

7 12 525 56 6 44 465 64 635 239 266 96 252 238 197 958 296 45 148 117 2 3,260 112 131 2,863 10 139 142 91 48 633 944 561 31 1,975 365 61 113 248 4,256 351 190 17 714 600 217 247 5,108 145 47 1,253 364 338 1,204 184

Appendix II 281 CHRONIC LUNG DISEASES Association

Population

Pecos County Polk County Potter County Presidio County Rains County Randall County Reagan County Real County Red River County Reeves County Refugio County Roberts County Robertson County Rockwall County Runnels County Rusk County Sabine County San Augustine County San Jacinto County San Patricio County San Saba County Schleicher County Scurry County Shackelford County Shelby County Sherman County Smith County Somervell County Starr County Stephens County Sterling County Stonewall County Sutton County Swisher County Tarrant County Taylor County Terrell County Terry County Throckmorton County Titus County Tom Green County Travis County Trinity County Tyler County Upshur County Upton County Uvalde County Val Verde County Van Zandt County Victoria County Walker County Waller County Ward County Washington County Webb County Wharton County Wheeler County Wichita County Wilbarger County

16,087 50,182 108,289 8,554 8,589 98,779 4,232 2,701 13,740 14,308 7,899 936 15,613 37,202 11,518 45,743 10,513 8,101 21,828 70,737 5,817 2,970 18,001 3,288 22,882 2,866 168,070 6,385 55,443 9,732 1,384 1,796 4,468 8,280 1,354,040 122,036 1,174 12,892 1,704 25,423 102,685 709,182 12,611 20,373 35,821 3,767 25,448 43,637 43,961 81,672 54,802 27,248 11,795 29,119 186,798 40,120 5,286 128,497 14,076

Lung Cancer1 9 44 92 0 14 57 5 4 22 14 12 1 12 23 16 43 10 10 29 44 4 6 22 3 32 0 129 4 13 13 0 4 3 0 771 90 3 1 3 35 75 334 22 23 32 0 22 20 57 73 48 12 9 18 48 36 1 129 17

Emphysema 170 582 1,164 87 97 1,063 39 31 156 145 87 10 167 401 124 497 125 93 243 727 61 30 195 36 253 31 1,857 65 509 108 14 20 47 89 14,722 1,329 13 132 19 270 1,117 7,975 146 237 391 37 258 432 492 855 661 303 119 326 1,775 422 58 1,434 153

Chronic Bronchitis 515 1,766 3,532 264 293 3,223 118 94 474 439 263 30 507 1,215 377 1,509 380 281 737 2,206 184 91 592 108 766 94 5,633 198 1,545 326 41 61 141 271 44,658 4,030 38 400 59 819 3,390 24,190 444 720 1,186 112 784 1,310 1,493 2,594 2,004 918 360 989 5,384 1,280 175 4,351 464

Adult Asthma Pediatric Asthma 390 1,339 2,678 200 222 2,444 89 72 359 333 199 23 384 921 286 1,144 288 213 559 1,672 139 69 449 82 581 71 4,271 150 1,172 247 31 46 107 206 33,861 3,056 29 304 44 621 2,570 18,342 337 546 899 85 594 993 1,132 1,967 1,519 696 273 750 4,083 970 133 3,299 352

253 604 1,628 147 114 1,484 87 33 176 248 113 15 238 557 172 668 115 103 299 1,182 94 51 265 49 321 43 2,350 108 1,140 136 25 25 73 123 19,783 1,777 18 217 22 394 1,497 9,427 152 241 518 70 437 788 592 1,309 571 376 206 392 3,635 637 76 1,745 205

282 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF TEXAS (cont.) Willacy County Williamson County Wilson County Winkler County Wise County Wood County Yoakum County Young County Zapata County Zavala County UTAH CONSTITUENT: ALA OF UTAH Beaver County Box Elder County Cache County Carbon County Daggett County Davis County duch*esne County Emery County Garfield County Grand County Iron County Juab County Kane County Millard County Morgan County Piute County Rich County Salt Lake County San Juan County Sanpete County Sevier County Summit County Tooele County Uintah County Utah County Wasatch County Washington County Wayne County Weber County VERMONT CONSTITUENT: ALA OF VERMONT Addison County Bennington County Caledonia County Chittenden County Essex County Franklin County Grand Isle County Lamoille County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

19,599 223,665 31,304 7,971 44,326 34,317 7,969 17,555 11,446 11,887

3 110 9 6 20 61 5 27 5 4

189 2,294 322 79 476 393 78 194 110 116

573 6,958 976 240 1,445 1,193 238 587 335 351

434 5,275 740 182 1,096 905 180 445 254 266

372 3,757 523 143 667 430 146 247 217 221

2,100,562

451

20,954

63,558

48,191

37,367

5,901 41,930 87,227 21,021 722 233,600 14,514 11,013 4,294 8,070 28,777 7,602 6,219 12,280 7,032 1,407 1,858 845,913 13,640 21,590 18,435 26,798 33,474 25,637 339,904 13,273 82,276 2,358 183,797

5 8 6 8 0 44 3 6 1 9 12 4 3 0 3 0 0 194 0 6 6 1 9 10 35 3 26 0 49

58 395 871 215 7 2,224 132 101 44 86 293 72 63 111 66 15 17 8,613 124 210 176 277 334 240 3,337 127 824 23 1,899

177 1,198 2,643 651 22 6,746 400 306 133 260 889 217 190 336 200 45 51 26,125 377 638 534 842 1,012 729 10,123 384 2,501 69 5,760

134 908 2,004 494 17 5,115 303 232 101 197 674 165 144 255 152 34 38 19,809 286 484 405 638 767 553 7,675 291 1,896 53 4,367

107 828 1,548 356 12 4,532 304 228 73 125 491 150 108 260 140 22 40 14,429 284 401 355 441 597 511 6,235 257 1,451 44 3,038

590,579

451

6,741

20,446

15,505

7,500

35,150 35,936 28,562 142,487 6,585 43,973 6,229 21,638

13 36 20 112 5 32 4 14

398 413 318 1,664 74 475 70 245

1,208 1,253 964 5,047 226 1,440 213 743

916 950 731 3,827 171 1,092 162 563

457 446 392 1,676 86 655 82 282

Appendix II 283 CHRONIC LUNG DISEASES Association Orange County Orleans County Rutland County Washington County Windham County Windsor County VIRGINIA CONSTITUENT: ALA OF VIRGINIA Accomack County Albemarle County Alleghany County Amelia County Amherst County Appomattox County Arlington County Augusta County Bath County Bedford County Bland County Botetourt County Brunswick County Buchanan County Buckingham County Campbell County Caroline County Carroll County Charles City County Charlotte County Chesterfield County Clarke County Craig County Culpeper County Cumberland County Dickenson County Dinwiddie County Essex County Fairfax County Fauquier County Floyd County Fluvanna County Franklin County Frederick County Giles County Gloucester County Goochland County Grayson County Greene County Greensville County Halifax County Hanover County Henrico County Henry County Highland County Isle of Wight County James City County King and Queen County King George County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

27,866 25,366 62,543 56,178 42,699 55,367

26 21 51 48 30 39

310 279 726 642 488 639

939 846 2,201 1,946 1,481 1,939

712 642 1,669 1,476 1,123 1,471

384 359 753 712 539 677

6,789,225

4,975

77,081

233,821

177,294

87,625

32,252 79,417 12,197 10,400 29,978 13,146 174,607 60,296 4,911 56,728 6,805 28,657 17,388 28,986 14,629 50,102 21,989 27,776 7,153 12,323 250,161 12,718 4,877 33,107 7,846 16,868 25,477 9,081 927,895 53,939 13,063 18,908 44,604 55,667 16,244 34,942 17,406 16,399 14,044 10,908 36,736 82,302 241,766 55,842 2,486 29,181 44,488 6,500 17,187

49 49 9 1 26 12 91 48 1 49 6 23 13 27 12 53 18 32 1 20 160 13 1 22 8 16 21 9 364 38 8 17 27 29 16 39 13 20 5 13 44 62 220 43 4 25 20 8 18

370 930 140 116 347 149 2,187 685 58 650 80 334 203 323 172 573 245 327 83 141 2,660 149 56 369 87 186 294 105 10,549 597 152 214 518 616 191 383 208 192 154 131 420 936 2,796 650 29 326 510 74 186

1,123 2,820 424 353 1,053 451 6,635 2,077 177 1,972 242 1,013 616 978 521 1,738 743 991 250 427 8,070 452 171 1,119 265 564 893 317 31,998 1,810 460 650 1,572 1,868 579 1,160 632 583 467 398 1,273 2,840 8,482 1,971 89 990 1,548 223 565

851 2,138 321 267 798 342 5,031 1,575 134 1,495 184 768 467 742 395 1,318 564 751 190 323 6,119 343 130 848 201 427 677 240 24,262 1,372 349 493 1,192 1,416 439 880 479 442 354 302 965 2,154 6,432 1,494 68 750 1,174 169 429

402 926 153 141 363 172 1,529 778 54 711 78 340 204 397 168 632 300 318 88 157 3,866 148 59 453 108 238 310 112 11,929 752 157 246 534 776 187 501 186 190 201 115 465 1,056 2,939 665 28 395 556 84 253

284 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF VIRGINIA (cont.) King William County Lancaster County Lee County Loudoun County Louisa County Lunenburg County Madison County Mathews County Mecklenburg County Middlesex County Montgomery County Nelson County New Kent County Northampton County Northumberland County Nottoway County Orange County Page County Patrick County Pittsylvania County Powhatan County Prince Edward County Prince George County Prince William County Pulaski County Rappahannock County Richmond County Roanoke County Rockbridge County Rockingham County Russell County Scott County Shenandoah County Smyth County Southampton County Spotsylvania County Stafford County Surry County Sussex County Tazewell County Warren County Washington County Westmoreland County Wise County Wythe County York County Alexandria City2 Bedford City2 Bristol City2 Buena Vista City2 Charlottesville City2 Chesapeake City2 Clifton Forge City2 Colonial Heights City2 Covington City2

Population 12,819 11,339 23,862 144,514 24,540 11,989 12,636 9,105 31,046 9,633 76,884 13,901 12,870 12,721 11,473 15,168 25,374 23,056 18,446 56,536 21,492 19,234 28,333 262,414 34,405 7,329 8,680 81,264 19,275 63,234 28,890 22,644 34,721 32,789 17,524 83,846 89,668 6,496 10,054 46,659 30,083 49,574 16,319 39,123 26,270 57,554 114,978 6,590 16,988 6,624 36,988 199,407 4,249 16,431 6,924

Lung Cancer1 8 16 34 48 21 21 12 16 29 10 46 20 10 20 17 14 17 22 23 46 13 17 17 101 39 4 5 72 5 35 29 25 32 30 14 55 43 13 18 60 23 66 23 47 26 34 66 3 25 10 32 140 9 25 9

Emphysema 141 137 265 1,583 275 139 143 109 360 116 941 160 147 143 139 178 291 266 217 646 247 229 312 2,744 404 86 105 950 225 719 326 266 408 381 203 878 940 72 115 526 340 581 188 433 304 617 1,452 78 203 78 455 2,143 50 194 83

Chronic Bronchitis 429 415 805 4,803 835 421 433 331 1,091 352 2,854 484 446 435 421 540 883 806 660 1,958 751 693 946 8,324 1,226 261 318 2,881 683 2,180 987 807 1,236 1,156 616 2,664 2,852 218 350 1,596 1,033 1,764 571 1,315 921 1,871 4,403 237 616 238 1,379 6,501 153 589 251

Adult Asthma Pediatric Asthma 325 315 611 3,642 633 319 328 251 827 267 2,164 367 338 330 319 410 669 611 500 1,485 569 526 717 6,312 930 198 242 2,185 518 1,653 749 612 938 876 467 2,020 2,162 165 265 1,210 783 1,337 433 997 698 1,419 3,338 180 467 181 1,046 4,929 116 447 190

180 118 327 2,068 328 145 166 98 376 101 751 173 162 168 118 175 317 284 210 716 265 212 400 4,219 396 84 89 953 227 813 382 260 401 392 212 1,343 1,433 90 126 616 392 574 200 543 320 872 967 73 184 74 354 3,002 47 185 75

Appendix II 285 CHRONIC LUNG DISEASES Association Danville City2 Emporia City2 Fairfax City2 Falls Church City2 Franklin City2 Fredericksburg City2 Galax City2 Hampton City2 Harrisonburg City2 Hopewell City2 Lexington City2 Lynchburg City2 Manassas City2 Manassas Park City2 Martinsville City2 Newport News City2 Norfolk City2 Norton City2 Petersburg City2 Poquoson City2 Portsmouth City2 Radford City2 Richmond City2 Roanoke City2 Salem City2 Staunton City2 Suffolk City2 Virginia Beach City2 Waynesboro City2 Williamsburg City2 Winchester City2 WASHINGTON CONSTITUENT: ALA OF WASHINGTON Adams County Asotin County Benton County Chelan County Clallam County Clark County Columbia County Cowlitz County Douglas County Ferry County Franklin County Garfield County Grant County Grays Harbor County Island County Jefferson County King County Kitsap County Kittitas County Klickitat County Lewis County Lincoln County Mason County Okanogan County

Population

Lung

Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

51,710 5,747 20,774 9,763 8,474 19,028 6,651 136,706 33,931 22,962 7,343 64,261 32,656 7,736 15,282 178,001 227,108 4,057 34,853 11,431 99,049 15,559 191,001 93,797 24,225 24,619 62,675 430,656 19,064 12,363 22,396

70 9 21 5 9 18 5 108 9 30 8 58 10 5 13 135 208 3 40 4 116 5 209 98 27 31 36 194 20 8 25

605 65 252 119 94 233 79 1,547 426 258 97 755 351 80 181 1,936 2,592 45 401 125 1,091 202 2,285 1,102 292 296 685 4,648 222 169 266

1,835 198 764 361 284 706 240 4,694 1,293 782 295 2,290 1,065 242 550 5,873 7,863 138 1,216 378 3,309 613 6,930 3,343 887 899 2,079 14,100 673 512 807

1,391 150 580 274 215 535 182 3,559 981 593 224 1,737 808 184 417 4,453 5,962 104 922 287 2,509 464 5,255 2,535 673 682 1,577 10,691 510 388 612

605 74 211 97 118 186 74 1,781 292 306 46 739 491 128 170 2,598 2,883 55 431 166 1,397 111 2,055 1,079 251 258 901 6,412 227 59 248

5,687,832

3,695

63,216

191,748

145,393

78,244

15,339 21,286 136,132 60,169 64,273 327,418 4,158 91,409 33,600 7,163 46,511 2,317 70,667 67,463 71,747 26,275 1,654,329 232,933 31,403 19,361 68,094 9,766 49,826 38,286

9 14 96 43 68 228 5 84 22 6 21 3 40 96 43 36 954 133 22 10 57 8 61 38

148 231 1,433 648 739 3,521 47 1,004 368 75 450 26 724 743 794 309 19,246 2,525 369 206 734 109 563 412

448 701 4,348 1,966 2,242 10,679 142 3,044 1,115 226 1,364 78 2,198 2,254 2,410 937 58,378 7,659 1,120 624 2,228 330 1,707 1,249

340 531 3,297 1,490 1,700 8,098 108 2,308 846 172 1,034 59 1,666 1,709 1,827 711 44,265 5,808 850 473 1,689 250 1,294 947

292 312 2,155 901 797 4,923 55 1,301 483 116 878 32 1,188 951 997 301 19,715 3,430 360 300 1,016 134 654 575

286 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF WASHINGTON (cont.) Pacific County Pend Oreille County Pierce County San Juan County Skagit County Skamania County Snohomish County Spokane County Stevens County Thurston County Wahkiakum County Walla Walla County Whatcom County Whitman County Yakima County WEST VIRGINIA CONSTITUENT: ALA OF WEST VIRGINIA Barbour County Berkeley County Boone County Braxton County Brooke County Cabell County Calhoun County Clay County Doddridge County Fayette County Gilmer County Grant County Greenbrier County Hampshire County Hanco*ck County Hardy County Harrison County Jackson County Jefferson County Kanawha County Lewis County Lincoln County Logan County Mc Dowell County Marion County Marshall County Mason County Mercer County Mineral County Mingo County Monongalia County Monroe County Morgan County Nicholas County Ohio County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

20,855 11,523 675,962 12,545 99,389 9,779 585,487 408,221 39,591 202,264 3,862 53,671 157,244 38,706 218,808

34 10 391 12 77 6 303 309 30 133 3 39 92 17 142

239 123 7,392 150 1,100 104 6,395 4,517 411 2,226 44 605 1,769 476 2,241

726 372 22,424 456 3,336 315 19,398 13,702 1,247 6,752 132 1,835 5,365 1,442 6,799

551 282 17,003 346 2,529 239 14,708 10,389 946 5,120 100 1,391 4,068 1,094 5,155

260 177 9,724 133 1,385 151 8,451 5,686 646 2,860 51 708 2,089 372 3,685

1,811,688

2,040

21,030

63,797

48,372

21,746

16,106 71,021 26,164 13,220 26,015 94,112 7,945 10,519 7,503 47,094 7,180 11,114 35,349 19,148 34,010 11,857 70,808 27,980 41,445 201,477 17,609 22,185 41,023 29,997 56,466 35,235 25,933 64,342 27,044 31,911 77,452 13,191 13,706 27,557 48,232

9 56 32 23 27 117 5 8 5 49 10 4 40 17 36 16 84 25 35 292 26 42 62 34 74 43 35 72 27 40 42 16 16 35 47

184 808 295 151 311 1,132 89 114 84 541 85 129 416 218 406 139 822 322 477 2,386 205 247 459 330 670 409 298 755 313 344 950 153 164 309 578

560 2,451 896 457 944 3,434 270 347 255 1,642 256 390 1,262 661 1,230 422 2,492 977 1,446 7,238 620 750 1,392 1,001 2,033 1,242 903 2,290 950 1,045 2,882 464 497 938 1,754

424 1,859 679 347 716 2,603 205 263 193 1,245 194 296 957 501 933 320 1,890 741 1,096 5,488 470 569 1,056 759 1,541 942 685 1,737 720 792 2,185 352 376 711 1,330

202 911 344 169 280 990 107 154 101 584 82 135 404 246 370 137 851 345 513 2,251 211 303 554 424 626 421 323 744 328 475 750 159 148 369 514

Appendix II 287 CHRONIC LUNG DISEASES Association Pendleton County Pleasants County Pocahontas County Preston County Putnam County Raleigh County Randolph County Ritchie County Roane County Summers County Taylor County Tucker County Tyler County Upshur County Wayne County Webster County Wetzel County Wirt County Wood County Wyoming County WISCONSIN CONSTITUENT: ALA OF WISCONSIN Adams County Ashland County Barron County Bayfield County Brown County Buffalo County Burnett County Calumet County Chippewa County Clark County Columbia County Crawford County Dane County Dodge County Door County Douglas County Dunn County Eau Claire County Florence County Fond du Lac County Forest County Grant County Green County Green Lake County Iowa County Iron County Jackson County Jefferson County Juneau County Kenosha County Kewaunee County La Crosse County Lafayette County Langlade County Lincoln County

Population

Lung Cancer1

Emphysema

Chronic Bronchitis

Adult Asthma Pediatric Asthma

8,066 7,498 9,093 29,805 51,195 79,232 28,672 10,381 15,323 13,919 15,359 7,592 9,789 23,546 41,978 10,238 18,307 5,710 86,694 27,341

3 10 5 29 40 77 31 17 13 20 23 6 12 27 52 10 21 6 105 32

95 86 107 337 580 902 335 120 173 164 177 89 113 271 483 115 211 64 1,011 304

287 260 326 1,021 1,761 2,737 1,017 363 525 498 537 271 342 822 1,467 347 640 195 3,067 923

218 197 247 774 1,335 2,075 771 276 398 378 407 205 260 623 1,112 263 485 148 2,325 700

93 94 103 391 664 1,013 335 127 201 157 189 87 120 291 518 138 225 76 1,024 375

5,222,124

3,498

58,099

176,232

133,623

71,626

18,427 16,443 43,839 15,187 214,942 14,240 14,639 38,468 54,566 33,139 51,148 16,598 424,665 83,007 27,049 43,128 39,036 89,235 5,179 94,559 9,677 49,292 33,465 19,508 22,333 6,346 17,735 73,601 23,800 144,388 19,875 102,425 16,177 20,486 29,750

16 9 29 12 120 8 13 12 31 18 53 10 178 73 21 43 9 34 0 60 13 40 18 14 12 12 12 49 36 94 8 58 21 12 22

220 181 479 168 2,370 157 167 403 593 349 570 179 4,946 917 305 482 440 1,010 57 1,045 106 547 368 218 242 75 195 824 263 1,589 216 1,160 174 227 329

666 548 1,452 510 7,188 477 505 1,223 1,799 1,060 1,728 542 15,004 2,783 925 1,461 1,335 3,063 174 3,169 321 1,658 1,117 662 733 228 591 2,500 796 4,819 656 3,518 529 689 999

505 415 1,101 387 5,450 362 383 927 1,364 804 1,310 411 11,377 2,110 701 1,107 1,012 2,323 132 2,403 244 1,257 847 502 556 173 448 1,895 604 3,654 497 2,667 401 522 757

201 234 634 211 3,025 200 188 615 798 523 699 249 5,039 1,160 357 586 515 1,163 72 1,323 139 683 473 263 330 71 252 991 334 2,043 290 1,333 241 284 414

288 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1 ESTIMATED PREVALENCE AND INCIDENCE OF LUNG DISEASE BY COUNTY, STATE, AND LUNG ASSOCIATION, 1998 (continued) CHRONIC LUNG DISEASES Association ALA OF WISCONSIN (cont.) Manitowoc County Marathon County Marinette County Marquette County Menominee County Milwaukee County Monroe County Oconto County Oneida County Outagamie County Ozaukee County Pepin County Pierce County Polk County Portage County Price County Racine County Richland County Rock County Rusk County St. Croix County Sauk County Sawyer County Shawano County Sheboygan County Taylor County Trempealeau County Vernon County Vilas County Walworth County Washburn County Washington County Waukesha County Waupaca County Waushara County Winnebago County Wood County

Population

82,454 123,082 43,009 15,125 4,977 911,536 39,513 33,878 35,750 156,395 81,132 7,145 35,527 38,786 64,818 15,715 185,537 17,859 150,720 15,194 58,915 53,373 16,083 38,818 109,986 19,247 26,493 27,364 21,257 85,481 15,427 113,899 353,035 50,515 21,648 149,995 76,084

Lung Cancer1

57 58 39 22 9 710 22 26 38 101 40 5 12 43 34 12 134 14 131 12 30 27 20 22 90 6 14 13 20 65 16 53 211 43 23 116 40

Emphysema

917 1,337 477 173 44 10,153 422 371 415 1,693 909 77 391 419 727 174 2,029 196 1,663 167 626 588 178 429 1,216 204 295 300 250 978 173 1,243 3,934 558 247 1,721 834

Chronic Bronchitis

2,782 4,056 1,447 524 134 30,797 1,280 1,127 1,259 5,134 2,758 233 1,186 1,272 2,206 529 6,155 595 5,046 506 1,898 1,782 540 1,301 3,687 618 896 911 759 2,966 525 3,771 11,934 1,691 748 5,221 2,530

Adult Asthma Pediatric Asthma

2,109 3,075 1,097 398 101 23,352 970 854 955 3,893 2,092 176 899 965 1,673 401 4,667 452 3,826 383 1,439 1,351 409 986 2,796 469 679 691 575 2,249 398 2,859 9,049 1,283 567 3,959 1,918

1,132 1,802 595 191 108 12,461 605 484 429 2,313 1,089 108 503 575 867 217 2,669 253 2,115 217 914 754 224 543 1,537 301 361 390 243 1,077 207 1,647 4,818 708 277 1,871 1,088

Notes: (1) Lung cancer estimates are for 1997. 1998 data has not been released as of this printing. (2) City population estimates overlap with county population estimates. Please do not add the two population estimates to calculate disease prevalence or incidence, as the existing overlap would overestimate disease in your community. (3) Does not include the population of Holliston Town, Natick Town, Newton City, and Sherborn Town. These are in the territory serviced by the ALA of Greater Norfolk County. Sources: (1) U.S. Census Bureau, Population Estimates Branch: County Resident Population by Age Group, July 1, 1998. (2) U.S. Census Bureau, Population Estimates Branch: Estimates of Population of Minor Civil Divisions: Annual Time Series, July 1, 1998. Reprinted by permission of the American Lung Association.

APPENDIX III TRENDS IN LUNG CANCER MORBIDITY AND MORTALITY Table of Contents TRENDS IN LUNG CANCER MORBIDITY AND MORTALITY Introduction Mortality Trends Incidence Trends Hospitalization Trends in Hospital Discharges, 1979–1999 Trends in Survival Rates Lung Cancer Types Smoking-Attributable Lung Cancer Deaths Lifetime Risk of Being Diagnosed with Cancer References

LIST OF TABLES Table 1: Age-Adjusted Death Rates for Selected Cancer Sites by Sex, 1979–1998 Table 2: Number of Deaths and Age-Adjusted Mortality Rates by Sex, 1979–1998 Table 3: Age-Adjusted Mortality Rates by Race and Sex, 1979–1998 Table 4: Cancer of the Lung and Bronchus: Average Annual Age-Specific Mortality Rates by Race, Sex, and Age, selected years 1980–1998 Table 5: Age-Adjusted Mortality Rates for Cancer of the Trachea, Bronchus, and Lung (ICD-9-CM Code 162) by State and Sex, 1996–1998

Table 6: Age-Adjusted Mortality Rates for Cancer of the Trachea, Bronchus, and Lung (ICD-9-CM Code 162) by State and Race, 1998 Table 7: Age-Adjusted Incidence Rates for Lung and Bronchus Cancer and All Cancer Sites, 1973–1998 Table 8: Respiratory Cancer: Age-Adjusted Incidence Rates by Site, Race, and Sex: All SEER Areas Combined, 1973–1998 Table 9: Lung Cancer: Total Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Age (ICD-9-Code 162, 197.0, 197.3), 1979–1999 Table 10: Lung Cancer: Number of First-Listed Hospital Discharges and Rate per 10,000 Persons by Race (ICD-9-Code 162, 197.0, 197.3), 1988–1999 Table 11: Trends in Survival Rates by Selected Cancer Sites by Race, Cases Diagnosed in 1960–1963, 1970–1973, 1974–1976, 1977–1979, 1980–1982, 1983–1985, 1986–1988, 1989–1991, 1992–1997 Table 12: Estimates of Smoking-Attributable Lung Cancer Deaths United States, 1990, 1995 Table 13: Lifetime Risk (Percent) of Being Diagnosed with Lung Cancer and Lifetime Risk (percent of Dying From Lung Cancer) by Race and Sex, 1996–1998

289

290 The Encyclopedia of Asthma and Respiratory Disorders INTRODUCTION1 Lung cancer is the leading cause of cancer mortality in both men and women in the United States and will cause an estimated 157,400 deaths in 2001, accounting for 28 percent of all cancer deaths. The incidence and mortality attributed to this disorder has been rising steadily since the 1930s. Lung cancer has been the leading cause of cancer deaths among men since the early 1950s and, in 1987, surpassed breast cancer to become the leading cause of cancer deaths in women.

MORTALITY TRENDS2 Table 1 depicts the age-adjusted death rates for the most common cancer sites by sex between 1979 and 1998. This table indicates that mortality rates for most cancers are decreasing in both sexes. The main exception to this trend is deaths due to malignant neoplasms of respiratory and intrathoracic organs in females. During the period 1979–98, the respiratory cancer death rate has decreased in males by 11.8 percent, but has increased 63.3 percent in females. By contrast, mortality for cancer at all sites has decreased by 9.6 percent in males and 1.5 percent in females. Table 2 delineates the number of deaths and age-adjusted mortality rates for lung cancer, specifically, between 1979 and 1998. The number of deaths due to lung cancer has increased 57 percent, from 98,541 in 1979 to 154,561 in 1998. In 1998, 91,447 males and 63,114 females died from lung cancer. Overall the age-adjusted mortality rate increased from 33.6 per 100,000 to 37.0 per 100,000, an increase of 10.1 percent. The rate in males has fluctuated; however, the rate reported in 1998 was 11.1 percent lower than that reported in 1979. Conversely, over the same time period the mortality rate in females has grown by over 65 percent. Despite the increase observed in women, the mortality rate in males is still almost double the rate in females. Table 3 delineates mortality data by race and sex for 1979–98. Mortality in whites has increased by almost 12 percent during this time, from 33.0 per 100,000 to 36.8 per 100,000. However, the mortality rate in white males decreased (-10.9 percent) over this time span. The overall increase in whites

is, therefore, due entirely to the 68 percent increase observed in white females. Overall, mortality among blacks has increased by 7.2 percent, from 41.6 per 100,000 to 44.6 per 100,000. Mortality among black females has increased by almost 66 percent, from 16.6 per 100,000 to 27.5 per 100,000. The mortality rate in black males decreased 7.7 percent during this time. However, the mortality rate in black males (68.5 per 100,000) is almost 42 percent higher than that of white males (48.4 per 100,000). In contrast, mortality reported among females of both races has been similar since 1973. In 1998, the mortality rate was reported at 27.5 per 100,000 for both white and black females. Figure 1 graphically depicts the trend in ageadjusted death rates discussed above. The disparity in death rates between black and white males is clearly displayed here, as is the congruence in the rates of black and white females. Table 4 shows the age-specific mortality rates for lung cancer by sex and race for selected years from 1980–98. Age-specific mortality attributed to lung cancer increases with age and is greatest in the oldest age groups. If we examine the age-specific data for the most recent year, we see the rates are greater in black males than in white males across all age groups, as is expected based on the overall mortality differential. The difference in rates between black and white males is much more pronounced in the younger age groups. When we examine the trend in females, the mortality rates are only higher in black females in the younger age groups. Above age 65, the trend shifts and mortality is higher in white females. Figure 2 depicts the death rate for respiratory system neoplasms by age for 1998. Mortality rates increase with age and reach their peak at 378.4 per 100,000 persons aged 75 to 84. Table 5 delineates the age-adjusted death rates for cancer of the trachea and lung by sex and state for 1998. Overall, Kentucky experienced the greatest death rate (52.3 per 100,000) and Utah had the lowest (16.6 per 100,000). Mississippi experienced the greatest death rate for males (74.7 per 100,000) and Nevada had the greatest death rate for females (37.3 per 100,000). The lowest state-specific mortality rates for males (22.2 per 100,000) and females

Appendix III 291 (11.9 per 100,000) were seen in Utah. Figure 3 portrays 1998 lung cancer death rates by state. Table 6 depicts 1998 data on state-specific ageadjusted mortality rates by race. For whites, the greatest state-specific death rate is reported in Kentucky (52.1 per 100,000). When we examine the rate in blacks, the small number of deaths in some states makes the corresponding data unreliable. Among the states with more than 20 deaths, high mortality rates among blacks are reported in Iowa (68.4 per 100,000) and Nebraska (66.7 per 100,000). The overall mortality rate in blacks (44.6 per 100,000) is 17.5 percent greater than the rate observed in whites (36.8 per 100,000). Figure 4 examines 1998 age-adjusted lung cancer death rates in blacks by state.

INCIDENCE TRENDS Data on cancer incidence is collected by the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. The SEER Program is a continuing project of the National Cancer Institute that collects cancer data on a routine basis from designated populationbased cancer registries in various areas of the country. Trends in cancer incidence and patient survival in the United States are derived from the SEER database. Cancer of the Trachea, Bronchus, and Lung The American Cancer Society estimates that there will be 169,500 new cases of the lung cancer in 2001. These new cases will account for 13 percent of all cancer diagnoses. Table 7 delineates the ageadjusted cancer incidence rates for the lung and bronchus, as well as cancer of all sites between 1973 and 1998. Lung cancer incidence increased by 29 percent over this time period; the incidence rate for cancer at all sites increased by 23.5 percent. The lung cancer incidence rate in 1998 was 54.8 per 100,000. When the incidence rate is examined by race and sex (Figure 5 and Table 8), varying trends emerge. Overall, the incidence rates for lung cancer in men and women were 69.8 per 100,000 and 43.4 per 100,000, respectively. The rate in white

males decreased by 5.5 percent while the rate in black males decreased by 4.0 percent between 1973 and 1998. However, the 1998 incidence rate in black men is more than 47 percent higher than that of white men. The incidence rate among females has increased at a much greater rate than the rate in males over this time period. Lung cancer in both white and black women has more than doubled between 1973 and 1998, +152 percent and +129 percent, respectively. Unlike the rates in males, lung cancer rates in white women (44.8 per 100,000) and black women (47.9 per 100,000) were similar. The SEER Program has examined trends in lung cancer incidence during the period 1973–98. Evaluation of the estimated annual percentage change (EAPC) in incidence indicates that the EAPC was different from zero p<.05 for white males, and white and black females. Between 1973 and 1998, the EAPC was -0.4 in white males, 3.2 percent in white females, and 2.9 percent in black females. During the same time period, black males saw an estimated annual percentage change of -0.1 percent. Cancer of the Oral Cavity and Pharynx Table 8 also reports the incidence rates for respiratory cancer by site, race, and sex for 1973–98. Overall, cancer of the oral cavity and pharynx for both races decreased during this time period. However, the rate in black males has increased (+9.6 percent) since 1973. Between 1997 and 1998, the rate of oral cavity and pharynx cancer in blacks has increased while rates overall and in whites have declined. Cancer of the Larynx The overall incidence rate for cancer of the larynx has decreased 26.7 percent between 1973 and 1998. However, if we examine the data by race and sex specifically, white and black females have experienced an increase in incidence of 14 percent and 33 percent, respectively. White and black males have experienced a decrease in incidence of 37 percent and 18 percent, respectively. The 1998 incidence rate in black females (2.4 per 100,000) is 71 percent higher than white females (1.4 per 100,000). Black males had an incidence rate that

292 The Encyclopedia of Asthma and Respiratory Disorders was 85 percent higher than that of white males, 9.8 per 100,000 vs. 5.3 per 100,000, respectively.

HOSPITALIZATION TRENDS Table 9 delineates age-specific hospital discharge data derived from the National Hospital Discharge survey for 1979–99. Of the more than 1.27 million discharges attributed to cancer in 1999, 13.0 percent were attributed to lung cancer. The total number of discharges reported for lung cancer was 164,000. This represents a discharge rate of 6.0 per 10,000 and is almost a 38 percent decrease from the discharge rate of 9.7 per 10,000 reported in 1988. The hospital discharge rate attributed to lung cancer is the second highest among all malignant neoplasms, with the exception of colorectal cancer. The greatest number of discharges is experienced in the population over age 65. In 1999 all age groups experienced declines in the number of discharges and the discharge rate except for the over 65 age group. When examined by sex, the number of discharges and discharge rate between 1979 and 1999 has decreased in males and females, -41 percent and -34 percent, respectively. The trend in hospital discharges by sex is portrayed in Figure 6. Table 10 displays the race-specific number of discharges and discharge rate between 1988 and 1999. The 1999 discharge rate for lung cancer was highest in all other races (6.3 per 10,000), followed by whites (5.1 per 10,000) and then blacks (3.5 per 10,000). These rates, however, should be interpreted with caution due to the large percentage of discharges (17.2 percent) for which race was not reported.

TRENDS IN SURVIVAL RATES Table 11 depicts trends in survival rate for lung and other types of cancer by race from 1960 through 1997. Survival rates for lung cancer tend to be much lower than those of most other cancers. In whites, survival rates for all cancers listed have experienced statistically significant increases since 1974–76. However, the survival rate for lung cancer has increased by only 18.4 percent, which is a relatively low increase when compared to the other cancers listed. With the exception of the survival rate for lung cancer (11.7 percent), the sur-

vival rates in blacks for all listed cancers showed statistically significant increases since 1974–76. Compared to whites, blacks experienced lower five-year survival rates for each type of cancer listed. The five-year survival rate for lung cancer in blacks during the period spanning 1992–97 was 11.7 percent. The survival rate for lung cancer in whites was only slightly better at 14.4 percent. Black men and women have poorer survival rates for lung cancer than whites, even when controlling for age at diagnosis. The prognosis (outlook for survival) for a patient with lung cancer depends, to a large extent, on the cancer’s stage. Staging is used to determine whether the cancer has spread and, if so, to what parts of the body. Stages include localized (within lungs), regional (spread to lymph nodes), and distant (spread to other organs). Figure 7 displays the five-year survival rates for all stages by type of lung cancer. The average five-year survival rate between 1992 and 1997 for localized lung cancer was 48 percent compared to 14.5 percent overall and 2.5 percent for a distant tumor. Unfortunately, only 15 percent of people are diagnosed at an early, localized stage.

LUNG CANCER TYPES3 There are two major types of lung cancer: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Sometimes a lung cancer may have characteristics of both types, which is known as mixed small cell/large cell carcinoma. SCLC is less common, accounting for 20 percent of all lung cancer. This type of lung cancer grows more quickly and is more likely to spread to other organs in the body. Small cell lung cancer often starts in the bronchi and toward the center of the lungs. Smoking almost always causes it. NSCLC accounts for the remaining 80 percent of all lung cancer cases. It generally grows and spreads more slowly. There are three main types of NSCLC. They are named for the type of cells in which the cancer develops: squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. Figure 8 delineates the stage distribution for the most common lung cancer types. Between 1992 and 1997, 62 percent of all SCLC cases were diag-

Appendix III 293 nosed during the distant stage and only 6 percent were diagnosed in the local stage. This compares to the 45 percent of NSCLC diagnosed in the distant stage and the 16 percent of cases diagnosed in the localized stage.

SMOKING-ATTRIBUTABLE LUNG CANCER DEATHS The most important cause of lung cancer in the United States is cigarette smoking. It is estimated that 87 percent of lung cancer cases are caused by smoking. Table 12 delineates, by sex and age, the estimated number and proportion of smokingattributable lung cancer deaths in the United States in 1990 and 1995. In males, the overall expected number of smoking-attributable deaths has increased between 1990 and 1995, although the percentage of deaths caused by smoking remained the same. In females, both the number of deaths and the proportion of deaths caused by smoking increased. Overall, for both sexes combined, the percentage of lung cancer deaths attributed to smoking increased slightly (1 percent). However, the overall estimated number of deaths attributed to smoking increased by 19 percent.

LIFETIME RISK OF BEING DIAGNOSED WITH CANCER Using data from the Surveillance, Epidemiology, and End Results registry, the National Cancer Institute has calculated the lifetime risk of being diag-

nosed with lung cancer, as well as the lifetime risk of dying from lung cancer. This risk is calculated for the entire population and includes smokers and nonsmokers. These data are displayed in Table 13 by race and sex for 1996–98. As shown in the table, the lifetime risk of a lung cancer diagnosis is highest in black males (8.47 percent) and white males (7.83 percent). The lifetime risk of dying from lung cancer is highest in whites.

REFERENCES 1. American Cancer Society. Cancer Facts and Figures, 2001. 2. National Center for Health Statistics. Report of Final Mortality Statistics, 1979–1998. 3. CDC Wonder: Unpublished Mortality Data, 1998. 4. National Cancer Institute SEER Program: Cancer Statistics Review, 1973–1998. 5. National Center for Health Statistics. Detailed Diagnoses & Procedures, National Hospital Discharge Survey, 1999. FOOTNOTES: (1) Unless otherwise noted, terms such as higher or less are not intended to indicate statistical significance. (2) Information on mortality for lung cancer is available from two different sources: the National Center for Health Statistics (NCHS) and the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute. Since these mortality numbers are age-adjusted to different populations (SEER adjusts to the 1970 U.S. Population; NCHS adjusts to the 1940 U.S. population), the mortality rates from different sources should not be compared to each other. (3) Information on lung cancer types and stages comes from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute and the American Cancer Society.

Male Female

Digestive3

Respiratory4

Breast5

Genital6 14.8 13.8

0.2 22.3

58.6 16.9

41.8 26.4

163.4 107.1

1979

14.9 13.4

0.2 22.7

59.6 18.8

41.3 25.7

163.8 108.7

1981

15.2 13.0

0.2 22.7

60.1 21.0

40.8 25.2

165.3 110.1

1983

15.3 12.6

0.2 23.3

60.7 22.5

40.6 24.8

166.1 111.7

1985

1989

1991

15.6 12.3

0.2 23.0

61.1 23.8

39.7 24.1

16.4 12.1

0.2 23.1

60.5 25.6

39.3 23.2

17.1 12.2

0.1 22.7

60.1 26.5

38.7 23.0

165.5 165.5 165.0 111.4 112.3 112.6

1987

Source: Division of Vital Statistics, National Center for Health Statistics, 1998. Notes: (1) Rates are per 100,000 persons and age-adjusted to the 1940 U.S. Census population. (2) Includes ICD Codes 140–208. (3) Includes ICD Codes 150–159. (4) Includes ICD Codes 160–165. (5) Includes ICD Codes 174–175. (6) Includes ICD Codes 179–187.

All

Male Female

SEX

Sites2

SITES

16.8 11.7

0.2 21.5

58.1 27.2

37.9 22.7

161.9 111.4

1993

15.8 11.6

0.2 21.0

55.3 27.5

37.4 22.3

156.8 110.4

1995

14.3 11.3

0.2 19.4

52.8 27.5

36.5 21.4

150.4 107.3

1997

13.6 11.1

0.2 18.8

51.7 27.6

36.2 21.4

147.7 105.5

1998

Percent Change

5.4 -10.9

0.0 3.1

4.3 40.8

-5.0 -8.7

1.3 4.0

-12.8 -9.8

0.0 -18.3

-15.4 16.0

-8.8 -11.2

-10.8 -5.3

-8.1 -19.6

0.0 -15.7

-11.8 63.3

-13.4 -18.9

-9.6 -1.5

1979–1987 1987–1998 1979–1998

Percent Change

TABLE 1 AGE-ADJUSTED DEATH RATES1 FOR SELECTED CANCER SITES BY SEX, 1979–1998

294 The Encyclopedia of Asthma and Respiratory Disorders

Appendix III 295 TABLE 2 NUMBER OF DEATHS AND AGE-ADJUSTED MORTALITY RATES1 FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CM CODE 162) BY SEX, 1979–1998 TOTAL

MALE

FEMALE

YEAR

NUMBER

RATE

NUMBER

RATE

NUMBER

RATE

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

98,541 103,844 106,561 111,393 115,023 118,730 122,566 125,522 130,009 133,284 137,150 141,285 143,758 145,943 148,855 149,482 151,200 152,015 153,310 154,561

33.6 34.8 35.1 35.9 36.4 37.0 37.6 37.8 38.5 38.9 39.3 39.9 39.6 39.3 39.3 38.7 38.3 37.8 37.4 37.0

72,803 75,535 76,764 79,228 80,338 82,491 83,854 85,057 87,261 88,059 89,052 91,091 91,690 91,405 92,564 91,893 91,856 91,620 91,352 91,447

55.7 56.9 56.9 57.6 57.3 58.0 58.1 57.9 58.5 58.2 57.9 58.5 57.5 56.0 55.7 54.2 52.9 51.8 50.5 49.5

25,648 28,309 29,797 32,165 34,685 36,239 38,702 40,465 42,748 45,225 48,098 50,194 52,068 54,538 56,291 57,589 59,344 60,395 61,958 63,114

16.3 17.6 18.2 19.2 20.3 20.8 21.8 22.3 23.1 24.0 24.9 25.6 25.8 26.4 26.6 26.6 26.9 26.8 27.0 27.0

Source: National Center for Health Statistics, Mortality Data, 1979–1998. CDC Wonder, Unpublished Mortality Data, 1998. Note: (1) Rates are per 100,000 persons and age-adjusted to the 1940 U.S. Census population.

TABLE 3 AGE-ADJUSTED MORTALITY RATES(1) FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CM CODE 162) BY RACE AND SEX, 1979–1998 ALL OTHER RACES2 ALL RACES

WHITE

TOTAL

BLACK

YEAR

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

33.6 34.8 35.1 35.9 36.4 37.0 37.6 37.8 38.5 38.9 39.3 39.9 39.6 39.3 39.3 38.7 38.3 37.8

55.7 56.9 56.9 57.6 57.3 58.0 58.1 57.9 58.5 58.2 57.9 58.5 57.5 56.0 55.7 54.2 53.0 51.8

16.3 17.6 18.2 19.2 20.3 20.8 21.8 22.3 23.1 24.0 24.9 25.6 25.8 26.4 26.6 26.6 26.9 26.8

33.0 34.2 34.4 35.3 35.8 36.4 37.0 37.2 37.9 38.3 38.6 39.3 39.1 38.8 38.9 38.4 38.0 37.6

54.3 55.5 55.3 56.0 55.7 56.2 56.4 56.2 56.8 56.5 56.0 56.6 55.8 54.4 54.0 52.7 51.6 50.5

16.4 17.6 18.2 19.4 20.5 21.0 22.1 22.5 23.3 24.3 25.3 25.9 26.1 26.7 27.0 27.1 27.4 27.5

38.4 39.8 40.2 40.6 41.3 41.9 41.9 42.1 42.8 42.5 43.4 43.9 42.7 42.4 41.7 40.7 40.1 40.7

67.4 69.2 70.0 70.6 70.6 72.5 71.6 71.4 71.9 71.0 72.3 72.3 70.0 68.1 67.7 64.9 63.0 64.8

15.7 17.1 17.2 17.6 19.1 18.9 19.5 20.2 21.3 21.6 22.1 23.2 22.8 23.6 22.9 23.1 23.5 23.3

41.6 43.9 44.7 45.6 46.5 47.2 47.6 48.0 49.0 48.9 50.2 51.3 49.9 49.8 48.9 47.9 47.3 46.2

74.2 77.2 79.0 80.4 80.4 83.1 82.6 82.8 84.0 83.1 85.3 86.2 83.2 81.4 80.8 77.6 75.8 73.2

16.6 18.5 18.9 19.5 21.2 20.7 21.8 22.6 23.7 24.3 25.0 26.4 26.1 27.3 26.2 26.7 26.9 26.5

296 The Encyclopedia of Asthma and Respiratory Disorders TABLE 3 AGE-ADJUSTED MORTALITY RATES1 FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CM CODE 162) BY RACE AND SEX, 1979-1998 (continued) ALL OTHER RACES2 ALL RACES

WHITE

TOTAL

BLACK

YEAR

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

TOTAL

MALE

FEMALE

1997 1998

37.4 37.0

50.5 49.5

27.0 27.0

37.1 36.8

49.3 48.4

27.5 27.5

39.4 39.2

61.4 56.8

23.8 23.6

45.3 44.6

70.6 68.5

27.4 27.5

Source: CDC Wonder, 1979–1998. Notes: (1) Rates are per 100,000 persons and age-adjusted to the 1940 U.S. Census population. (2) All other races includes blacks and all races other than white.

TABLE 4 CANCER OF THE LUNG AND BRONCHUS: AVERAGE ANNUAL AGE-SPECIFIC MORTALITY RATES1 BY RACE, SEX, AND AGE, SELECTED YEARS, 1980-1998 YEAR

SEX & RACE

1-4

5-9

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

1980

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

0.1 0.4 0.1 0.4

0.0 0.1 0.0 **

** 0.1 0.0 **

0.0 ** ** **

0.0 0.1 0.0 **

0.1 0.3 0.0 0.1

0.3 0.9 0.2 0.4

1.1 2.6 0.8 0.8

5.5 12.2 3.3 3.6

17.3 39.3 10.4 11.5

45.4 95.1 162.7 93.9 174.6 274.8 22.7 42.5 60.7 34.6 52.3 74.4

255.6 377.2 84.5 86.2

358.7 460.3 103.2 84.9

458.6 489.2 106.4 92.2

502.4 485.8 100.7 77.5

477.7 446.5 86.8 83.1

374.1 311.3 92.4 85.8

1985

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

0.3 * 0.2 *

1.0 2.5 0.9 *

4.3 9.5 2.9 3.0

15.0 34.4 8.7 12.8

40.1 87.0 167.6 262.8 75.5 175.8 294.7 416.0 23.9 47.5 75.5 109.3 25.1 54.8 87.9 120.6

364.7 495.9 138.6 107.1

468.7 602.0 153.6 129.3

541.5 560.6 140.9 100.7

538.0 548.3 125.4 101.9

440.0 382.3 99.3 114.3

1990

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

0.3 * 0.2 *

1.1 3.5 0.8 *

3.8 9.0 2.8 4.8

11.6 30.6 7.5 10.9

34.6 80.5 159.3 268.1 79.7 157.6 293.9 429.8 22.9 48.5 82.4 127.8 27.8 57.2 96.7 140.2

373.9 544.0 165.5 158.9

485.5 644.4 200.2 171.4

565.0 659.2 206.4 152.9

584.8 620.2 177.6 140.6

516.3 449.5 138.3 134.9

1991

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

0.3 * 0.2 *

0.9 1.7 0.9 *

3.6 8.9 2.8 4.2

10.8 25.5 7.5 11.2

33.5 75.9 154.6 263.4 79.9 153.9 272.2 388.9 21.8 45.8 84.9 126.3 26.7 57.1 85.0 132.7

377.3 545.0 171.6 159.7

475.3 626.1 201.4 178.4

550.5 643.6 217.2 178.9

603.5 721.8 190.9 156.6

532.5 510.1 148.9 152.1

1992

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

* * 0.3 *

0.9 2.5 0.8 *

3.5 9.0 2.9 4.7

10.9 25.7 7.4 12.0

31.4 75.2 146.8 253.3 68.0 150.9 270.2 385.5 20.6 45.2 82.7 130.9 26.7 55.6 94.0 135.6

378.9 523.2 176.3 172.1

490.7 631.6 215.7 194.6

547.9 631.4 224.1 179.4

591.5 694.1 206.2 150.4

522.5 529.7 156.0 154.7

1993

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

1.0 2.8 0.8 1.5

3.9 7.7 2.5 3.4

10.2 25.3 7.0 10.2

28.7 70.5 147.8 255.7 71.8 141.9 245.0 348.0 20.2 44.0 82.3 132.7 29.3 49.7 86.9 124.6

376.2 510.7 180.8 165.0

463.6 670.1 221.0 194.3

540.9 662.6 234.6 180.5

591.4 708.4 215.3 177.2

531.8 565.9 168.9 163.5

1994

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

1.0 1.7 0.9 *

3.6 7.3 2.7 4.1

10.1 23.8 10.1 9.4

26.6 68.6 136.8 251.2 60.4 141.5 239.1 367.8 26.6 68.6 136.8 251.2 24.1 47.9 89.2 127.2

369.1 488.2 369.1 172.4

461.8 645.0 461.8 211.0

530.7 647.4 530.7 196.3

589.5 726.8 589.5 189.0

528.5 584.0 528.5 152.0

1995

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* * * *

1.2 * 0.9 *

3.3 6.6 3.1 3.3

9.5 24.0 6.7 10.5

26.2 66.1 132.7 233.6 54.8 132.3 230.6 371.3 18.7 43.1 80.4 130.9 25.2 47.7 83.5 132.6

359.6 476.9 182.2 177.6

470.9 647.5 229.1 217.6

529.9 647.5 251.2 191.1

580.6 684.9 239.2 185.0

542.4 573.2 184.0 163.7

85+

Appendix III 297 TABLE 4 CANCER OF THE LUNG AND BRONCHUS: AVERAGE ANNUAL AGE-SPECIFIC MORTALITY RATES(1) BY RACE, SEX, AND AGE, SELECTED YEARS, 1980-1998 (continued) YEAR

SEX & RACE

1-4

5-9 10-14 15-19 20-24

25-34

34-44

45-54

55-64

65-74

75-84

85+

1996 (2) WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

** ** * **

** ** ** **

* ** * **

** ** * 0.1

* 0.1 * **

0.7 0.9 0.6 0.6

6.5 14.7 4.9 7.4

42.7 85.3 28.4 33.0

174.4 287.0 102.9 99.3

404.9 520.8 209.9 196.1

543.7 660.8 251.5 209.3

524.5 544.7 188.2 162.1

1997

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* ** ** **

** ** * **

** ** ** **

** * ** **

* * * *

* ** * *

0.6 0.8 0.5 *

6.3 13.7 5.2 7.8

39.6 79.4 26.8 33.6

167.4 270.1 100.9 101.8

400.4 507.9 213.2 200.5

540.1 660.1 259.7 220.1

549.1 553.8 200.5 184.2

1998

WHITE MALE BLACK MALE WHITE FEMALE BLACK FEMALE

* ** ** **

** ** ** **

** ** * **

* * * *

0.6 * 0.6 *

6.4 12.4 5.1 7.7

37.5 78.8 25.8 33.4

162.5 263.2 99.7 102.6

399.2 487.5 216.6 202.5

531.7 647.5 263.1 222.4

516.6 533.1 200.3 176.6

Source: CDC Wonder, 1979–1998. Notes: (1) Rates are per 100,000 population. (2) As of 1996, data are only available for the age groups indicated in charts. *Figure does not meet standards for reliability or precision (number of deaths is less than 20). **Quantity is zero. 0.0 Quantity is more than zero but less than 0.05.

TABLE 5 AGE-ADJUSTED MORTALITY RATES1 FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CM CODE 162) BY STATE AND SEX, 1996–1998

STATE

TOTAL

1996 MALE

FEMALE

TOTAL

1997 MALE

FEMALE TOTAL

1998 MALE

FEMALE

PERCENT CHANGE(2) 1996-1998

PERCENT CHANGE(2) 1997-1998

298 The Encyclopedia of Asthma and Respiratory Disorders TABLE 5 AGE-ADJUSTED MORTALITY RATES1 FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CM CODE 162) BY STATE AND SEX, 1996-1998 (continued)

STATE

TOTAL

1996 MALE

FEMALE

TOTAL

1997 MALE

FEMALE TOTAL

1998 MALE

FEMALE

PERCENT CHANGE2 1996–1998

Source: CDC Wonder, 1996, 1997, 1998. Notes: (1) Rates are per 100,000 persons and are adjusted to the 1940 U.S. population. (2) Due to rounding, U.S. total rates presented in this table may differ from those in Table 2.

TABLE 6 AGE-ADJUSTED MORTALITY RATES1 FOR CANCER OF THE TRACHEA, BRONCHUS AND LUNG (ICD-9-CODE 162) BY STATE AND RACE, 1998 STATE

BLACK

WHITE

OTHER2

PERCENT CHANGE2 1997–1998

Appendix III 299 TABLE 6 AGE-ADJUSTED MORTALITY RATES (1) FOR CANCER OF THE TRACHEA, BRONCHUS, AND LUNG (ICD-9-CODE 162) BY STATE AND RACE, 1998 (continued) STATE

BLACK

WHITE

Source: CDC Wonder, 1998 Notes: *These rates should be interpreted with caution as they represent 20 or fewer deaths. (1) Rates are per 100,000 persons and age-adjusted to the 1940 U.S. population. (2) Includes races other than black and white. (3) Due to rounding, U.S. total rates presented in this table may differ from those in Table 3.

OTHER2

300 The Encyclopedia of Asthma and Respiratory Disorders TABLE 7 AGE-ADJUSTED INCIDENCE RATES(1) FOR LUNG AND BRONCHUS CANCER AND ALL CANCER SITES, 1973-1998 YEAR OF DIAGNOSIS

LUNG & BRONCHUS

Source: National Cancer Institute: SEER Cancer Statistics Review, 1973–1998. Note: (1) Rates are per 100,000 persons and are age-adjusted to the 1970 U.S. population.

ALL SITES

Appendix III 301 TABLE 8 RESPIRATORY CANCER: AGE-ADJUSTED INCIDENCE RATES1 BY SITE, RACE, AND SEX: ALL SEER AREAS COMBINED, 1973–1998 YEAR/SITE

TOTAL

ALL RACES MALES

FEMALES

TOTAL

WHITES MALES

FEMALES

TOTAL

BLACKS MALES

FEMALES

302 The Encyclopedia of Asthma and Respiratory Disorders TABLE 8 RESPIRATORY CANCER: AGE-ADJUSTED INCIDENCE RATES1 BY SITE, RACE, AND SEX: ALL SEER AREAS COMBINED, 1973–1998 (continued) YEAR/SITE

TOTAL

ALL RACES MALES

FEMALES

TOTAL

WHITES MALES

FEMALES

Source: National Cancer Institute: SEER Cancer Statistics Review, 1973–1998. Note: (1) Rates are per 100,000 persons and are age-adjusted to the 1970 U.S. standard population.

TOTAL

BLACKS MALES

FEMALES

Appendix III 303 TABLE 9 LUNG CANCER: TOTAL NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION BY AGE (ICD-9-CODE 162, 197.0, 197.3), 1979–19991

<15

YEAR

15–44

NUMBER OF RATE PER DISCHARGES 10,000

1,000*

1979

0.2* *

1980

—

1981

—

1982

—

* * *

NUMBER OF DISCHARGES

45–64

RATE PER 10,000

TOTAL(2)

65+

NUMBER OF RATE PER DISCHARGES 10,000

NUMBER OF DISCHARGES

RATE PER 10,000

12.7

12,000

1.2

130,000

29.3

131,000

52.1

274,000

12,000

1.2

123,000

27.8

142,000

55.3

277,000

12.4

11,000

1.0

134,000

30.2

145,000

55.2

293,000

12.9

15,000

1.4

147,000

33.2

155,000

58.0

319,000

13.9

12,000

1.1

151,000

34.0

176,000

64.1

339,000

14.6

13,000

1.2

155,000

34.1

172,000

61.2

340,000

14.5

13,000

1.2

132,000

29.4

169,000

59.4

315,000

13.3

1.3

120,000

26.7

155,000

53.3

290,000

12.1

1983

---

1984

—

1985

—

1986

—

15,000 12,000

1.1

129,000

28.5

169,000

54.9

305,000

12.6

8,000*

0.7 *

102,000

22.2

125,000

41.2

236,000

9.7 9.7

* * *

0.1*

—

1989

—

11,000

1.0

101,000

21.8

127,000

40.9

239,000

1990

—

12,000

1.0

101,000

21.4

119,000

37.7

231,000

9.3

1991

—

10,000

0.8

101,000

21.6

125,000

39.3

236,000

9.4

0.6*

86,000

17.8

122,000

37.8

215,000

8.5

75,000

15.1

110,000

33.9

194,000

7.6

14.3

126,000

37.9

199,000

7.6

1987 1988

* *

1992

—

7,000*

1993

—

7,000*

0.6*

1994

—

9,000*

0.7*

73,000

1995

—

8,000*

0.7*

75,000

14.4

110,000

32.8

197,000

7.5

1996

—

10,000

0.8

72,000

13.4

122,000

36.0

210,000

8.0

1997

—

60,000

10.9

123,000

36.4

192,000

7.1

1998

—*

—

9,000

0.7*

55,000

9.6

99,000

29.0

165,000

6.0

1999

—

5,000

0.4*

54,000

9. 2

104,000

30.5

164,000

6.0

Source: National Center for Health Statistics: National Hospital Discharge Survey, 1979–98, and National Hospital Discharge Survey, Advanced Data 1999. Notes: *Estimates of 5,000–10,000 and corresponding rates to be used with caution. — Figure does not meet standards of reliability or precision. (1) Includes malignant neoplasms of the trachea, bronchus, and lung. (2) Due to rounding and the exclusion of numbers that do not meet standards of reliability, numbers across may not sum to the total of hospital discharges. (3) Data from 1988–99 may not be comparable to earlier years due to the redesign of the survey in 1988.

304 The Encyclopedia of Asthma and Respiratory Disorders TABLE 10 LUNG CANCER: TOTAL NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 PERSONS BY RACE (ICD-9-CODE 162, 197.0, 197.3), 1988–1999

NUMBER OF DISCHARGES

YEAR

TOTAL1

WHITE

BLACK

RATE PER 10,000 POPULATION ALL OTHER

TOTAL (1)

WHITE

BLACK

ALL OTHER

Source: National Center for Health Statistics National Hospital Discharge Survey 1988–1999. Notes: (1) Total includes white, black, other race and unspecified race discharges. (2) In 1994 discharges for ICD-9-CM Code 176.4 were added to this category. *Figure does not meet standard of reliability or precision. N/A Not available.

TABLE 11 TRENDS IN SURVIVAL RATES BY SELECTED CANCER SITES, by RACE, CASES DIAGNOSED IN 1960– 1963, 1970–1973, 1974–1976, 1977–1979, 1980–1982, 1983–1985, 1986–1988, 1989–1991, 1992–1997 SITE

Lung and Bronchus Colon Rectum Breast Esophagus Prostate SITE

Lung and Bronchus Colon Rectum Breast Esophagus Prostate

1960–631

* * * * * *

1960–631

8.0 43.0 38.0 63.0 4.0 50.0

TOTAL RELATIVE 5-YEAR SURVIVAL 1970–731 1974–762 1977–792 1980–822

* * * * * *

12.4 50.4 48.5 74.7 4.8 67.1

13.4 52.9 49.9 74.7 5.1 71.1

13.4 55.4 52.1 76.3 6.7 73.4

WHITE RELATIVE 5-YEAR SURVIVAL 1970–731 1974–762 1977–792 1980–822

10.0 49.0 45.0 68.0 4.0 63.0

12.5 50.6 48.9 75.3 5.1 68.1

13.7 52.9 50.8 75.4 5.6 72.2

13.5 55.6 52.9 77.1 7.4 74.5

1983–852

13.6 57.7 55.0 78.1 8.3 74.8

1986–882

13.3 60.9 58.5 82.8 9.8 81.1

1983–852

1986–882

14.0 58.4 55.9 79.2 9.3 76.2

13.8 61.5 59.1 83.8 10.8 82.6

1989–912 1992–972

13.9 62.5 60.0 84.8 10.8 90.4

14.53 61.23 60.83 85.53 13.73 96.23

1989–912 1992–972

14.3 63.1 60.5 86.1 11.6 91.7

14.83 62.13 61.53 86.83 15.13 97.03

Appendix III 305 TABLE 11 TRENDS IN SURVIVAL RATES BY SELECTED CANCER SITES, by RACE, CASES DIAGNOSED IN 1960– 1963, 1970–1973, 1974–1976, 1977–1979, 1980–1982, 1983–1985, 1986–1988, 1989–1991, 1992–1997 (continued) SITE

1960–631

Lung and Bronchus Colon Rectum Breast Esophagus Prostate

5.0 34.0 27.0 46.0 1.0 35.0

BLACK RELATIVE 5-YEAR SURVIVAL 1970–731 1974–762 1977–792 1980–822

7.0 37.0 30.0 51.0 4.0 55.0

11.5 45.9 42.1 63.1 4.0 58.3

11.1 48.1 38.8 63.2 2.8 62.5

12.2 49.2 38.2 65.9 5.4 64.7

1983–852

1986–882

11.5 49.2 43.8 63.5 6.3 64.1

11.8 52.5 51.0 69.2 7.3 69.0

1989–912 1992–972

10.7 53.7 54.1 71.2 8.8 80.4

11.7 51.33 51.93 72.03 9.03 91.83

Source: National Cancer Institute: SEER Cancer Statistics Review, 1973–1998. Notes: (1) Rates are based on data from a series of hospital registries and one population based registry. (2) Rates are from the SEER program and are based on follow-up of all patients through 1998. (3) The difference in rates between 1974-76 and 1992-97 is statistically significant (p<0.05).

TABLE 12 ESTIMATES OF SMOKING-ATTRIBUTABLE LUNG CANCER DEATHS, United States, 1990, 1995

Source: Mortality from smoking in developed countries, 1950–2000. Indirect estimates from National Vital Statistics, 1994.

306 The Encyclopedia of Asthma and Respiratory Disorders TABLE 13 LIFETIME RISK (PERCENT) OF BEING DIAGNOSED WITH LUNG CANCER AND LIFETIME RISK (PERCENT OF DYING FROM LUNG CANCER) BY RACE AND SEX, 1996–1998

Source: SEER Cancer Statistics Review, 1973–1998.

APPENDIX IV TRENDS IN ASTHMA MORBIDITY AND MORTALITY Table of Contents TRENDS IN ASTHMA MORBIDITY AND MORTALITY Introduction Asthma Mortality Trends, 1970–1998 Asthma Prevalence Trends, 1982–1996 and 1997–1998 Asthma Trends in Hospital Discharges, 1970–1998 Economic Cost of Asthma Summary Glossary References

LIST OF TABLES Table 1: Asthma: Age-Adjusted Mortality Rate by Race and Sex per 100,000 Population, 1970–1998 Table 2: Asthma: Crude Mortality Rate by Race and Sex Per 100,000 Population, 1970–1998 Table 3: Asthma: Number of Deaths by Race and Sex, 1979–1998 Table 4: Asthma: Mortality Rate by 10-Year Age Groups per 100,000 Population, 1979–1998 Table 5: Asthma: Number of Deaths in 10-Year Age-Groups, 1979–1998 Table 6: Asthma: Number of People Ever Told by a Doctor or Other Health Professional That They Had Asthma and Rates per 1,000 People by Age, Sex, and Race, 1997–1998 (Period Prevalence) Table 7: Asthma: Number of Conditions and AgeSpecific Prevalence Rates per 1,000 Persons, 1982–1996, 1997–1998 (Attack Prevalence) Table 8: Asthma: Trends in Sex-Specific Prevalence per 1,000 persons, 1982–1996, 1997–1998 (Attack Prevalence)

Table 9: Asthma: Number of Conditions and Prevalence Rate per 1,000 Persons by Race and Age, 1982–1996, 1997–1998 Table10: Asthma: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Sex, 1970–1998 Table11: Asthma: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Age, 1970–1998 Table12: Asthma: Number of First-Listed Hospital Discharges and Rate per 10,000 Population by Race, 1988–1998 Table13: Economic Cost of Asthma: Direct Medical and Indirect Expenditures, United States, 2000

LIST OF FIGURES Figure 1: Asthma: Age-Adjusted Death Rate by Sex, 1970–1998 Figure 2: Asthma Deaths by Sex, 1979–1998 Figure 3: Asthma Prevalence by Age, 1982–1996 Figure 4: Asthma Prevalence by Age, 1997–1998 Figure 5: Asthma Prevalence by Sex, 1982–1996 Figure 6: Asthma Prevalence by Race, 1982–1996 Figure 7: Asthma Prevalence by Sex and Race, 1997–1998 Figure 8: Percentage Distribution of Asthma by Sex, Age, Race, and Geographic Region, 1998 Figure 9: Asthma: First-Listed Hospital Discharge Rate per 10,000 Population by Age, 1979–1998 Figure10: Asthma: First-Listed Hospital Discharge Rate per 10,000 Population by Race, 1988–1998

307

308 The Encyclopedia of Asthma and Respiratory Disorders INTRODUCTION1,2 Asthma is a serious chronic condition affecting many Americans. Public attention has recently focused on this condition because its prevalence and the associated mortality rate have increased over the last decade. The following delineates information available from national surveys and reports on trends in asthma morbidity and mortality. As an overview of the widespread and growing nature of the asthma problem in the United States, we have examined data on hospitalization, prevalence,mortality, and economic costs.

ASTHMA MORTALITY TRENDS, 1970–1998 Due to decennial revisions of the International Classification of Diseases (ICD) coding system, there is a lack of comparability in cause of death statistics. The number and rate of asthma deaths reported prior to 1979 are not directly comparable to those reported after 1979. Although time trends covering different revisions of the code should be examined separately, it is important to note that increases in mortality attributed to asthma have been sustained through changes in the code and have been consistent since 1979. Table 1 documents the trend in age-adjusted asthma mortality between 1970 and 1998. Overall, the age-adjusted death rate increased from 0.9 per 100,000 in 1979 to 1.4 per 100,000 in 1998, a 55.6 percent increase. In contrast, the age-adjusted death rate attributed to all causes decreased 18 percent and seven out of the ten leading causes of death experienced decreases in age-adjusted mortality. Trends in Sex and Race-Specific Mortality Rates Between 1979 and 1998, the age-adjusted mortality rate for asthma increased 33 percent in males, from 0.9 to 1.2, and increased 67 percent in females, from 0.9 to 1.5 per 100,000 population. Females tend to have higher asthma mortality rates. In 1998, the female death rate was 25 percent greater than the rate seen in males. Figure 1 illustrates the ageadjusted death rate by sex from 1970 to 1998. In 1998, the age-adjusted death rate for asthma in the black population (3.7 per 100,000) was more than three times the rate in the white population

(1.1 per 100,000). Between 1979 and 1998, the age-adjusted asthma mortality rate has increased 12.5 percent in white males and 50 percent in white females. During the same period, the ageadjusted mortality rate increased by 78.9 percent in black males and 90 percent in black females. Ageadjusted mortality rates in nonwhites (all races other than white) increased 61 percent in males and 72 percent in females over this time span. Table 2 summarizes the trend in the crude death rate by sex and race from 1970 to 1998. Table 3 depicts the number of asthma deaths from 1979 to 1998 by sex and race. The number of deaths due to asthma has increased from 2,598 to 5,438 over this time period, an increase of 109 percent. This trend of increase in the number of asthma deaths is depicted by sex in Figure 2. Trends in Age-Specific Mortality

Table 4 delineates mortality rates for asthma by 10year age groups from 1979 through 1998. Between 1979 and 1998, increases in age-specific mortality were seen in all age groups. The death rate increases with age and is highest in those over age 85. Between 1979 and 1998, the death rate in those over 85 increased by 131.4 percent. Table 5 shows the number of deaths by 10-year age groups from 1979 to 1998.

ASTHMA PREVALENCE TRENDS, 1982–1996 AND 1997–1998 The National Health Interview Survey (NHIS) is a multipurpose health survey conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). It is the principal source of information on the health of the civilian, noninstitutionalized, household population of the United States. Despite the periodic revision of the NHIS Core questionnaire, Supplements began to play an increasingly important role in the survey as a means of enhancing topic coverage in the Core section. The unintended result was an increasingly unwieldy survey instrument and longer interviewing sessions: recent questionnaires (Core and Supplements combined) ran almost 300 pages, while the interviews averaged two hours. This imposed an unacceptable burden on NCHS staff, U.S.

Appendix IV 309 Bureau of Census interviewers, the data collection budget, and on the NHIS respondents. Furthermore, the excessive length of NHIS interviews contributed to declines in both response rate and data quality. For all these reasons, NCHS implemented a redesigned NHIS questionnaire in 1997. The new questionnaire design has made it impossible to compare current asthma estimates with those prior to 1997. The revised questionnaire evaluates both period and point prevalence of asthma. Asking respondents or their proxies if they have been diagnosed with asthma by a health professional within their lifetime assessed the period prevalence of asthma. The point prevalence of asthma was measured by asking all those diagnosed if they had an asthmatic attack or episode in the past 12 months. Between 1982 and 1996, respondents were asked to self-report asthma prevalence by letting interviewers know if any family member had asthma during the past 12 months. In contrast with the prior questionnaire, the redesigned survey measures physician-diagnosed asthma and produces a more specific estimate than self-report. In addition, estimating asthma attack prevalence is more helpful for planning public health interventions by measuring the population at risk for serious outcomes from asthma. These new estimates most likely continue to reflect an underestimate of true asthma prevalence, since studies have shown that there are many individuals suffering from undiagnosed asthma. Period Prevalence Based on the 1997 NHIS sample, it was estimated that 25.7 million people had been diagnosed with asthma by a health professional within their lifetime. That estimated number increased to 26.3 million people in 1998. The highest prevalence rate was seen in children 5–17 years of age for both years: 130.1 per 1,000 in 1997 and 135.0 per 1,000 in 1998. Females had higher rates than males, 99.0 vs. 94.0 per 1,000 persons in 1997 and 100.3 vs. 95.8 per 1,000 in 1998, but this difference was not significant in either year. The prevalence rate in blacks was 15 percent higher in 1997 and 30 percent higher in 1998 compared to the rate seen in whites. The difference between races was significant for both 1997 and 1998. This data is displayed in Table 6.

Point Prevalence

For simplicity, Tables 7, 8, and 9 will display point prevalence estimates for both trend phases—1982 to 1996 and 1997 to 1998, but again the data should not be compared to each other. In addition, this trend report will mainly focus on the revised survey data. Data from 1982 to 1996 will be highlighted but more detailed information on this trend series can be found in past versions of the morbidity and mortality reports. Age-Specific Prevalence Age-specific asthma prevalence trends are shown in Table 7. Between 1982 and 1996 the asthma prevalence rate increased 58.6 percent. There were significant differences seen in the rate increases for those under 45 but not for those in older age groups. The greatest increase was seen in those 18–44 (123.4%) and the smallest increase was seen in those over 65 (39.6%). The trend in age specific prevalence for 1982–1996 is delineated in Figure 3. The new revised NHIS trends show that between 1997 and 1998 the asthma attack prevalence rate for all ages decreased 5.3 percent. However, the prevalence rate in those under five increased 12.9 percent and by 5 percent in those over 65+. In 1997 and 1998 5–17 year olds had the highest prevalence rates (59.5 and 55.6 per 1,000 population) while those over 65 had the lowest (27.3 and 28.7 per 1,000 population). For both years the rate in those under 18 was significantly greater than those over 18. Overall, an estimated 10.6 million people (3.8 million children under 18) had an asthma attack or episode in 1998. This trend in age-specific prevalence is delineated in Figure 4. Sex-Specific Prevalence Sex-specific prevalence trends are delineated in Table 8. Between 1982 and 1996, the prevalence rate increased by almost 22 percent in males and 97 percent in females. The 1996 rate was 44.4 per 1,000 in males and 65.3 per 1,000 persons in females. These rates were significantly different from each other. The trend in sex-specific prevalence is depicted in Figure 5. Between 1997 and 1998, the prevalence rate decreased 2.0 percent in males and 7.7 percent in females. In 1997, 4.6 males (35.3 per 1,000) and

310 The Encyclopedia of Asthma and Respiratory Disorders 6.5 million females (47.8 per 1,000) had an asthma attack or episode. In 1998, an estimated 4.6 million males had an asthma attack or episode (34.5 per 1,000) compared to 6.1 million females (43.9 per 1,000). The difference between sexes was significant for both years. This trend in sex-specific prevalence is depicted in Figure 7. Race-Specific Prevalence Race-specific prevalence trends are displayed in Table 9. In 1996 the prevalence rate in whites was 53.5 per 1,000 persons while the prevalence rate in blacks was 69.6 per 1,000 persons. Both of these rates represent significant differences from the rates reported in 1982, when they were 34.6 and 39.2 for whites and blacks, respectively. This trend in racespecific prevalence is also shown in Figure 6. Between 1997 and 1998 the prevalence rate among whites decreased 6.8 percent from 41.0 to 38.2 per 1,000, while the prevalence rate among blacks increased 2.5 percent from 48.9 to 50.1 per 1,000. During both years, the prevalence rate for whites was highest in the 5–17 age group and lowest in those over 65. In 1997 the prevalence rate for blacks was highest in the 5–17 age group and lowest in the 18 to 44 group. In 1998 the rate was highest in those under five and lowest in those over 65. This trend in race-specific prevalence is also shown in Figure 7. Percentage Distribution of Conditions, 1998 The percentage distribution of asthma cases in 1998 is displayed in Figure 8. Four pie charts show the distribution of asthma by sex, age group, race, and geographic region.

ASTHMA TRENDS IN HOSPITAL DISCHARGES, 1970–1998 Tables 10, 11, and 12 delineate the number of firstlisted hospital discharges and discharge rate by sex, age, and race for asthma from 1970–1998, respectively. The first listed diagnosis is the diagnosis identified as the principal diagnosis or listed first on the medical record. Although data are presented for 1970 through 1998, due to the 1979 change in disease classification, the data on hospital discharges between 1970

and 1978 are not directly comparable to years 1979 and after. In addition, due to a second change in the design of the survey, data from 1988–1998 is not directly comparable to that of earlier years. We have restricted our analysis to estimates made since 1988. Hospital Discharges: 1988–1998 The hospital discharge rate for asthma increased dramatically from 1970 to 1988, it then plateaued into the mid-1990s and has been on the decline since 1996. In 1998, 423,000 discharges (15.5 per 10,000 people) were due to asthma. Sex-Specific Trends Table 10 delineates the trend in the hospital discharge rate by sex from 1970–1998. Between 1988 and 1995 the number of hospital discharges stayed relatively the same. However, since 1995 the number of hospital discharges decreased 17 percent overall, 20 percent in males and 15 percent in females. In 1998, a total of 255,000 discharges were reported in females and 168,000 were reported in males. The discharge rate in females (18.3 per 10,000) was significantly different from that reported in males (12.6 per 10,000). Age-Specific Trends As shown in Table 11, hospital discharge rates for asthma decreased in all age groups between 1995 and 1998. Those under 15 and those 15–44 years of age exhibited a 25 percent decline in rate followed by a 23 percent drop in those over age 65 and a 3 percent decline among those 45–64 years old. Unlike other chronic lung diseases, asthma discharges are very common among the pediatric population. Over 39 percent of asthma discharges in 1998 were in those under 15, whereas only 22 percent of the population were less than 15 years old. However, the discharge rate in the population <15 was only statistically greater than the rate in those 15–44. Figure 9 depicts this age-specific trend. Race-Specific Trends The trend in hospital discharges by race is delineated in Table 12. The 1998 discharge rate for asthma was highest in blacks (32.2 per 10,000) and lowest in whites (10.0 per 10,000). The rate in all other races was 21.0 per 10,000. These rates, how-

Appendix IV 311 ever, should be interpreted with caution due to the large percentage of discharges (13.7% in 1998) for which race was not reported. Figure 10 also displays this race-specific trend.

GLOSSARY

ECONOMIC COST OF ASTHMA

Period Prevalence: The proportion of cases that exist within a population at any point during a specified period of time.

Estimates of direct medical expenditures and indirect costs (in 2000 dollars) attributed to asthma are shown in Table 13. Asthma entails an annual economic cost to our nation in direct health care costs of $8.1 billion; indirect costs (lost productivity) add another $4.6 billion for a total of $12.7 billion. Inpatient hospital services represented the largest single direct medical expenditure, over $3.5 billion. The value of reduced productivity due to loss of school days represented the largest single indirect cost at $1.5 billion.

SUMMARY Asthma is a serious chronic condition affecting many Americans. Asthma accounts for an estimated 3 million lost work days for adults and 10.1 million lost school days in children annually. Over the past 20 years mortality, morbidity, and hospital discharge rates attributed to asthma have substantially increased. Between 1979 and 1998, the age-adjusted mortality rate increased 56 percent, while the prevalence rate increased by almost 22 percent in males and 97 percent in females between 1982 and 1996. However, new evidence suggests that these asthma mortality and morbidity rates may be beginning to plateau. The age-adjusted mortality rate for asthma has remained the same over the past two years and the asthma attack prevalence rate decreased 5.3 percent between 1997 and 1998. Since the National Health Interview Survey revised their questionnaire in 1997, more years of data are needed to accurately assess this prevalence trend. Hospital discharges have been declining over the past few years. The rate peaked at 19.5 per 10,000 in 1995 and has declined since then. Although asthma estimates seem to be declining, it is still a major public health concern. Asthma ranks within the top ten prevalent conditions causing limitation of activity and costs our nation $12.7 billion in health care costs annually.

Prevalence: The number of existing cases of a particular condition, disease, or other occurrence (e.g., persons smoking) at a given time.

Point Prevalence: The proportion of cases that exist within a population at a single point in time. Crude Rate: Cases in a particular population quantity (e.g., per hundred). Age-Adjusted Rate: A figure that is statistically corrected to remove the distorting effect of age when comparing populations of different age structures. P value: The probability of observing a result as extreme as that observed solely to chance. If p=0.05, then there is no more than a 5% chance of seeing that result again, but if p=0.05, then chance cannot be excluded as a likely explanation and the findings are said to be not significant at that level.

REFERENCES: 1. National Center for Health Statistics. Current Estimates from the National Health Interview Survey, U.S., selected years, 1970–1996. 2. National Center for Health Statistics. National Hospital Discharge Survey: 1980–1998 and data provided upon special request to the NCHS. 3. National Center for Health Statistics. Raw Data from the National Health Interview Survey, U.S., 1997–1998. (Analysis by the American Lung Association Best Practices Division, using SPSS and SUDAAN software) 4. National Center for Health Statistics. Report of Final Mortality Statistics: 1970–1998. 5. National Heart, Lung and Blood Institute Chartbook, U.S. Department of Health and Human Services, National Institute of Health, 2000. 6. Weiss, Kevin B., M.D.; Peter J. Gergen, M.D. M.P.H.; and Thomas A. Hodgson, Ph.D. “An Economic Evaluation of Asthma in the U.S.” The New England Journal of Medicine, 1992, 326: 862-6. FOOTNOTES: 1Unless

otherwise noted, terms such as higher or less are not intended to indicate statistical significance. this document, an association is considered statistical significance if the p value is less than or equal to 0.05

2In

312 The Encyclopedia of Asthma and Respiratory Disorders TABLE 1

ASTHMA: AGE-ADJUSTED MORTALITY RATE BY RACE AND SEX PER 100,000 POPULATION, 1970–19981

Source: National Center for Health Statistics, Final Mortality Statistics Report, 1970–1998. Notes: (1) Rates are age-adjusted to the 1940 U.S. standard population. (2) All races other than white. (3) International Classification of Diseases, 8th Revision (ICD-8) Code 493. (4) International Classification of Diseases, 9th Revision (ICD-9) Code 493.

Appendix IV 313 TABLE 2

ASTHMA: CRUDE MORTALITY RATE BY RACE AND SEX PER 100,000 POPULATION, 1970–1998

314 The Encyclopedia of Asthma and Respiratory Disorders TABLE 3

ASTHMA: NUMBER OF DEATHS BY RACE AND SEX, 1979–1998

Source: National Center for Health Statistics, Monthly Vital Statistics Report, 1979–1998. Note: (1) All races other than white.

Appendix IV 315 TABLE 4

ASTHMA: MORTALITY RATE BY 10-YEAR AGE GROUPS PER 100,000 POPULATION, 1979–1998

Source: National Center for Health Statistics, Monthly Vital Statistics Report, 1979–1998. Note: — Figure does not meet standard of reliability or precision (estimate based on fewer than 20 deaths)

TABLE 5

ASTHMA: NUMBER OF DEATHS IN 10-YEAR AGE GROUPS, 1979–1998

Source

316 The Encyclopedia of Asthma and Respiratory Disorders TABLE 5

ASTHMA: NUMBER OF DEATHS IN 10-YEAR AGE GROUPS, 1979–1998 (continued)

Source: National Center for Health Statistics, Final Vital Statistics Report, 1979–1998.

TABLE 6

ASTHMA: NUMBER OF PEOPLE EVER TOLD BY A DOCTOR OR OTHER HEALTH PROFESSIONAL THAT THEY HAD ASTHMA AND RATES PER 1,000 PEOPLE BY AGE, SEX, AND RACE, 1997–19981 (PERIOD PREVALENCE)

AGE TOTA L <5 5–17 <18 18–44 45–64 65+

25,747, 105 1,398, 233 6,719, 692 8,117, 925 10,377, 177 4,810, 974 2,441, 029

96.6 70.9 130. 1 113. 8 95.7 87.7 76.3

(93.3 – 99.8) (61.0 – 80.8) (122.2 – 138.1) (107.3 – 120.3) (90.7 – 100.8) (81.0 – 94.3) (68.9 – 83.6)

26,394, 037 1,627, 352 7,022, 501 8,649, 853 9,935, 452 5,304, 135 2,504, 597

98.1 82.6 135. 0 120. 6 91.6 93.6 77.7

(94.7 – 101.6) (71.2 – 94.1) (127.0 – 143.0) (113.8 – 127.5) (86.4 – 96.9) (86.4 – 100.7) (70.7 – 84.8)

MA LE FEM AL E

12,238, 763 13,508, 342

94.0 99.0

(89.3 – 98.7) (94.6 – 103.5)

12,589, 221 13,804, 816

95.8 100. 3

(90.8 – 100.8) (95.5 – 105.2)

WHITE <5 5–17 18–44 45–64 65+

20,799, 967 944, 392 5,120, 714 8,514, 352 4,067, 545 2,152, 964

95.5 62.1 128. 3 97.4 87.3 75.1

(91.9 – 99.0) (50.9 – 73.2) (119.5 – 137.1) (91.7 – 103.0) (80.0 – 94.6) (67.3 – 83.0)

20,827, 971 1,064, 697 5,287, 332 7,869, 545 4,437, 937 2,168, 460

95.3 70.5 131. 6 90.9 92.1 76.0

(91.5 – 99.1) (58.4 – 82.6) (122.8 – 140.5) (85.0 – 96.9) (84.2 – 99.9) (68.6 – 83.4)

SEX

RA CE

Appendix IV 317 TABLE 6

ASTHMA: NUMBER OF PEOPLE EVER TOLD BY A DOCTOR OR OTHER HEALTH PROFESSIONAL THAT THEY HAD ASTHMA AND RATES PER 1,000 PEOPLE BY AGE, SEX AND RACE, 1997–19981 (PERIOD PREVALENCE)

3,659, 349 331, 716 1,205, 433 1,350, 218 536, 779 235, 203

BL ACK <5 5-17 18- 44 45- 64 65+

109. 8 108. 0 148. 7 97.0 95.7 89.4

(101. 3--118. 3) (82.3--133. 7) (130. 4--167. 1) (84.4--109. 7) (78.7--112. 8) (65.0--113. 7)

4,165, 356 397, 810 1,311, 478 1,529, 102 685, 390 241, 576

124. 2 134. 4 160. 7 109. 5 118. 4 90.7

(115. 4--132. 9) (100. 3--168. 5) (136. 6--184. 7) (96.2--122. 7) (96.5--140. 2) (68.5--112. 9)

Source: National Center for Health Statistics, National Health Interview Survey, 1997–1998. Calculation of rates and confidence intervals performed by the Epidemiology and Statistics Unit. Note: (1) In 1997, the National Health Interview Survey’s questionnaire was completely redesigned. Therefore, estimates prior to 1997 cannot be compared with later estimates.

TABLE 7

ASTHMA: NUMBER OF CONDITIONS AND AGE-SPECIFIC PREVALENCE RATE PER 1,000 PERSONS, 1982–1996, 1997–19981,2 (ATTACK PREVALENCE)

1982

7,899,000

34.8

2,513,000

40.1

2,749,000

29.0

1,603,000

36.3

1,035,000

1983

8,787,000

38.3

2,828,000

45.2

3,487,000

36.1

1,529,000

34.6

943,000

36.4

1984

8,388,000

36.2

2,668,000

42.5

3,152,000

32.1

1,485,000

33.5

1,093,000

41.3

1985

8,612,000

36.8

2,997,000

47.8

3,323,000

33.4

1,255,000

28.2

1,036,000

38.3

1986

9,690,000

41.0

3,223,000

51.1

3,672,000

36.4

1,622,000

36.3

1,173,000

42.6

1987

9,565,000

40.1

3,323,000

52.5

3,522,000

34.5

1,633,000

36.3

1,087,000

38.6

1988

9,934,000

41.2

3,171,000

49.9

3,989,000

38.7

1,587,000

34.8

1,188,000

41.4

1989

11,621,000

47.7

3,901,000

61.0

4,302,000

41.3

1,914,000

41.5

1,504,000

51.5

1990

10,311,000

41.9

3,725,000

57.6

3,703,000

35.2

1,800,000

38.6

1,082,000

36.3

40.8

1991

11,735,000

47.2

4,094,000

62.5

4,594,000

43.4

1,921,000

40.7

1,126,000

37.2

1992

12,375,000

49.2

4,218,000

63.4

4,748,000

44.9

2,183,000

45.0

1,226,000

39.8

1993

13,074,000

51.4

4,830,000

71.6

4,495,000

42.5

2,242,000

45.0

1,506,000

48.2

1994

14,562,000

56.1

4,837,000

69.1

5,598,000

51.7

2,561,000

50.8

1,566,000

50.5

1995

14,878,000

56.8

5,294,000

74.9

5,577,000

51.6

2,754,000

53.3

1,253,000

39.8

1996

14,596,000

55.2

4,429,000

62.0

6,141,000

56.9

2,581,000

48.6

1,445,000

45.5

1997

11,113,225

41.7

812,410

41.2

3,072,538

59.5

3,884,948

54.4

4,367,913

40.3

1,985,366

36.2

874,998

27.3

1998

10,613,056

39.5

914,961

46.5

2,894,220

55.6

3,809,181

53.1

3,817,945

36.2

2,061,312

36.4

924,618

28.7

Source: National Center for Health Statistics, National Health Interview Survey, 1982–1996, 1997–1998. Calculations performed by the Epidemiology and Statistics Unit. Notes: *Data for these age groups were not calculated. (1) Due to rounding, numbers across may not sum up to totals. (2) In 1997, the National Health Interview Survey’s questionnaire was completely redesigned. Therefore, estimates prior to 1997 cannot be compared with later estimates.

318 The Encyclopedia of Asthma and Respiratory Disorders TABLE 8

ASTHMA: TRENDS IN SEX-SPECIFIC PREVALENCE PER 1,000 PERSONS, 1982–1996, 1997–19981 (ATTACK PREVALENCE)

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

3,994,000 3,818,000 3,924,000 3,864,000 4,670,000 4,609,000 4,650,000 5,593,000 4,741,000 5,724,000 5,516,000 5,946,000 6,542,000 6,687,000 5,751,000

36.5 34.5 35.1 34.2 40.8 39.9 39.9 47.4 39.7 47.4 45.1 48.1 51.7 52.4 44.4

3, 906,000 4, 968,000 4, 464,000 4, 748,000 5, 019,000 4, 956,000 5, 285,000 6, 028,000 5, 570,000 6, 011,000 6, 859,000 7, 127,000 8, 019,000 8, 190,000 8, 845,000

33.2 41.9 37.3 39.3 41.1 40.3 42.5 48.0 44.0 47.0 53.1 54.6 60.2 61.0 65.3

1997 1998

4,591,616 4,550,372

35.3 34.6

6 ,521,609 6 ,062,684

47.8 44.1

Source: National Center for Health Statistics, National Health Interview Survey, 1982–1996, 1997–1998. Calculations performed by the Epidemiology and Statistics Unit. Note: (1) In 1997, the National Health Interview Survey’s questionnaire was completely redesigned. Therefore, estimates prior to 1997 cannot be compared with later estimates.

Appendix IV 319 TABLE 9 ASTHMA: NUMBER OF CONDITIONS AND PREVALENCE RATE PER 1,000 PERSONS BY RACE AND AGE, 1982–1996, 1997–19981 (continued)

1982

6,711,000

34.6

4,393,000

33.3

1,423,000

36.5

895,000

39.0

1983

7,412,000

37.7

5,197,000

38.8

1,367,000

35.0

848,000

36.2

1984

7,296,000

36.9

4,982,000

37.0

1,295,000

33.1

1,019,000

42.6

1985

7,425,000

37.2

5,372,000

39.6

1,121,000

28.7

932,000

38.1

1986

8,190,000

40.9

5,758,000

42.2

1,451,000

37.2

981,000

39.6

1987

8,126,000

40.3

5,676,000

41.3

1,463,000

37.4

987,000

38.8

1988

8,101,000

39.9

5,728,000

41.6

1,327,000

33.5

1,046,000

40.5

1989

9,675,000

47.1

6,619,000

47.6

1,743,000

43.6

1,313,000

49.9

1990

8,544,000

41.3

6,033,000

43.1

1,585,000

39.3

926,000

34.6

1991

9,660,000

46.4

6,958,000

49.6

1,689,000

41.6

1,013,000

37.2

1992

10,309,000

49.2

7,341,000

52.4

1,900,000

45.5

1,068,000

38.8

1993

10,616,000

50.2

7,338,000

52.2

1,904,000

44.5

1,374,000

49.2

1994

12,052,000

56.2

8,353,000

58.2

2,258,000

52.3

1,441,000

51.9

1995

12,198,000

56.2

8,834,000

61.0

2,323,000

52.5

1,041,000

37.0

1996

11,764,000

53.5

8,301,000

56.9

2,168,000

47.4

1,295,000

45.3

1997

8,924,460

41.0

562,767

37.0

2,316,765

58.0

3,657,439

41.8

6,536,971

45.8

1,653,314

35.5

734,175

25.6

1998

8,351,811

38.2

600,960

39.8

2,191,663

54.6

3,001,924

34.7

5,794,547

40.9

1,755,150

36.4

802,114

28.1

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

1,055,000 1,230,000 965,000 1,119,000 1,212,000 1,281,000 1,631,000 1,586,000 1,414,000 1,740,000 1,787,000 1,967,000 1,861,000 2,217,000 2,310,000

39.2 45.1 34.8 39.8 42.5 44.3 55.5 53.1 46.6 56.3 56.8 61.4 56.3 67.7 69.6

* * * * * * * * * * * * * * *

796,000 985,000 750,000 913,000 902,000 1,033,000 1,301,000 1,304,000 1,107,000 1,462,000 1,393,000 1,554,000 1,495,000 1,726,000 1,926,000

38.6 47.1 35.2 42.5 41.5 46.9 58.2 57.4 48.0 62.3 58.4 64.2 58.9 69.0 76.6

156,000 150,000 153,000 122,000 164,000 148,000 225,000 112,000 180,000 195,000 249,000 315,000 255,000 313,000 275,000

37.2* 35.5* 35.9* 27.5 36.5 32.5 48.5 23.8* 37.6 40.1 49.9 61.3 49.7 60.0 50.7*

103,000 95,000 62,000 84,000 146,000 100,000 105,000 170,000 127,000 83,000 145,000 98,000 111,000 178,000 109,000

48.7* 44.5* 28.4* 37.2* 63.5* 42.5* 43.7* 69.3 50.7* 32.4* 55.3* 36.7* 44.0* 70.1* 41.7*

1997 1998

1,629,383 1,679,906

48.9 50.1

176,626 208,240

57.5 70.4

596,741 528,300

73.6 64.7

483,297 614,097

34.7 44.0

1,256,664 1,350,637

50.1 53.8

251,084 265,660

44.8 45.9

121,635 63,609

46.2 23.9

Source: National Center for Health Statistics, National Health Interview Survey, 1982–1996, 1997–1998. NOTES: * Estimate for which the numerator has a relative standard error of more than 30%. (1) In 1997, the National Health Interview Survey’s questionnaire was completely redesigned. Therefore, estimates prior to 1997 cannot be compared with later estimates.

320 The Encyclopedia of Asthma and Respiratory Disorders TABLE 10

ASTHMA: NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION BY SEX, 1970–19981

1970 2

133,000

6.7

53,866

5.4

79,126

1971

134,000

6.7

54,037

5.4

79,223

7.5

1972

162,000

7.9

67,365

6.6

93,995

8 .8

7.6

1973

161,000

7.8

73,111

7.1

87,024

8 .0

1974

159,000

7.6

67,041

6.5

91,495

8 .4

1975

183,000

8.7

71,799

6.8

111,371

10.1

1976

190,000

9.0

78,718

7.4

111,730

10.0

1977

199,000

9.4

86,391

8.1

112,125

10.0

1978

201,000

9.4

82,939

7.7

117,928

10.3

1979 3

339,000

15.7

143,000

13.1

196,000

17.0

1980

408,000

18.0

180,000

16.3

228,000

19.6

1981

418,000

18.4

180,000

16.2

237,000

20.1

1982

434,000

18.9

190,000

17.1

245,000

20.6

1983

459,000

19.8

190,000

17.0

269,000

22.4

1984

465,000

19.8

197,000

17.1

268,000

22.0

1985

462,000

19.5

195,000

17.0

266,000

21.8

1986

477,000

19.9

206,000

17.8

271,000

21.9 20.9

1987

454,000

18.8

193,000

16.5

261,000

1988 4

479,000

19.6

210,000

17.7

270,000

21.4

1989

475,000

19.3

204,000

17.1

271,000

21.3

1990

476,000

19.1

191,000

15.8

285,000

22.2

1991

490,000

19.6

221,000

18.2

269,000

20.9

1992

463,000

18.3

201,000

16.3

263,000

20.1

1993

468,000

18.3

191,000

15.3

278,000

21.1

189,000

15.0

262,000

19.7

1994

451,000

17.4

1995

511,000

19.5

210,000

16.5

301,000

22.4

1996

474,000

17.9

195,000

15.1

279,000

20.6

1997

484,000

17.9

204,000

15.4

279,000

20.2

1998

423,000

15.5

168,000

12.6

255,000

18.3

Source: National Center for Health Statistics, National Hospital Discharge Survey, 1970–1998. Notes: (1) Due to rounding, numbers across may not add up to the total number of hospital discharges. (2) International Classification of Diseases, 8th Revision (ICD-8) Code 493. (3) International Classification of Diseases, 9th Revision (ICD-9) Code 493. (4) Data from 1988–98 may not be comparable to earlier years due to the redesign of the survey.

Appendix IV 321 TABLE 11

ASTHMA: NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION BY AGE, 1970–19981

1970 2

33,000

5.8

36,000

4.4

38,000

9.0

26,000

13.6

133,000

6.7

1971

32,000

5.5

38,000

4.5

41,000

9.7

24,000

12.1

134,000

6.7

1972

48,000

8.6

41,000

4.8

40,000

9.5

32,000

16.1

162,000

7.9

1973

55,000

9.9

36,000

4.1

42,000

9.7

29,000

14.1

161,000

7.8

1974

56,000

10.2

38,000

4.2

36,000

8.3

29,000

14.1

159,000

7.6

1975

58,000

10.9

49,000

5.3

49,000

11.4

27,000

12.9

183,000

8.7

1976

60,000

11.5

49,000

5.3

48,000

11.4

33,000

14.9

190,000

9.0

1977

69,000

13.3

51,000

5.4

46,000

10.6

33,000

14.8

199,000

9.4

1978

61,000

12 .1

60,000

6.2

50,000

11.6

29,000

12.9

201,000

9.4

1979 3

99,000

19.8

94,000

9.5

83,000

19.1

63,000

27.0

339,000

15.7

1980

124,000

24.2

99,000

9.5

101,000

22.7

84,000

32.7

408,000

18.0

1981

128,000

25.0

12,000

10.6

104,000

23.4

74,000

28.2

418,000

18.4

1982

151,000

29.3

104,000

9.7

98,000

22.1

81,000

30.4

434,000

18.9

1983

136,000

26.4

110,000

10.1

119,000

26.7

94,000

34.2

459,000

19.8

1984

150,000

29.0

109,000

9.9

102,000

22.8

105,000

37.4

466,000

19.8

1985

144,000

27.8

241,000

11.1

97,000

21.5

97,000

34.1

462,000

19.5

1986

158,000

30.3

122,000

10.8

99,000

22.0

98,000

33.7

477,000

19.9

1987

149,000

28.4

112,000

9.8

92,000

20.4

101,000

33.8

454,000

18.8

1988 4

164,000

31.0

110,000

9.6

93,000

20.3

112,000

36.8

479,000

19.6

1989

168,000

31.2

127,000

11.0

88,000

19.0

93,000

29.9

475,000

19.3

1990

169,000

30.8

119,000

10.3

86,000

18.2

102,000

32.4

476,000

19.1

1991

187,000

33.9

128,000

10.9

85,000

18.2

90,000

28.5

490,000

19.6

1992

193,000

34.4

117,000

10.0

78,000

16.1

76,000

23.6

463,000

18.3

1993

159,000

28.0

128,000

10.9

94,000

19.0

87,000

26.6

468,000

18.3

1994

169,000

29.5

125,000

10.6

80,000

15.7

76,000

22.9

451,000

17.4

1995

212,000

36.7

135,000

11.4

87,000

16.7

77,000

23.0

511,000

19.5

1996

195,000

33.8

132,000

11.1

88,000

16.4

59,000

17.4

474,000

17.9

1997

214,000

35.8

117,000

9.6

98,000

15.9

65,000

19.2

484,000

17.9

1998

166,000

27.7

104,000

8.6

92,000

16.2

60,000

17.7

423,000

15.5

322 The Encyclopedia of Asthma and Respiratory Disorders TABLE 12

ASTHMA: NUMBER OF FIRST-LISTED HOSPITAL DISCHARGES AND RATE PER 10,000 POPULATION BY RACE, 1988–1998

1988

479,000

295,000

116,000

31,000

37,000

19.6

14.4

39.4

36.1

1989

475,000

286,000

117,000

22,000

50,000

19.3

13.9

39.2

24.2

1990

476,000

263,000

116,000

19,000

78,000

19.1

12.7

38.3

19.8

1991

490,000

269,000

120,000

23,000

78,000

19.6

12.8

38.9

22.9

1992

463,000

215,000

134,000

25,000

89,000

18.3

10.2

42.8

23.8

1993

468,000

246,000

103,000

22,000

97,000

18.3

11.5

32.3

20.1

1994

451,000

227,000

125,000

29,000

70,000

17.4

10.5

38.6

26.0

1995

511,000

256,000

140,000

25,000

90,000

19.5

11.6

42.7

21.4

1996

474,000

237,000

133,000

33,000

70,000

17.9

10.8

40.1

27.6

1997

484,000

262,000

125,000

39,000

58,000

17.9

11.8

35.5

30.7

1998

423,000

222,000

115,000

28,000

58,000

15.5

10.0

32.2

21.0

Source: National Center for Health Statistics: National Hospital Discharge Survey, 1988–1998. Notes: 1. Rates shown here may differ from previously published rates due to adjustments made to population used. 2. Total includes white, black and other race discharges as well as discharges of an unspecified race. 3. Between 1988 and 1998, the number of discharges not reporting race increased dramatically. It appears that hospital discharges in whites might be disproportionately underestimated, particularly in later years. For this reason, comparisons between races should be made with caution.

Appendix IV 323 TABLE 13 ECONOMIC COST OF ASTHMA: DIRECT MEDICAL AND INDIRECT EXPENDITURES, UNITED STATES, 2000 CATEGORY

DOLLAR COST (in billions)

Direct Medical Expenditures: Hospital Care Inpatient Emergency Room Outpatient

3,474.90 656.10 421.20

Physicians’ Services Inpatient Outpatient

324.00 769.50

Medications

2,446.20

All Direct Expenditures

8,091.90

Indirect Costs: School Days Lost

1,495.00

Loss of Work Outside Employment Men Women Housekeeping

225.40 349.60 837.20

Mortality Men Women

805.00 887.80

All Indirect Costs All Costs:

4,600.00 12,691.90

Sources: New England Journal of Medicine, Vol. 326, No. 13, March 26, 1992. Morbidity and Mortality, Chartbook on Cardiovascular, Lung and Blood Diseases, NHLBI, 2000. Note: Estimates of direct medical expenditures and indirect costs were derived using mortality and health survey data available from the National Center for Health Statistics, health expenditure data from the Health Care Financing Administration, and income data from the U.S. Bureau of Census. The cost estimates were projected to 2000 dollars. These numbers are estimates and should be cited as such.

APPENDIX V GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA Excerpted from the Expert Panel Report 2, National Institutes of Health and National Heart, Lung, and Blood Institute, April 1997 (some illustrations have been omitted)

eral approach to diagnosing and managing asthma based on current science. The Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (NAEPP 1991) was published in 1991, and the recommendations for the treatment of asthma were organized around four components of effective asthma management:

INTRODUCTION Asthma is a chronic inflammatory disease of the airways. In the United States, asthma affects 14 million to 15 million persons. It is the most common chronic disease of childhood, affecting an estimated 4.8 million children (Adams and Marano 1995; Centers for Disease Control and Prevention 1995). People with asthma collectively have more than 100 million days of restricted activity and 470,000 hospitalizations annually. More than 5,000 people die of asthma annually. Asthma hospitalization rates have been highest among blacks and children, while death rates for asthma were consistently highest among blacks aged 15 to 24 years (Centers for Disease Control and Prevention 1996). These rates have increased or remained stable over the past decade. This report describes the appropriate use of the available therapies in the management of asthma. To help health care professionals bridge the gap between current knowledge and practice, the National Heart, Lung, and Blood Institute’s (NHLBI) National Asthma Education and Prevention Program (NAEPP) has convened two Expert Panels to prepare guidelines for the diagnosis and management of asthma. The NAEPP Coordinating Committee, under the leadership of Claude Lenfant, M.D., director of the NHLBI, convened the first Expert Panel in 1989. The charge to this panel was to develop a report that would provide a gen-

• Use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy • Environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations • Comprehensive pharmacologic therapy for longterm management designed to reverse and prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma exacerbations • Patient education that fosters a partnership among the patient, his or her family, and clinicians The principles addressed within these four components of asthma management served as the starting point for the development of two additional reports prepared by asthma experts from many countries in cooperation with the NHLBI: the International Consensus Report on Diagnosis and Management of Asthma (NHLBI 1992) and the Global Initiative for Asthma (NHLBI/WHO 1995). The Expert Panel Report 2 Guidelines for the Diagnosis and Management of Asthma (EPR-2) is the latest report from the NAEPP and updates the 1991 Expert Panel Report. The second Expert Panel critically reviewed and built upon the reports listed above.

324

Appendix V 325 This report presents basic recommendations for the diagnosis and management of asthma that will help clinicians and patients make appropriate decisions about asthma care. Of course, the clinician and patient need to develop individual treatment plans that are tailored to the specific needs and circ*mstances of the patient. The NAEPP, and all who participated in the development of this latest report, hope that the patient with asthma will be the beneficiary of the recommendations in this document. This report is not an official regulatory document of any government agency.

METHODS USED TO DEVELOP THIS REPORT The NAEPP Coordinating Committee established a Science Base Committee of U.S. asthma experts who began work in early 1994 to monitor the scientific literature and advise the Coordinating Committee when an update of the 1991 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma was needed. The Science Base Committee, along with international members of the Global Initiative for Asthma, examined all the relevant literature on asthma in human subjects published in English between 1991 and mid-1995, obtained through a series of MEDLINE database searches. More than 5,000 abstracts were reviewed. In 1995, the Science Base Committee recommended to the NAEPP Coordinating Committee that sufficient new information had been published since 1991 to convene a panel of experts to update the first Expert Panel Report. The second Expert Panel is a multidisciplinary group of clinicians and scientists with expertise in asthma management. The panel includes health care professionals in the areas of general medicine, family practice, pediatrics, emergency medicine, allergy, pulmonary medicine, nursing, pharmacy, and health education. Among the panel members are individuals who served on either the Science Base Committee or the 1991 Expert Panel. Other members were chosen based on names submitted by NAEPP Coordinating Committee member organizations. Several Expert Panel members are themselves members of the Coordinating Committee.

Representatives from several Federal agencies also have participated. The charge to the panel was to prepare recommendations for use by clinicians working in diverse health care settings that address the practical decision-making issues in the diagnosis and management of asthma. The panel also was requested to develop specific aids to facilitate implementation of the recommendations. Panel members were asked to base their recommendations on their review of the scientific literature and to cite studies that support the recommendations. When a clear recommendation could not be extracted from the studies (e.g., studies were not available, were conflicting, or were equivocal), the panel was asked to label the recommendation as “based on the opinion of the Expert Panel,” “recommended by the Expert Panel,” or similar terminology. When a whole section was “based on the opinion of the Expert Panel,” this was indicated at the beginning of the section (e.g., see component 1-Initial Assessment and Diagnosis). This report was prepared in a systematic and iterative process. In addition to the Science Base Committee review of the scientific literature, the panel conducted in-depth reviews of the literature in selected areas it considered controversial. In interpreting the literature, the panel considered the nature and quality of the study designs and analyses. Given the complexities of several issues, the panel chose not to use the strict evidence ranking system used in the guidelines development procedures of the U.S. Preventive Services Task Force. However, this procedure was applied in the area of peak flow monitoring. The panel submitted their interpretation of the literature and related recommendations for multiple reviews by their fellow Expert Panel members and outside reviewers. The development of EPR-2 was directed by an Executive Committee; each member of the Executive Committee headed a subcommittee assigned to prepare a specific chapter. Each member of the panel was assigned to one of the subcommittees. The subcommittees were responsible for reviewing the pertinent literature and drafting the recommendations with the supporting evidence for the full panel to review. Once the subcommittee

326 The Encyclopedia of Asthma and Respiratory Disorders reports were prepared, the full panel critically reviewed the evidence and rationale for each recommendation, discussed revisions, and reached final agreement on each recommendation. A vote was taken to confine the consensus of the panel. The final report was approved by the NAEPP Coordinating Committee via mail. . . . The development of this report was entirely funded by the National Heart, Lung, and Blood Institute, National Institutes of Health. Panel members and reviewers participated as volunteers and were compensated only for travel expenses related to the two Expert Panel meetings and the Executive Committee meetings. The goal of the EPR-2: Guidelines for the Diagnosis and Management of Asthma is to serve as a comprehensive guide to diagnosing and managing asthma. Implementation of EPR-2 recommendations is likely to increase some costs of asthma care by increasing the number of primary care visits for asthma and the use of asthma medications, environmental control products and services, and equipment (e.g., spacer/holding chamber devices). However, asthma diagnosis and management are expected to improve, which should reduce the numbers of lost school and work days, hospitalizations and emergency department visits, and deaths due to asthma. A net reduction in total health care costs should result. The NAEPP encourages research to evaluate the impact of implementing the recommendations in this report.

OVERVIEW OF THE REPORT Each section of EPR-2 begins with a list of “Key Points” and “Differences from the 1991 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma.’ A brief overview of each section is provided below. Pathogenesis and Definition In the 1991 Expert Panel Report, the role of inflammation in the pathogenesis of asthma was emphasized although the scientific evidence for the involvement of inflammation in asthma was just emerging. Now in 1997, although the role of inflammation is still evolving as a concept, a much firmer scientific basis exists to indicate that asthma

results from complex interactions among inflammatory cells, mediators, and the cells and tissues resident in the airways. Thus, asthma is now defined as a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Component 1: Measures of Assessment and Monitoring Initial Assessment and Diagnosis of Asthma Making the correct diagnosis of asthma is extremely important. Clinical judgment is required because signs and symptoms vary widely from patient to patient as well as within each patient over time. To establish the diagnosis of asthma, the clinician must determine that: • Episodic symptoms of airflow obstruction are present. • Airflow obstruction is at least partially reversible. • Alternative diagnoses are excluded. This section differs from the 1991 Expert Panel Report in several ways. Asthma severity classifications have been changed from mild, moderate, and severe to mild intermittent, mild persistent, moderate persistent, and severe persistent to more accurately reflect the clinical manifestations of asthma. The panel emphasizes that patients at any level of severity can have mild, moderate, or severe exacerbations. In addition, information on wheezing in infancy and vocal cord dysfunction has been expanded in the differential diagnosis section in Component 1. Situations that may warrant referral to an asthma specialist have been refined with input from specialty and primary care physicians.

Appendix V 327 Periodic Assessment and Monitoring To establish whether the goals of asthma therapy have been achieved, ongoing monitoring and periodic assessment are needed. The goals of asthma therapy are to:

• Prevent chronic and troublesome symptoms • Maintain (near) “normal” pulmonary function • Maintain normal activity levels (including exercise and other physical activity) • Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations • Provide optimal pharmacotherapy with minimal or no adverse effects • Meet patients’ and families’ expectations of and satisfaction with asthma care Several types of monitoring are recommended: signs and symptoms, pulmonary function, quality of life/functional status history of asthma exacerbations, pharmacotherapy, patient-provider communication, and patient satisfaction. The panel recommends that patients, especially those with moderate to severe persistent asthma or a history of severe exacerbations, be given a written action plan based on signs and symptoms and/or peak expiratory flow. As in the 1991 report, daily peak flow monitoring is recommended for patients with moderate to severe persistent asthma. In addition, the panel states that any patient who develops severe exacerbations may benefit from peak flow monitoring. A complete review of the literature on peak flow monitoring was conducted, evidence tables were prepared, and the results of this analysis are summarized in the report. Component 2: Control of Factors Contributing to Asthma Severity Exposure of sensitive patients to inhalant allergens has been shown to increase airway inflammation, airway hyperresponsiveness, asthma symptoms, need for medication, and death due to asthma. Substantially reducing exposures significantly reduces these outcomes. Environmental tobacco smoke is a major precipitant of asthma symptoms

in children, increases symptoms and the need for medications, and reduces lung function in adults. Increased air pollution levels of respirable particulates, ozone, SO2, and NO2 have been reported to precipitate asthma symptoms and increase emergency department visits and hospitalizations for asthma. Other factors that can contribute to asthma severity include rhinitis and sinusitis, gastroesophageal reflux, some medications, and viral respiratory infections. EPR-2 discusses environmental control and other measures to reduce the effects of these factors. Component 3: Pharmacologic Therapy EPR-2 offers an extensive discussion of the pharmacologic management of patients at all levels of asthma severity. It is noted that asthma pharmacotherapy should be instituted in conjunction with environmental control measures that reduce exposure to factors known to increase the patient’s asthma symptoms. As in the 1991 report, a stepwise approach to pharmacologic therapy is recommended, with the type and amount of medication dictated by asthma severity. EPR-2 continues to emphasize that persistent asthma requires daily long-term therapy in addition to appropriate medications to manage asthma exacerbations. To clarify this concept, the EPR-2 now categorizes medications into two general classes: long-term control medications to achieve and maintain control of persistent asthma and quick-relief medications to treat symptoms and exacerbations. Observations into the basic mechanisms of asthma have had a tremendous influence on therapy. Because inflammation is considered an early and persistent component of asthma, therapy for persistent asthma must be directed toward longterm suppression of the inflammation. Thus EPR-2 continues to emphasize that the most effective medications for long-term control are those shown to have anti-inflammatory effects. For example, early intervention with inhaled corticosteroids can improve asthma control and normalize lung function, and preliminary studies suggest that it may prevent irreversible airway injury. An important addition to EPR-2 is a discussion of the management of asthma in infants and young

328 The Encyclopedia of Asthma and Respiratory Disorders children that incorporates recent studies on wheezing in early childhood. Another addition is discussions of long-term–control medications that have become available since 1991—long-acting inhaled beta2-agonists, nedocromil, zafirlukast, and zileuton. Recommendations for managing asthma exacerbations are similar to those in the 1991 Expert Panel Report. However, the treatment recommendations are now on a much firmer scientific basis because of the number of studies addressing the treatment of asthma exacerbations in children and adults in the past six years. Component 4: Education for a Partnership in Asthma Care As in the 1991 Expert Panel Report, education for an active partnership with patients remains the cornerstone of asthma management and should be carried out by health care providers delivering asthma care. Education should start at the time of asthma diagnosis and be integrated into every step of clinical asthma care. Asthma self-management education should be tailored to the needs of each patient, maintaining a sensitivity to cultural beliefs and practices. New emphasis is placed on evaluating outcomes in terms of patient perceptions of improvement, especially quality of life and the ability to engage in usual activities. Health care providers need to systematically teach and frequently review with patients how to manage and control their asthma. Patients also should be provided with and taught to use a written daily selfmanagement plan and an action plan for exacerbations. It is especially important to give a written action plan to patients with moderate to severe persistent asthma or a history of severe exacerbations. Appropriate patients should also receive a daily asthma diary. Adherence should be encouraged by promoting open communication; individualizing, reviewing, and adjusting plans as needed; emphasizing goals and outcomes; and encouraging family involvement. In summary, the 1997 Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma reflects the experience of the past six years as well as the increasing scientific base of published articles on asthma. The Expert Panel hopes this new report

will assist the clinician in forming a valuable partnership with patients to achieve excellent asthma treatment and outcomes.

REFERENCES Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 1995; 10:94. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults—United States, 1990–1995. MMWR 1996;45:350–353. Centers for Disease Control and Prevention. AsthmaUnited States, 1989–1992. MMWR 1995;43:952–955. National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma. National Institutes of Health publication 91-3642. Bethesda, Md., 1991. National Heart, Lung, and Blood Institute. International Consensus Report on Diagnosis and Management of Asthma. National Institutes of Health publication 92-3091. Bethesda, Md., 1992. National Heart, Lung, and Blood Institute and World Health Organization. Global Initiative for Asthma. National Institutes of Health Publication 95-3659. Bethesda, Md., 1995. U.S. Preventive Services Task Force. Guide to Clinical Preventive Health Services. Baltimore, Md.: Williams and Wilkins, 1989.

PATHOGENESIS AND DEFINITION Key Points • Asthma, whatever the severity, is a chronic inflammatory disorder of the airways. This has implications for the diagnosis, management, and potential prevention of the disease. • The immunohistopathologic features of asthma include: • Denudation of airway epithelium • Collagen deposition beneath basem*nt membrane • Edema • Mast cell activation • Inflammatory cell infiltration • Neutrophils (especially in sudden-onset, fatal asthma exacerbations)

Appendix V 329 • Eosinophils • Lymphocytes (TH2-like cells) • Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity. • Airway inflammation also contributes to several forms of airflow limitation, including acute bronchoconstriction, airway edema, mucus plug formation, and airway wall remodeling. These features lead to bronchial obstruction. • Atopy, the genetic predisposition for the development of an IgE-mediated response to 10 common aeroallergens, is the strongest identifiable predisposing factor for developing asthma. Differences from 1991 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma

• The critical role of inflammation in asthma has been further substantiated by research. It is recognized that asthma results from complex interactions among inflammatory cells, mediators, and other cells and tissues resident in the airway. • Evidence indicates that subbasem*nt membrane fibrosis may occur in some patients and that these changes contribute to persistent abnormalities in lung function. The importance of airway remodeling and the development of persistent airflow limitation need further exploration and may have significant implications for the treatment of asthma. The clinician, physiologist, immunologist, and pathologist all may have different perspectives on asthma based on their individual viewpoints and experience. The merging of these different perspectives into an acceptable definition of asthma has occurred and is important for more specific and effective treatment of this disease and for investigation into its pathogenesis. Furthermore, even though this disorder affects virtually the entire spectrum of life, asthma has certain age-specific characteristics and differential diagnosis issues that

need to be considered in both its treatment and its etiology. Based on current knowledge, a working definition of asthma is: a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli (NHLBI 1995). Moreover, recent evidence indicates that subbasem*nt membrane fibrosis may occur in some patients with asthma and that these changes contribute to persistent abnormalities in lung function (Roche 1991). This working definition and its expanded recognition of key features of asthma have been derived from studying how airway changes in asthma relate to various factors associated with the development of allergic inflammation (e.g., allergens, respiratory viruses, and some occupational exposures. . . . From this approach has come a more comprehensive understanding of asthma pathogenesis, the development of persistent airway inflammation, and the profound implications these issues have for the diagnosis, treatment, and potential prevention of asthma.

AIRWAY PATHOLOGY AND ASTHMA Until recently, information on airway pathology in asthma has come largely from postmortem examination (Dunnill 1960), which shows that both large and small airways often contain plugs composed of mucus, serum proteins, inflammatory cells, and cellular debris. Viewed microscopically, airways are infiltrated with eosinophils and mononuclear cells, and there is vasodilation and evidence of microvascular leakage and epithelial disruption. The airway smooth muscle is often hypertrophied, which is characterized by new vessel formation, increased numbers of epithelial goblet cells, and deposition of interstitial collagens

330 The Encyclopedia of Asthma and Respiratory Disorders beneath the epithelium. These features of airway wall remodeling further underscore the importance of chronic, recurrent inflammation in asthma and its effects on the airway. Moreover, these morphologic changes may not be completely reversible. Consequently, research is currently focused on determining whether these changes can be prevented or modified by early diagnosis, avoidance of factors that contribute to asthma severity, and pharmacologic therapy directed at suppressing airway inflammation. Establishing the relationship between the pathologic changes and the clinical features of asthma has been difficult. Fiber-optic bronchoscopy with lavage and biopsy provide new insight into mechanisms of airway disease and features that link altered lung function to a specific type of mucosal inflammation (Laitinen et al. 1985; Beastey et al. 1989; Jeffery et al. 1989). From such studies, evidence has emerged that mast cells, eosinophils, epithelial cells, macrophages, and activated T cells are key features of the inflammatory process of asthma (Djukanovic et al. 1990). . . . These cells can influence airway function through secretion of preformed and newly synthesized mediators that act either directly on the airway or indirectly through neural mechanisms (Emanuel and Howarth 1995). Furthermore, with the use of cellular and molecular biological techniques, subpopulations of T lymphocytes (TH2) have been identified as important cells that may regulate allergic inflammation in the airway through the release of selective cytokines and also establish disease chronicity (Robinson et al. 1992). In addition, constituent cells of the airway, including fibroblasts, endothelial cells, and epithelial cells, also contribute to this process by releasing cytokines and chemokines. The above factors may be important in both initiating and maintaining the level of airway inflammation (Robinson et al. 1993). It is hypothesized that airway inflammation can be acute, subacute, and chronic. The acute inflammatory response is represented by the early recruitment of cells to the airway. In the subacute phase, recruited and resident cells are activated to cause a more persistent pattern of inflammation. Chronic inflammation is characterized by a persistent level of cell damage and an ongoing repair process, changes that may

cause permanent abnormalities in the airway. Finally, it is recognized that specific adhesion proteins, found in the vascular tissue, lung matrix, and bronchial epithelium, may be critical in directing and anchoring cells in the airway, thus causing the inflammatory changes noted (Albelda 1991). From these studies of the histological features associated with asthma has come evidence of an association between airway inflammation and markers of airway disease severity and an indication that this process is multicellular, redundant, and selfamplifying. Cell-derived mediators can influence airway smooth muscle tone, modulate vascular permeability, activate neurons, stimulate mucus secretion, and produce characteristic structural changes in the airway (Horwitz and Busse 1995). These mediators can target ciliated airway epithelium to cause injury or disruption. As a consequence, epithelial cells and myofibroblasts present beneath the epithelium-proliferate and begin to deposit interstitial collagens in the lamina reticularis of the basem*nt membrane. This may explain apparent basem*nt membrane thickening and the irreversible airway changes that may occur in some asthma patients (Roche 1991). Other changes, including hypertrophy and hyperplasia of airway smooth muscle, increases in goblet cell number, enlargement of submucous glands, and remodeling of the airway connective tissue, are components of asthma that need to be recognized in both its pathogenesis and treatment. This inflammatory process is redundant in its ability to alter airway physiology and architecture. Child-Onset Asthma Asthma often begins in childhood, and when it does, it is frequently found in association with atopy, which is the genetic susceptibility to produce IgE directed toward common environmental allergens, including house-dust mites, animal proteins, and fungi (Larsen 1992). With the production of IgE antibodies, mast cells and possibly other airway cells (e.g., lymphocytes) are sensitized and become activated when they encounter specific antigens. Although atopy has been found in 30 to 50 percent of the general population, it is frequently found in the absence of asthma. Nevertheless, atopy is one

Appendix V 331 of the strongest predisposing factors in the development of asthma (Sporik et al. 1990). Furthermore, among infants and young children who have wheezing with viral infections, allergy or family history of allergy is the factor that is most strongly associated with continuing asthma through childhood (Martinez et al. 1995). Adult-Onset Asthma Although asthma begins most frequently in childhood and adolescence, it can develop at any time in life. Adult-onset asthma can occur in a variety of situations. In adult-onset asthma, allergens may continue to play an important role. However, in some adults who develop asthma, IgE antibodies to allergens or a family history of asthma are not detected. These individuals often have coexisting sinusitis, nasal polyps, and sensitivity to aspirin or related nonsteroidal anti-inflammatory drugs. The mechanisms of nonallergic, or intrinsic, asthma are less well established, although the inflammatory process is similar (but not identical) to that seen in atopic asthma (Walker et al. 1992). Occupational exposure to workplace materials (animal products; biological enzymes; plastic resin; wood dusts, particularly cedar; and metals) (see Component 2) can cause airway inflammation, bronchial hyperresponsiveness, and clinical signs of asthma (Chan-Yeung and Malo 1994; Fabbri et al. 1994). Identification of the causative agent and its removal from the workplace can reduce symptoms; however, some individuals will have persistent asthma even though exposure to the causative agent is eliminated. The mechanisms of this form of asthma are not clearly established.

RELATIONSHIP OF AIRWAY INFLAMMATION AND LUNG FUNCTION Airway Hyperresponsiveness An important feature of asthma is an exaggerated bronchoconstrictor response to a wide variety of stimuli. The propensity for airways to narrow too easily and too much is a major, but not necessarily unique, feature of asthma. Airway hyperresponsiveness leads to clinical symptoms of wheezing and dyspnea after exposure to allergens,

environmental irritants, viral infections, cold air, or exercise. Research indicates that airway hyperresponsiveness is important in the pathogenesis of asthma and that the level of airway responsiveness usually correlates with the clinical severity of asthma. Airway hyperresponsiveness can be measured by inhalation challenge testing with methacholine or histamine, as well as after exposure to such nonpharmacologic stimuli as hyperventilation with cold dry air, inhalation of hypotonic or hypertonic aerosols, or after exercise (O’Connor et al. 1989). In addition, variability between morning and evening peak expiratory flow (PEF) appears to reflect airway hyperresponsiveness and may serve as a measure of airway hyperresponsiveness, asthma instability, or asthma severity. The factors contributing to airway inflammation in asthma are multiple and involve a variety of different inflammatory cells (as illustrated in Figure 2) (Busse et al. 1993). It is also apparent that asthma is not caused by either a single cell or a single inflammatory mediator but rather results from complex interactions among inflammatory cells, mediators, and other cells and tissues resident in airways. An initial trigger in asthma may be the release of inflammatory mediators from bronchial mast cells, macrophages, T lymphocytes, and epithelial cells. These substances direct the migration and activation of other inflammatory cells, such as eosinophils and neutrophils, to the airway where they cause injury, such as alterations in epithelial integrity, abnormalities in autonomic neural control of airway tone, mucus hypersecretion, change in mucociliary function, and increased airway smooth muscle responsiveness. The importance of the airway inflammatory response to airway hyperresponsiveness is substantiated by several observations. First, airway markers of inflammation correlate with bronchial hyperresponsiveness. Second, treatment of asthma and modification of airway inflammatory markers not only reduce symptoms but also diminish airway responsiveness. However, the relationship between airway inflammation and airway responsiveness is complex. Some investigations have shown that although anti-inflammatory therapy reduced airway hyperresponsiveness, it did not

332 The Encyclopedia of Asthma and Respiratory Disorders eradicate it. A small study found that control of airway inflammation did not control bronchial hyperresponsiveness (Lundgren et al. 1988). Thus, factors in addition to inflammation may contribute to airway hyperresponsiveness. Airflow Obstruction Airflow limitation in asthma is recurrent and caused by a variety of changes in the airway. These include: • Acute bronchoconstriction. Allergen-induced acute bronchoconstriction results from an IgEdependent release of mediators from the mast cell that include histamine, tryptase, leukotrienes, and prostaglandins (Marshall and Bienenstock 1994), which directly contract airway smooth muscle. Aspirin and other nonsteroidal antiinflammatory drugs (see Component 2) can also cause acute airflow obstruction in some patients, and evidence indicates that this non–IgE-dependent response also involves mediator release from airway cells (Fischer et al. 1994). In addition, other stimuli, including exercise, cold air, and irritants, can cause acute airflow obstruction. The mechanisms regulating the airway response to these factors are less well-defined, but the intensity of the response appears related to underlying airway inflammation (Busse et al. 1993). There is emerging evidence that stress can play a role in precipitating asthma exacerbations. The mechanisms involved have yet to be established and may include enhanced generation of proinflammatory cytokines (Friedman et al. 1994). • Airway edema. Airway wall edema, even without smooth muscle contraction or bronchoconstriction, limits airflow in asthma. Increased microvascular permeability and leakage caused by released mediators also contribute to mucosal thickening and swelling of the airway. As a consequence, swelling of the airway wall causes the airway to become more rigid and interferes with airflow. • Chronic mucous plug formation. In severe intractable asthma, airflow limitation is often persistent. In part, this change may arise as a consequence of mucous secretion and the formation of inspissated mucous plugs.

• Airway remodeling. In some patients with asthma, airflow limitation may be only partially reversible. The etiology of this component is not as well studied as other features of asthma but may relate to structural changes in the airway matrix that may accompany long-standing and severe airway inflammation. There is evidence that a histological feature of asthma in some patients is an alteration in the amount and composition of the extracellular matrix in the airway wall (Djukanovic et al. 1990; Laitinen and Laitinen 1994). As a consequence of these changes, airway obstruction may be persistent and not responsive to treatment. Regulation of this repair and remodeling process is not well established, but both the process of repair and its regulation are likely to be key events in explaining the persistent nature of the disease and limitations to a therapeutic response. Although yet to be fully explored, the importance of airway remodeling and the development of persistent airflow limitation suggest a rationale for early intervention with anti-inflammatory therapy.

RELEVANCE OF CHRONIC AIRWAY INFLAMMATION TO ASTHMA THERAPY Although inflammation can be used to describe a variety of conditions in various diseases, the inflammatory response in asthma has special features that include eosinophil infiltration, mast cell degranulation, interstitial airway wall injury, and lymphocyte activation. Furthermore, there is evidence that a TH2 lymphocyte cytokine profile (i.e., IL-4 and IL-5) is instrumental in initiating and sustaining the inflammatory process (James and Kay 1995; Ricci et al. 1993) . . . These observations also have become important in directing treatment in asthma. It is hypothesized that inflammation is an early and persistent component of asthma. As a consequence, therapy to suppress the inflammation must be long term. Furthermore, preliminary evidence suggests that early intervention with antiinflammatory therapy may modify the disease process (Agertoft and Pedersen 1994; Laitinen et al. 1992; Djukanovic et al. 1992). Observations into the basic mechanisms of asthma have had tremendous impact and influence

Appendix V 333 on therapy. Studies have shown that improvements in asthma control achieved with high doses of inhaled corticosteroids are associated with improvement in markers of airway inflammation (Laitinen et al. 1992; Djukanovic et al. 1992). These observations indicate that a strong link may exist between features of airway inflammation, bronchial hyperresponsiveness, asthma symptoms, and severity. Furthermore, insight into the mechanisms of asthma with airway inflammation and bronchial wall repair has become a driving factor in designing logical, and hopefully, effective, treatment paradigms. Another area that needs clarification is the classification of compounds as anti-inflammatory in nature. Because many factors contribute to the inflammatory response in asthma, many drugs may fit this category. At present, corticosteroids are the anti-inflammatory compounds that have been demonstrated to modify histopathological features of asthma (Barnes 1995). It may be necessary to evaluate each new compound for the specificity of its “anti-inflammatory” action and determine from appropriate observations whether the compound is indeed anti-inflammatory and what consequences this has on the clinical features of the disease.

REFERENCES Agertoft L, Pedersen S. Effects of long-term treatment with an inhaled corticosteroid on growth and pulmonary function in asthmatic children. Respir Med 1994;88:373–381. Albelda SM. Endothelial and epithelial cell adhesion molecules. Am J Respir Cell Mol Biol 1991;4:195–203. Barnes PJ. Inhaled glucocorticosteroid for asthma. N Engl J Med 1995;332:868–875. Beasley R, Roche WR, Roberts TA, Holgate ST. Cellular events in the bronchi in mild asthma and bronchial provocation. Am Rev Respir Dis 1989;139:806–817. Busse WW, Calhoun WI, Sedgwick JD. Mechanisms of airway inflammation in asthma. Am Rev Respir Dis 1993;147:S20–S24. Chan-Yeung M, Malo JL. Aetiological agents in occupational asthma. Eur Respir J 1994;7:346–371. Djukanovic R, Roche WR, Wilson JW, et al. Mucosal inflammation in asthma. Am Rev Respir Dis 1990;142:434–457. Djukanovic R, Wilson TW, Britten Icil, et al. Affect of an inhaled corticosteroid on airway inflammation and

symptoms of asthma. Am Rev Respir Dis 1992; 145:669–674. Dunnill MS. The pathology of asthma, with special reference to changes in the bronchial mucosa. J Clin Pathol 1960;13:27–33. Emanuel MB, Howarth PH. Asthma and anaphylaxis: a relevant model for chronic disease? An historical analysis of directions in asthma research. Clin Exp Allergy 1995;25:15–26. Fabbri IM, Maestrelli F, Saetta M, Mapp CM. Mechanisms of occupational asthma. Clin Exp Allergy 1994;24:628–635. Fischer AR, Rosenherg MA, Lilly CM, et al. Direct evidence for a role of the mast cell in the nasal response to aspirin in aspirin-sensitive asthma. J Allergy Clin Immunol 1994;94:1046–1056. Friedman EM, Cue CL, Ershler WB. Bidirectional effects of interleukin-1 on immune responses in rhesus monkeys. Brain Behav Immunol 1994;8: 87–99. Horwitz RJ, Busse WW. Inflammation and asthma. Clin Chest Med 1995;16:583–602. James DG, Kay AB. Are you TH-1 or TH-2? [editorial] Clin Exp Allergy 1995;25:389–90. Jeffery PK, Wardlaw AJ, Nelson FC, Collins JV, Kay AB. Bronchial biopsies in asthma. An ultrastructural, qualitative study and correlation with hyperreactivity. Am Rev Respir Dis 1989;140:1745–1753. Laitinen A, Laitinen LA. Airway morphology: endothelial/basem*nt membrane. Am J Respir Crit Care Med 1994;150:514–517. Laitinen IA, Heino M, Leitinen A, Kava T, Haahtela T. Damage of the airway epithelium and bronchial reactivity in patients with asthma. Am Rev Respir Dis 1985;131:599–606. Laitinen LA, Laitinen A, Haahtela T. A comparative study of the effects of an inhaled corticosteroid, budesonide, and a beta2-agonist, terbutaline, on airway inflammation in newly diagnosed asthma: a randomized, double-blind, parallel-group controlled trial. J Allergy Clin Immunol 1992;90:32–42. Larsen GL. Asthma in children. N Engl J Med 1992; 326:1540–1545. Lundgren R, Stiderherg M, Horstedt P, et al. Morphological studies of bronchial biopsies from asthmatics before and after 10 years of treatment with inhaled steroids. Eur Respir J 1988;1:853–859. Marshall JS, Bienenstock J. The role of mast cells in inflammatory reactions of the airways, skin and intestine. Curr Opin Immunol 1994;6:853–859. Martinez PD, Wright AL, Taussig IM, Holherg CJ, Halonen M, Morgan WI, Group Health Medical Associates.

334 The Encyclopedia of Asthma and Respiratory Disorders Asthma and wheezing in the first six years of life. N Engl J Med 1995;332:133–138. National Heart, Lung, and Blood Institute. Global Initiative for Asthma. National Institutes of Health publication 95–3659. 1995. O’Connor GT, Sparrow D, Weiss ST. The role of allergy and nonspecific airway hyperresponsiveness in the pathogenesis of chronic obstructive pulmonary disease. Am Rev Respir Dis 1959;140:225–252. Ricci M, Rossi O, Bertoni M, Matucci A. The importance of TH2-like cells in the pathogenesis of airway allergic inflammation. Clin Exp Allergy 1993; 23:360–369. Robinson DS, Durham SR, Kay AB. Cytokines in asthma. Thorax 1993;48:845–853. Robinson DS, Hamid Q, Ying S, et al. Predominant TH2-like broncheoalveolar T-lymphocyte population in atopic asthma. N Engl J Med 1992;326: 298–304. Roche WR. Fibroblasts and asthma. Clin Exp Allergy 1991;21:545–548. Sporik R, Holgate ST, Platts-Mills TA, Cogswell JJ. Exposure to house-dust mite allergen (Der pI) and the development of asthma in childhood. A prospective study. N Engl J Med 1990;323:502–507. Walker C, Bode E, Boer L, Hausel TT, Blaser K, Virchow JC Jr. Allergic and nonallergic asthmatics have distinct patterns of T-cell activation and cytokine production in peripheral blood and bronchoalveolar lavage. Am Rev Respir Dis 1992;146:109–115.

COMPONENT 1 MEASURES OF ASSESSMENT AND MONITORING: INITIAL ASSESSMENT AND DIAGNOSIS OF ASTHMA Key Points • To establish a diagnosis of asthma, the clinician should determine that: Episodic symptoms of airflow obstruction are present. Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded. • Recommended mechanisms to establish the diagnosis are: Detailed medical history Physical exam focusing on the upper respiratory tract, chest, and skin Spirometry to demonstrate reversibility

• Additional studies may be considered to: Evaluate alternative diagnoses Identify precipitating factors Assess severity Investigate potential complications • Recommendations are presented for referral for consultation or care to a specialist in asthma care. Differences from 1991 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma • Severity classifications were changed from mild, moderate, and severe to mild intermittent, mild persistent, moderate persistent, and severe persistent. • Examples of questions to use for diagnosis and initial assessment of asthma were added. • Information on wheezing in infancy and vocal cord dysfunction was expanded in the differential diagnosis section. • Criteria for referral were refined with input from specialty and primary care physicians. • More specific recommendations for measuring peak expiratory flow (PEF) diurnal variation are made. The guidelines to help establish a diagnosis of asthma presented in this component are based on the opinion of the Expert Panel. The clinician trying to establish a diagnosis of asthma should determine that: •

Episodic symptoms of airflow obstruction are present.

•

Airflow obstruction is at least partially reversible.

•

Alternative diagnoses are excluded.

A careful medical history, physical examination, pulmonary function tests, and additional tests will provide the information needed to ensure a correct diagnosis of asthma . . . Each of these methods of assessment is described in this section. Clinical judgment is needed in conducting the assessment for asthma. Patients with asthma are heterogeneous and present signs and symptoms

Appendix V 335 that vary widely from patient to patient as well as within each patient over time. Medical History A detailed medical history of the new patient known or thought to have asthma should address the items listed in Figure 1-1. The medical history can help: • Identify the symptoms likely to be due to asthma. See Figure 1-2 for sample questions. • Support the likelihood of asthma (e.g., patterns of symptoms, family history of asthma or allergies). • Assess the severity of asthma (e.g., symptom frequency and severity, exercise tolerance, hospitalizations, current medications). See Figure 1-3 for a description of the levels of asthma severity. • Identify possible precipitating factors (e.g., viral respiratory infections; exposure at home, work, day care, or school to inhalant allergens or irritants such as tobacco smoke). See Component 2, Control of Factors Contributing to Asthma Severity, for more details.

Physical Examination The upper respiratory tract, chest, and skin are the focus of the physical examination for asthma. Physical findings that increase the probability of asthma include: • Hyperexpansion of the thorax, especially in children; use of accessory muscles; appearance of hunched shoulders; and chest deformity. • Sounds of wheezing during normal breathing or a prolonged phase of forced exhalation (typical of airflow obstruction). Wheezing during forced exhalation is not a reliable indicator of airflow limitation. In mild intermittent asthma, or between exacerbations, wheezing may be absent. • Increased nasal secretion, mucosal swelling, and nasal polyps. • Atopic dermatitis/eczema or any other manifestation of an allergic skin condition. Pulmonary Function Testing (Spirometry) Spirometry measurements (FEV1, FVC, FEV1/FVC) before and after the patient inhales a short-acting bronchodilator should be undertaken for patients

BOX 1. KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA Consider asthma and performing spirometry if any of these indicators are present.* These indicators are not diagnostic by themselves, but the presence of multiple key indicators increases the probability of a diagnosis of asthma. Spirometry is needed to establish a diagnosis of asthma. • Wheezing—high-pitched whistling sounds when breathing out—especially in children. (Lack of wheezing and a normal chest examination do not exclude asthma.) • History of any of the following: Cough, worse particularly at night Recurrent wheeze Recurrent difficulty in breathing Recurrent chest tightness • Reversible airflow limitation and diurnal variation as measured by using a peak flow meter, for example: Peak expiratory flow (PEF) varies 20 percent or more from PEF measurement on arising in the morning (before taking

an inhaled short-acting beta2-agonist) to PEF measurement in the early afternoon (after taking an inhaled shortacting beta2-agonist). • Symptoms occur or worsen in the presence of: Exercise Viral infection Animals with fur or feathers House-dust mites (in mattresses, pillows, upholstered furniture, carpets) Mold Smoke (tobacco, wood) Pollen Changes in weather Strong emotional expression (laughing or crying hard) Airborne chemicals or dusts Menses • Symptoms occur or worsen at night, awakening the patient.

*Eczema, hay fever, or a family history of asthma or atopic diseases are often associated with asthma, but they are not key indicators.

336 The Encyclopedia of Asthma and Respiratory Disorders in whom the diagnosis of asthma is being considered (Bye et al. 1992; Li and O’Connell 1996). This helps determine whether there is airflow obstruction and whether it is reversible over the short term (see Box 2 for further information). Spirometry is generally valuable in children over age four; however, some children cannot conduct the maneuver adequately until after age seven. Spirometry typically measures the maximal volume of air forcibly exhaled from the point of maximal inhalation (forced vital capacity, FVC) and the volume of air exhaled during the first second of the FVC (forced expiratory volume in 1 second, FEV1). Airflow obstruction is indicated by reduced FEV1 and FEV1/FVC values relative to reference or predicted values. Significant reversibility is indicated by an increase of >12 percent and 200 ml in FEV, after inhaling a short-acting bronchodilator (American Thoracic Society 1991) (see Figure 14 [omitted] for example of a spirometric curve for this test). A two- to three-week trial of oral corticosteroid therapy may be required to demonstrate reversibility. The spirometry measurements that establish reversibility may not indicate the patient’s best lung function. Abnormalities of lung function are categorized as restrictive and obstructive defects. A reduced ratio of FEV1/FVC (i.e., <65 percent) indicates obstruction to the flow of air from the lungs, whereas a reduced FVC with a normal FEV1/FVC ratio suggests a restrictive pattern. The severity of abnormality of spirometric measurements is evaluated by comparison of the patient’s results with reference values based on age, height, sex, and race (American Thoracic Society 1991). Although asthma is typically associated with an obstructive impairment that is reversible, neither this finding nor any other single test or measure is adequate to diagnose asthma. Many diseases are associated with this pattern of abnormality. The patient’s pattern of symptoms (along with other information from the patient’s medical history) and exclusion of other possible diagnoses also are needed to establish a diagnosis of asthma. In severe cases, the FVC may also be reduced, due to trapping of air in the lungs. Office-based physicians who care for asthma patients should have access to spirometry, which is

useful in both diagnosis and periodic monitoring. Spirometry should be performed using equipment and techniques that meet standards developed by the American Thoracic Society (1995). Correct technique, calibration methods, and maintenance of equipment are necessary to achieve consistently accurate test results. Maximal patient effort in performing the test is required to avoid important errors in diagnosis and management. Training courses in the performance of spirometry that are approved by the National Institute for Occupational Safety and Health are available (800)35NIOSH. When office spirometry shows severe abnormalities, or if questions arise regarding test accuracy or interpretation, the Expert Panel recommends further assessment in a specialized pulmonary function laboratory. FIGURE 1-1. SUGGESTED ITEMS FOR MEDICAL HISTORY* A detailed medical history of the new patient who is known or thought to have asthma should address the following items: 1. Symptoms • Cough • Wheezing • Shortness of breath • Chest tightness • Sputum production 2. Pattern of symptoms • Perennial, seasonal, or both • Continual, episodic, or both • Onset, duration, frequency (number of days or nights, per week or month) • Diurnal variations, especially nocturnal and on awakening in early morning 3. Precipitating and/or aggravating factors • Viral respiratory infections • Environmental allergens, indoor (e.g., mold, house-dust mite, co*ckroach, animal dander, or secretory products) and outdoor (e.g., pollen) • Exercise • Occupational chemicals or allergens • Environmental change (e.g., moving to new home; going on vacation; and/or alterations in workplace, work processes, or materials used) • Irritants (e.g., tobacco smoke, strong odors, air pollutants, occupational chemicals, dusts and particulates, vapors, gases, and aerosols) • Emotional expressions (e.g., fear, anger, frustration, hard crying or laughing)

Appendix V 337 • Drugs (e.g., aspirin; beta-blockers, including eyedrops; nonsteroidal anti-inflammatory drugs; others) • Food, food additives, and preservatives (e.g., sulfites) • Changes in weather, exposure to cold air • Endocrine factors (e.g., menses, pregnancy, thyroid disease) 4. Development of disease and treatment • Age of onset and diagnosis • History of early-life injury to airways (e.g., bronchopulmonary dysplasia, pneumonia, parental smoking) • Progress of disease (better or worse) • Present management and response, including plans for managing exacerbations • Need for oral corticosteroids and frequency of use • Comorbid conditions 5. Family history • History of asthma, allergy, sinusitis, rhinitis, or nasal polyps in close relatives 6. Social history • Characteristics of home including age, location, cooling and heating system, wood-burning stove, humidifier, carpeting over concrete, presence of molds or mildew, characteristics of rooms where patient spends time (e.g., bedroom and living room with attention to bedding, floor covering, stuffed furniture), smoking (patient and others in home or day care) • Day care, workplace, and school characteristics that may interfere with adherence • Social factors that interfere with adherence, such as substance abuse • Social support/social networks • Level of education completed • Employment (if employed, characteristics of work environment) 7. Profile of typical exacerbation • Usual prodromal signs and symptoms • Usual patterns and management (what works?) 8. Impact of asthma on patient and family • Episodes of unscheduled care (emergency department, urgent care, hospitalization) • Life-threatening exacerbations (e.g., intubation, intensive care unit admission) • Number of days missed from school/work • Limitation of activity, especially sports and strenuous work • History of nocturnal awakening • Effect on growth, development, behavior, school or work performance, and lifestyle • Impact on family routines, activities, or dynamics • Economic impact 9. Assessment of patient’s and family’s perceptions of disease • Patient, parental, and spouse’s or partner’s knowledge of asthma and belief in the chronicity of asthma and in the efficacy of treatment

• Patient perception and beliefs regarding use and longterm effects of medications • Ability of patient and parents, spouse, or partner to cope with disease • Level of family support and patient’s and parents’, spouse’s, or partner’s capacity to recognize severity of an exacerbation • Economic resources • Sociocultural beliefs *This list does not represent a standardized assessment or diagnostic instrument. The validity and reliability of this list have not been assessed.

Additional Studies Even though additional studies are not routine, they may be considered. No one test or set of tests is appropriate for every patient. However, the following procedures may be useful when considering alternative diagnoses, identifying precipitating factors, assessing severity, and investigating potential complications: • Additional pulmonary function studies (e.g., lung volumes and inspiratory and expiratory flow volume loops) may be indicated, especially if there are questions about coexisting chronic obstructive pulmonary disease, a restrictive defect, or possible central airway obstruction. A diffusing capacity test is helpful in differentiating between asthma and emphysema in patients at risk for both illnesses, such as smokers and older patients. • Assessment of diurnal variation in peak expiratory flow over one to two weeks is recommended when patients have asthma symptoms but normal spirometry (Enright et al. 1994). PEF is generally lowest on first awakening and highest several hours before the midpoint of the waking day (e.g., between noon and 2 P.M.) (Quackenboss et al. 1991). Optimally, PEF should be measured close to those two times, before taking an inhaled short-acting beta2-agonist in the morning and after taking one in the afternoon. A 20 percent difference between morning and afternoon measurements suggests asthma. Measuring PEF on waking and in the evening may be more practical and feasible, but values will tend to underestimate the actual diurnal variation.

338 The Encyclopedia of Asthma and Respiratory Disorders • Bronchoprovocation with methacholine, histamine, or exercise challenge may be useful when asthma is suspected and spirometry is normal or near normal. For safety reasons, bronchoprovocation testing should be carried out by a trained individual in an appropriate facility and is not generally recommended if the FEV1 is <65 percent predicted. A negative bronchoprovocation may be helpful to rule out asthma. • Chest X ray may be needed to exclude other diagnosis. • Allergy testing (see Component 2). • Evaluation of the nose for nasal polyps and sinuses for sinus disease. • Evaluation for gastroesophageal reflux (Harding and Richter 1992) (see Component 2). The usefulness of measurements of biomarkers of inflammation (e.g., total and differential cell count and mediator assays) in sputum, blood, or urine as aids to the diagnosis of asthma is currently being evaluated in clinical research trials.

Differential Diagnosis of Asthma Recurrent episodes of cough and wheezing are almost always due to asthma in both children and adults. Underdiagnosis of asthma is a frequent problem, especially in children who wheeze when they have respiratory infections. These children are often labeled as having bronchitis, bronchiolitis, or pneumonia even though the signs and symptoms are most compatible with a diagnosis of asthma. However, the clinician needs to be aware of other causes of airway obstruction leading to wheezing (see Figure 1-5). There are two general patterns of wheezing in infancy: nonallergic and allergic. Nonallergic infants wheeze when they have an acute upper respiratory viral infection, but as their airways grow larger in the preschool years, the wheezing disappears. Allergic infants also wheeze with viral infections, but they are more likely to have asthma that will continue throughout childhood. This group may have eczema, allergic rhinitis, or food allergy as other manifestations of allergy. Both groups may benefit from asthma treatment.

FIGURE 1-3. CLASSIFICATION OF ASTHMA SEVERITY TABLE

Appendix V 339 Vocal cord dysfunction often mimics asthma. Patients with vocal cord dysfunction can present with recurrent severe shortness of breath and wheezing. Vocal cord dysfunction may even cause alveolar hypoventilation, with increases in Pco2 that prompt urgent intubation and mechanical ventilation. Vocal cord dysfunction that mimics asthma is more common in young adults with psychological disorders. It should be suspected when physical examination reveals a monophonic wheeze heard loudest over the glottis. Further evaluation by flow-volume curve revealing inspiratory flow limitation strongly supports the diagnosis of vocal cord dysfunction. Definitive diagnosis—and exclusion of organic causes of vocal cord narrowing—requires direct visualization of the vocal cords. Treatment with speech therapy that teaches techniques for relaxed throat breathing is often effective (Newman et al. 1995; Bucca et al. 1995; Christopher et al. 1983). FIGURE 1-2. SAMPLE QUESTIONS* FOR THE DIAGNOSIS AND INITIAL ASSESSMENT OF ASTHMA A “yes” answer to any question suggests that an asthma diagnosis is likely. In the past 12 months . . . • Have you had a sudden severe episode or recurrent episodes of coughing, wheezing (high-pitched whistling sounds when breathing out), or shortness of breath? • Have you had colds that “go to the chest” or take more than 10 days to get over? • Have you had coughing, wheezing, or shortness of breath during a particular season or time of the year? • Have you had coughing, wheezing, or shortness of breath in certain places or when exposed to certain things (e.g., animals, tobacco smoke, perfumes)? • Have you used any medications that help you breathe better? How often? • Are your symptoms relieved when the medications are used? In the past 4 weeks, have you had coughing, wheezing, or shortness of breath . . . • At night that has awakened you? • In the early morning? • After running, moderate exercise, or other physical activity? *These questions are examples and do not represent a standardized assessment or diagnostic instrument. The validity and reliability of these questions have not been assessed.

BOX 2.

IMPORTANCE OF SPIROMETRY IN ASTHMA DIAGNOSIS

Objective assessments of pulmonary function are necessary for the diagnosis of asthma because medical history and physical examination are not reliable means of excluding other diagnoses or of characterizing the status of lung impairment. Although physicians generally seem able to identify a lung abnormality as obstructive (Russell et al. 1986), they have a poor ability to assess the degree of airflow obstruction (Shim and Williams 1980) or to predict whether the obstruction is reversible (Russell et al. 1986). For diagnostic purposes, spirometry is generally recommended over measurements by a peak flow meter in the clinician’s office because there is wide variability even in the best published peak expiratory flow reference values. Reference values need to be specific to each brand of peak flow meter, and such normative brand-specific values currently are not available for most brands. Peak flow meters are designed as monitoring, not as diagnostic, tools in the office (see Component 1—Periodic Assessment and Monitoring: Essential for Asthma Monitoring). However, peak flow monitoring can establish peak flow variability and thus aid in the determination of asthma severity when patients have asthma symptoms and normal spirometry (see Additional Studies section).

General Guidelines for Referral to an Asthma Specialist Criteria for the referral of an asthma patient have been developed (Spector and Nicklas 1995; Shuttari 1995). Based on the opinion of the Expert Panel, referral for consultation or care to a specialist in asthma care (usually, a fellowship-trained allergist or pulmonologist; occasionally, other physicians with expertise in asthma management developed through additional training and experience) is recommended when: • Patient has had a life-threatening asthma exacerbation. • Patient is not meeting the goals of asthma therapy (see Component 1—Periodic Assessment and Monitoring) after three to six months of treatment. An earlier referral or consultation is appropriate if the physician concludes that the patient is unresponsive to therapy. • Signs and symptoms are atypical or there are problems in differential diagnosis.

340 The Encyclopedia of Asthma and Respiratory Disorders • Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, vocal cord dysfunction, gastroesophageal reflux, chronic obstructive pulmonary disease). • Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy, complete pulmonary function studies, provocative challenge, bronchoscopy). • Patient requires additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance. • Patient is being considered for immunotherapy. • Patient has severe persistent asthma, requiring step 4 care (referral may be considered for patients requiring step care; see Component 3— Managing Asthma Long Term). • Patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids or has required more than two bursts of oral corticosteroids in one year. • Patient is under age three and requires step 3 or 4 care (see Component 3—Managing Asthma Long Term). When patient is under age three and requires step 2 care initiation of daily long-term therapy, referral should be considered. • Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested substance is provoking or contributing to asthma. Depending on the complexities of diagnosis, treatment, or the intervention required in the work environment, it may be appropriate in some cases for the specialist to manage the patient over a period of time or co-manage with the primary care provider. In addition, patients with significant psychiatric, psychosocial, or family problems that interfere with their asthma therapy may need referral to an appropriate mental health professional for counseling or treatment. These characteristics have been shown to interfere with a patient’s ability to adhere to treatment (Strunk 1987; Strunk et al. 1985).

FIGURE 1-5. DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA Infants and Children Upper airway diseases • Allergic rhinitis and sinusitis Obstruction involving large airways • Foreign body in trachea or bronchus • Vocal cord dysfunction • Vascular rings or laryngeal webs • Laryngotracheomalacia, tracheal stenosis, or bronchostenosis • Enlarged lymph nodes or tumor Obstructions involving small airways • Viral bronchiolitis or obliterative bronchiolitis • Cystic fibrosis • Bronchopulmonary dysplasia • Heart disease Other causes • Recurrent cough not due to asthma • Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux Adults

• Chronic obstructive pulmonary disease (chronic bronchitis or emphysema) • Congestive heart failure • Pulmonary embolism • Laryngeal dysfunction • Mechanical obstruction of the airways (benign and malignant tumors) • Pulmonary infiltration with eosinophilia • Cough secondary to drugs (angiotensin-converting enzyme [ACE] inhibitors) • Vocal cord dysfunction

REFERENCES American Thoracic Society. Lung function testing: selection of reference values and interpretive strategies. Am Rev Respir Dis 1991;144:1202–1218. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995; 152: 1107–1136. Bucca C, Rolla G, Brussino L, De Rose V, Bugiani M. Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction? Lancet 1995;346:791–795. Bye MR, Kerstein D, Barsh B. The importance of spirometry in the assessment of childhood asthma. Am J Dis Child 1992;146:977–978. Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal cord dysfunction pre-

Appendix V 341 senting as asthma. N Engl J Med 1983; 308: 1566–1570. Enright PL, Lebowitz MD, co*ckroft DW. Physiologic measures: pulmonary function tests. Asthma outcome. Am J Respir Crit Care Med 1994;149:59–68. Harding SM, Richter JE. Gastroesophageal reflux disease and asthma. Semin Gastrointest Dis 1992;3:139–150. Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis 1983;127:725–734. Li JT, O’Connell EJ. Clinical evaluation of asthma. Ann Allergy Asthma Immunol 1996;76:1–13. Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med 1995;152:1382–1386. Quackenboss JJ, Lebowitz MD, Krzyzanowski M. The normal range of diurnal changes in peak expiratory flow rates. Relationship to symptoms and respiratory disease. Am Rev Respir Dis 1991;143:323–330. Russell NJ, Crichton NJ, Emerson PA, Morgan AD. Quantitative assessment of the value of spirometry. Thorax 1986;41:360–363. Shim CS, Williams MH Jr. Evaluation of the severity of asthma: patients versus physicians. Am J Med 1980;68:11–13. Shuttari MF. Asthma: diagnosis and management. Am Fam Physician 1995;52:2225–2235. Spector SL, Nicklas RA, eds. Practice parameters for the diagnosis and treatment of asthma. J Allergy Clin Immunol 1995;96:729–731. Strunk RC. Asthma deaths in childhood: identification of patients at risk and intervention. J Allergy Clin Immunol 1997;80:472–477. Strunk RC, Mrazek DA, Wolfson Fuhrmann GS, LaBrecque JR. Physiologic and psychological characteristics associated with deaths due to asthma in childhood. A case-controlled study. JAMA 1985; 254:1193–1198.

PERIODIC ASSESSMENT AND MONITORING: ESSENTIAL FOR ASTHMA MANAGEMENT Key Points • The goals of therapy are to: Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion) Maintain (near) “normal” pulmonary function

Maintain normal activity levels (including exercise and other physical activity) Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations Provide optimal pharmacotherapy with the least amount of adverse effects Meet patients’ and families’ expectations of and satisfaction with asthma care • Periodic assessments and ongoing monitoring of asthma are recommended to determine if the goals of therapy are being met. Measurements of the following are recommended: Signs and symptoms of asthma Pulmonary function Quality of life/functional status History of asthma exacerbations Pharmacotherapy Patient-provider communication and patient satisfaction • Clinician assessment and patient self-assessment are the primary methods for monitoring asthma. Population-based assessment is beginning to be used by managed care organizations. • Spirometry tests are recommended (1) at the time of initial assessment, (2) after treatment is initiated and symptoms and PEF have stabilized, and (3) at least every 1 to 2 years. • Patients should be given a written action plan based on signs and symptoms and/or PEF: This is especially important for patients with moderateto-severe persistent asthma or a history of severe exacerbations. • Patients should be trained to recognize symptom patterns indicating inadequate asthma control and the need for additional therapy. • Recommendations on how and when to do peak flow monitoring are presented. Differences from 1991 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma • The new report includes an additional goal of therapy (meet patients’ and families’ expectations of and satisfaction with asthma care) that was not listed in the 1991 report.

342 The Encyclopedia of Asthma and Respiratory Disorders • Periodic assessment of six domains of patient health that correspond with the goals of asthma therapy are now recommended, including signs and symptoms, pulmonary function, quality of life, history of exacerbations, pharmacotherapy, and patient-provider communication and patient satisfaction. • The following changes affecting peak flow monitoring have been made: The recommendation for peak flow monitoring was changed from twice daily to morning. If the morning reading is less than 80 percent of personal best PEF, more frequent peak flow monitoring may be desired. Discussion of inconsistencies in measurement among peak flow meters was added. Use of the individual patient’s personal best PEF is emphasized strongly. • The recommendation for patients at all severity levels to monitor symptoms to recognize early signs of deterioration is emphasized. • Sample questions to use in periodic assessments were added. Goals of Therapy The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved. The goals of therapy are as follows: • Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion) • Maintain (near) “normal” pulmonary function • Maintain normal activity levels (including exercise and other physical activity) • Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations • Provide optimal pharmacotherapy with minimal or no adverse effects • Meet patients’ and families’ expectations of and satisfaction with asthma care

Assessment Measures The Expert Panel recommends ongoing monitoring in the six areas listed below to determine whether the goals of therapy are being met. The assessment measures for monitoring these six areas are described in this section and are recommended based on the opinion of the Expert Panel. • Monitoring signs and symptoms of asthma • Monitoring pulmonary function • Spirometry • Peak flow monitoring • Monitoring quality of life/functional status • Monitoring history of asthma exacerbations • Monitoring patient-provider communication and patient satisfaction Monitoring Signs and Symptoms of Asthma Every patient with asthma should be taught to recognize symptom patterns that indicate inadequate asthma control (see Patient Self-Assessment section and Component 4). Symptom monitoring should be used as a means to determine the need for intervention, including additional medication, in the context of an action plan (see Figure 4-5 [omitted]). Symptoms and clinical signs of asthma should be assessed at each health care visit through physical examination and appropriate questions. This is crucial to optimal asthma care. A description of the important elements of an asthma-related physical examination can be found in Component 1—Initial Assessment and Diagnosis, which also discusses the variability in the types of symptoms associated with asthma. Detailed patient recall of symptoms decreases over time; therefore, the Expert Panel recommends that any detailed symptoms history be based on a short (two to four weeks) recall period. For example, the clinician may choose to assess over a twoweek, three-week, or four-week recall period (see Figure 1-6 [omitted]). Symptom assessment for periods longer than four weeks should reflect more global symptom assessment, such as inquiring whether the patient’s asthma has been better or worse since the last visit and inquiring whether the patient has encountered any particular difficulties

Appendix V 343 during specific seasons or events. Figure 1-6 provides an example of a set of questions that can be used to characterize both global (long-term recall) and recent (short-term recall) asthma symptoms. In addition, any assessment of the patient’s symptom history should include at least three key symptom expressions: • Daytime asthma symptoms (including wheezing, cough, chest tightness, or shortness of breath) • Nocturnal awakening as a result of asthma symptoms • Monitoring pharmacotherapy • Asthma symptoms early in the morning that are not improved 15 minutes after inhaling a shortacting beta2-agonist Monitoring Pulmonary Function In addition to assessing symptoms, it is also important to periodically assess pulmonary function. The main methods are spirometry and peak flow monitoring. Regular monitoring of pulmonary function is particularly important for asthma patients who do not perceive their symptoms until airflow obstruction is severe. Currently, there is no readily available method of detecting the “poor perceivers.” The literature reports that patients who had a near fatal asthma exacerbation, as well as older patients, are more likely to have poor perception of airflow obstruction (Kikuchi et al. 1994; Connolly et al. 1992). Spirometry The Expert Panel recommends that spirometry tests be done (1) at the time of initial assessment; (2) after treatment is initiated and symptoms and peak expiratory flow (PEF) have stabilized, to document attainment of (near) “normal” airway function; and (3) at least every one to two years to assess the maintenance of airway function. Spirometry may be indicated more often than every one to two years, depending on the clinical severity and response to management. Spirometry with measurement of the FEV1 is also useful: • As a periodic (e.g., yearly) check on the accuracy of the peak flow meter (Miles et al. 1995)

• When more precision is desired in measuring lung function (e.g., when evaluating response to bronchodilator or nonspecific airway responsiveness or when assessing response to a “step down” in pharmacotherapy) • When PEF results are unreliable (e.g., in some very young or elderly patients or when neuromuscular or orthopedic problems are present) and the physician needs the quality checks that are available only with spirometry (Hankinson and Wagner 1993). For routine monitoring at most outpatient visits, measurement of PEF with a peak flow meter is generally a sufficient assessment of pulmonary function, particularly in mild intermittent, mild persistent, and moderate persistent asthma. Peak Flow Monitoring Peak expiratory flow provides a simple, quantitative, and reproducible measure of the existence and severity of airflow obstruction. PEF can be measured with inexpensive and portable peak flow meters. It must be stressed that peak flow meters are designed as tools for ongoing monitoring, not diagnosis. Because the measurement of PEF is dependent on effort and technique, patients need instructions, demonstrations, and frequent reviews of technique (see Figure 1-7 [omitted], the patient handout How to Use Your Peak Flow Meter). Peak flow monitoring can be used for shortterm monitoring, managing exacerbations, and daily long-term monitoring. When used in these ways, the patient’s measured personal best is the most appropriate reference value. Four studies (Woolco*ck et al. 1988; Ignacio-Garcia and Gonzalez-Santos 1995; Lahdensuo et al. 1996; Beasley et al. 1989) have found that comprehensive asthma self-management programs, in which peak flow monitoring was a component, achieved significant improvements in health outcomes. Thus far, the few studies that have isolated a comparison of peak flow and symptom monitoring have not been sufficient to assess the relative contributions of each to asthma management (see Box 1, Peak Flow Monitoring Literature Review). The literature does suggest which patients may benefit most from peak flow monitoring. The Expert Panel concludes,

344 The Encyclopedia of Asthma and Respiratory Disorders on the basis of this literature and the panel’s opinion, that: • Patients with moderate-to-severe persistent asthma should learn how to monitor their PEF and have a peak flow meter at home. • Peak flow monitoring during exacerbations of asthma is recommended for patients with moderate-to-severe persistent asthma to: Determine severity of the exacerbation Guide therapeutic decisions (see Component 3 [omitted]—Managing Exacerbations and Figure 4-5) in the home, clinician’s office, or emergency department • Long-term daily peak flow monitoring is helpful in managing patients with moderate-to-severe persistent asthma to: Detect early changes in disease status that require treatment Evaluate responses to changes in therapy Provide assessment of severity for patients with poor perception of airflow obstruction Afford a quantitative measure of impairment • If long-term daily peak flow monitoring is not used, a short-term (two to three weeks) period of peak flow monitoring is recommended to: Evaluate responses to changes in chronic maintenance therapy Identify temporal relationship between changes in PEF and exposure to environmental or occupational irritants or allergens. It may be necessary to record PEF four or more times a day (Chan-Yeung 1995). • The Expert Panel does not recommend longterm daily peak flow monitoring for patients with mild intermittent or mild persistent asthma unless the patient/family and/or clinician find it useful in guiding therapeutic decisions. Any patient who develops severe exacerbations may benefit from peak flow monitoring.

Limitations of long-term peak flow monitoring include: • Difficulty in maintaining adherence to monitoring (Reeder et al. 1990; Chmelik and Doughty 1994; Mao et al. 1993), often due to inconve-

nience, lack of required level of motivation, or lack of a specific treatment plan based on PEF • Potential for incorrect readings related to poor technique, misinterpretation, or device failure Whether peak flow monitoring, symptom monitoring, or a combination of approaches is used, the Expert Panel believes that self-monitoring is important to the effective self-management of asthma The nature and intensity of self-monitoring should be individualized, based on such factors as asthma severity, patient’s ability to perceive airflow obstruction, availability of peak flow meters, and patient preferences. It is the opinion of the Expert Panel that, regardless of the type of monitoring used, patients should be given a written action plan and be instructed to use it . . . The panel believes it is especially important to give a written action plan to patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations. The action plan will describe the actions patients should take based on their signs and symptoms and/or PEF. The clinician should periodically review the plan, revise it as necessary, and confirm that the patient knows what to do if his or her asthma gets worse. Recommendations on How to Monitor Peak Flow The Expert Panel recommends that patients who are using a peak flow meter be instructed on how to establish their personal best peak expiratory flow (figure 1-7 [omitted]) and use it as the basis of their action plan (figure 4-5 [omitted]). Meters used to measure PEF should meet American Thoracic Society recommendations for monitoring devices (American Thoracic Society 1995). The patients personal best PEF can be estimated after a two to three week period in which the patient records PEF two to four times per day. The personal best value is usually achieved in the early afternoon measurement after maximal therapy has stabilized the patient (Quackenboss et al. 1991). A course of oral corticosteroids may be needed to establish the personal best PEF. The patient’s personal best value should be reassessed periodically to account for progression of disease in children

Appendix V 345 and adults and for growth in children. Occasionally, a PEF value is recorded that is markedly higher than other values. This may be due to “spitting” (especially if the peak flow meter mouthpiece is small) or coughing into the peak flow meter, as well as other reasons that are not well understood. Therefore, caution should be used in establishing a personal best value when an outlying value is observed. Children with moderato-to-severe persistent asthma should repeat the short-term monitoring period every six months to establish changes in personal best PEF that occur with growth. Patients requiring daily peak flow monitoring should measure their PEF on waking from sleep in the morning before taking a bronchodilator, if the patient uses a bronchodilator (Reddel et al. 1995; Morris et al. 1994). When the morning PEF is below 80 percent of the patient’s personal best, PEF should be measured more than once a day (again, before taking a bronchodilator). This recommendation is based, not on scientific data, but on the logic of reducing delays in treatment. The additional measurements of PEF during the day will enable patients to detect if their asthma is continuing to worsen or is improving after taking medication. If their asthma is worsening, they will have the opportunity to quickly respond to this. In addition, periodically having patients take their PEF first thing in the morning and in the early afternoon for one to two weeks will assess airflow variability, which is an indicator of the current level of the

patient’s asthma severity (see figure 1-3 and Additional Studies section, page 19 [omitted]). It is the Expert Panel’s opinion that, in general, PEF below 80 percent of the patient’s personal best before bronchodilator inhalation indicates a need for additional medication. PEF below 50 percent indicates a severe asthma exacerbation (see Component 3 for recommended treatment). These cutpoints of 80 and 50 percent of the personal best are somewhat arbitrary. The emphasis is not on a specific PEF value but, rather, on a patient’s change from personal best or from one reading to the next. Cutpoints should be tailored to individual patients’ needs and PEF patterns. Cutpoints may be easier to use and remember when they are adapted to a traffic light system . . . (Lewis et al. 1984; Mendoza et al. 1988; Plaut 1995). In this system, for example, the green zone (80 to 100 percent of personal best) signals good control, the yellow zone (50 to less than 80 percent of personal best) signals caution, and the red zone (below 50 percent of personal best) signals a medical alert (see figure 1-7 [omitted]). Because the yellow zone includes a wide spectrum of asthma severity, clinicians may consider recommending different interventions for a high yellow zone (e.g., 65 to less than 80 percent of personal best) and a low yellow zone (e.g., 50 to less than 65 percent of personal best).

—Excerpted from the Expert Panel Report

APPENDIX VI EDUCATION FOR A PARTNERSHIP IN ASTHMA CARE (Adapted from the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma published in April 1997 by the National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 97-4051) Patient education is an essential component of successful asthma management. Current management approaches require patients and families to effectively carry out complex pharmacologic regimens, institute environmental control strategies, detect and self-treat most asthma exacerbations, and communicate appropriately with health care providers. Patient education is the mechanism through which patients learn to successfully accomplish those tasks. It is also a powerful tool for helping patients gain the motivation, skill, and confidence to control their asthma. Research shows that asthma education can be cost-effective and can reduce morbidity for both adults and children, especially among high-risk patients. The following are strategies for enhancing the delivery of patient education and improving the likelihood that patients will follow clinical recommendations, as well as key messages to communicate to the patient. Establish a partnership. Patient education should begin at the time of diagnosis and be integrated into every step of medical care, in the context of medical appointments and other clinician-patient communication. When clinicians take the time to provide education, it sends a powerful message to patients and families about the importance of knowledgeable self-management of asthma. From the time of diagnosis, the clinician and other members of the health care team should begin to build a partnership with the patient and family. Building the partnership requires that clin-

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icians promote open communication and ensure that patients have a basic and accurate foundation of knowledge about asthma, understand the treatment approach, and have the self-management skills necessary to monitor the disease objectively, and take medication effectively. When nurses, pharmacists, respiratory therapists, and other health care professionals are available to support and expand patient education, a team approach should be used. The principal clinician should introduce the key educational messages and negotiate agreements with patients. Team members should document in the patient’s record the key educational points, patient concerns, and actions the patient agrees to take. Clinicians should teach basic facts about asthma so that the patient and family understand the rationale for needed actions. Give a brief verbal description of what asthma is and the intended role of each medication. Do not overwhelm the patient with too much information all at once, but repeat the important messages at each visit. Ask the patient to bring all medications to each appointment for review. Teach the patient necessary medication skills, such as correct use of the inhaler and spacer/holding chamber and knowing when and how to take quick-relief medications. Teach self-monitoring skills: symptom monitoring, peak flow monitoring as appropriate, and recognizing early signs of deterioration. Teach relevant environmental control/avoidance strategies. Teach how environmental precipi-

Appendix VI 347 tants or exposures can make the patient’s asthma worse (e.g., allergens and irritants) at home, school, and work, and how to recognize both immediate and delayed reactions. Jointly develop treatment goals. Fundamental to building a partnership is for clinicians and patients to jointly develop and agree on both shortand long-term treatment goals. Such agreements can encourage active participation, enhance the partnership, and improve asthma management. It is the opinion of the Expert Panel that clinicians should: Determine the patient’s personal treatment goals. Ask how the asthma interferes with the patient’s life (e.g., inability to sleep through the night, play a sport) and incorporate the responses into personal treatment goals. Asthma-specific quality-of-life instruments may be useful. Share the general goals of asthma treatment with the patient and family. Tell patients, “Our goals are to have you: Be free from severe symptoms day and night, including sleeping through the night; Have the best possible lung function; Be able to participate fully in any activities of your choice; Not miss work or school because of asthma symptoms; Need fewer or no urgent care visits and hospitalizations for asthma; Use medications to control asthma with as few side effects as possible; and Be satisfied with your asthma care.” Agree on the goals of treatment. The clinicians, the patient, and when appropriate, the patient’s family should agree on the goals of asthma management, which include both the patient’s personal goals and the general goals suggested by the clinicians. Provide the patient with tools for self-management. It is the opinion of the Expert Panel that, at the first visit, clinicians should develop a written, individualized, daily self-management plan in consultation with the patient. Include the recommended doses and frequencies of daily medications and the daily self-management activities needed to achieve the agreed-on goals. Review and refine the plan at subsequent follow-up visits. List the treatment goals in the plan and explain how following the plan will help the patient reach those goals. Emphasizing the patient’s personal goals is

essential to enhancing adherence. For example, ask, “Have you had any problems taking your bronchodilator immediately before playing basketball? Has it helped you stay in the game?” Discuss the long-term benefits of following the written, daily self-management plan. For some patients, focusing on long-term treatment goals and discussing “the big picture” of asthma control and how medications can be adjusted over time may improve adherence. Also at the first visit, jointly develop a written action plan to help the patient manage asthma exacerbations. This is especially important for patients with moderate-to-severe persistent asthma and patients with a history of severe exacerbations. Review and refine the plan at follow-up visits. The action plan directs the patient to adjust medicines at home in response to particular signs, symptoms, and peak flow measurements. It should also list the PEF levels and symptoms indicating the need for acute care and emergency telephone numbers for the physician, emergency department, rapid transportation, and family/friend for aid and support. Clinicians should choose an action plan that suits their practice, patients, and style. It is the opinion of the Expert Panel that clinicians should provide an asthma diary to appropriate patients for self-monitoring symptoms, peak flow measurements, frequency of daily quick-relief inhaler medication use, and activity restriction. Encourage adherence. Use effective techniques to promote open communication. Early in each visit, elicit the patient’s concerns, perceptions, and unresolved questions about his or her asthma. A question such as “What worries you most about your asthma?” which cannot be answered yes or no, encourages patients and families to voice issues, personal beliefs, or concerns they may be apprehensive about discussing or may not think are of interest to the clinician. These potential barriers to adherence can be dealt with only if they are identified. By asking about and discussing such concerns, clinicians build trust and a sense of partnership with the patient. Most nonadherence originates in personal beliefs or concerns about asthma that have not been discussed with the clinician. Until such fears and worries are identified and

348 The Encyclopedia of Asthma and Respiratory Disorders addressed, patients will not be able to adhere to the clinician’s recommendations. Assess the patient’s and family’s perceptions of the severity level of the disease. Two questions may prove useful: “How severe do you think your asthma is?” and “How much danger do you believe you are in from your asthma?” When patients are identified who are overwhelmed by fear of death, put their fears in perspective by providing them with the results of objective assessments and expert opinion. A clearly written, detailed action plan that directs the patient how to respond to worsening asthma may be extremely helpful in reducing anxiety. Patients’ perceptions about their disease severity and its threat to their well-being influence self-management behavior and use of the health care system. Assess the patient’s and family’s level of social support. Ask, “Who among your family or friends can you turn to for help if your asthma worsens?” Counsel patients to identify an asthma “partner” among their family or friends who is willing to be educated and provide support. Include at least one of these individuals in follow-up appointments so that he or she can hear what is expected of the patient in following the self-management and action plans. Encourage or enlist family involvement. Ask patients to identify ways their family members can help them follow the plans. Ask the patient to share the plans with family members, elicit their input, and agree on actions they can help with. It may be helpful for children and parents to discuss this with a clinician present. Consider referral to a psychologist, social worker, psychiatrist, or other licensed professional when stress seems to unduly interfere with daily asthma management. As with other chronic diseases, emotional and social stress may be a confounding factor for many patients struggling with asthma control. Although stress does not cause asthma, it can play a role in precipitating asthma exacerbations and can complicate an individual’s attempts at self-management. Referral to a local support group may be useful. Use methods to increase the chances that the patient will adhere to the written, daily self-management plan. For instance, adherence to the self-

management plan is enhanced when the plan is simplified as much as possible, when the number of medications and frequency of daily doses are minimized, when the medication doses and frequency fit into the patient’s and family’s daily routine, and when the plan considers the patient’s ability to afford the medications. Because nonadherence is difficult for clinicians to detect, it is prudent to explore potential barriers to adherence with every patient by asking what concerns they have about medicines (e.g., safety) or other aspects of treatment. Tailor education to the needs of the individual patient. Assess cultural or ethnic beliefs or practices that may influence and modify educational approaches, as needed. Cultural variables may affect patient understanding of and adherence to medical regimens. Open-ended questions such as “In your community, what does having asthma mean?” can elicit informative responses. The culturally sensitive clinician should attempt to find ways to incorporate harmless or potentially beneficial remedies with the pharmacologic plan. For example, a prevalent belief among the Latino population is that illnesses are either “hot” or “cold.” Asthma is viewed as a “cold” illness amenable to “hot” treatment. Suggesting that asthma medications be taken with hot tea or hot water incorporates this belief into the therapeutic regimen and helps build the therapeutic partnership. When harmful home remedies are being used, clinicians should discourage their use of suggesting a culturally acceptable alternative as a replacement or recommending a safer route of administration. These and other strategies may be useful in working with ethnic minorities. Every effort should be made to discuss asthma care, especially the self-management plan, in the patient’s native language so that educational messages are fully understood. Research suggests that lack of language concordance between the clinician and the patient affects adherence and appropriate use of health care services. Language barriers also may complicate the assessment of cultural differences. If interpreters are used, they should be equally competent in both English and the patient’s language and knowledgeable about medical terms.

Appendix VI 349 Maintain the partnership. As part of ongoing care, the clinician should continue to build the partnership by being a sympathetic coach and by helping the patient follow the self-management plan and take other needed actions. Educational efforts should be continuous, because it may take up to six months for the impact of education to be evident. Furthermore, it is necessary to periodically review information and skills covered previously because patient self-management behavior is likely to decline over time. In particular, it is essential that clinicians demonstrate, review, evaluate, and correct inhaler/spacer/holding chamber technique at each visit because these skills deteriorate rapidly. Written instructions are helpful, but insufficient. Research suggests that patients tend to make specific mistakes in using inhalers that need to be corrected. Patients especially need to be reminded to inhale slowly and to activate the inhaler only once for each breath. Clinicians should continue to promote open communication with the patient and family by addressing the following elements in each followup visit: • Continue asking patients early in each visit what concerns they have about their asthma and what they especially want addressed during the visit. • Review the short-term goals agreed upon in the initial visit. Assess how well they are being achieved (e.g., was the patient’s wish to engage in physical activity achieved?). Revise the goals as needed. Achievement of short-term goals should be discussed as indicators that the patient is moving toward long-term goals. Give positive verbal reinforcement for achievement of a goal and recognize the patient’s success in moving closer to full control of the disease. • Review the daily self-management plan and the steps the patient was to take. Adjust the plan as needed (e.g., the recommendations of how to use medicines if the dose or type is not working). Identify other problems the patient has in following the agreed-upon steps (e.g., disguising the bad taste of medicine); treat these as areas

needing more work, not as adherence failures. Write a self-management plan to help school personnel manage a child’s asthma. • Periodically review the asthma action plan and revise as necessary. Confirm that the patient knows what to do if his or her asthma gets worse. • Continue teaching and reinforcing educational messages. Provide information skills over several visits so as not to overwhelm the patient with too much information at one time. Repeat important points often. • Give patients simple, brief written materials that reinforce the actions recommended and skills taught. Many organizations distribute patient education materials, including some Spanishlanguage materials.

Supplement patient education delivered by clinicians. All patients may benefit from a formal asthma education program that has been evaluated and reported in the literature to be effective. These programs should be taught by qualified asthma educators who are knowledgeable about asthma and experienced in patient education. Communication among the asthma educator, the clinicians providing direct care, and the patient/family is critical. When formal programs are available in local communities, they can supplement, but not replace, patient education provided in the office. Individual and group programs have been developed and tested for patients of all ages, including parents of very young children (birth to four years). These patient education programs should be delivered as designed. Some validity and effectiveness may be compromised when segments of various programs are pieced together or when programs are condensed. In the interest of saving time, educators should not delete educational strategies, such as using small groups or scheduling multiple sessions spaced with “homework” assignments, because these strategies have demonstrated effectiveness in motivating individuals to make significant behavior changes. A variety of other educational formats, such as videotapes and interactive computer software may

350 The Encyclopedia of Asthma and Respiratory Disorders also enhance, but not replace, education delivered by clinicians. Provide patient education in other clinical settings. Patient education also should be delivered in the context of emergency department visits and hospitalization. Asthma exacerbations may represent teachable moments when patients are more receptive to educational message. Research

on adults with asthma who are referred to emergency department providers to an asthma education program shows that education can decrease utilization of emergency services. Educational programs delivered to hospitalized children and adult asthma patients show increased knowledge and use of self-management behaviors, reduced length of hospital stay, and overall reduction in asthma readmissions.

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APPENDIX VII STEPWISE APPROACHES FOR MANAGING ACUTE OR CHRONIC ASTHMA SYMPTOMS IN INFANTS AND CHILDREN UNDER AGE FIVE AND ADULTS AND CHILDREN OVER AGE FIVE

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APPENDIX VIII USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS AND LONG-TERM CONTROL MEDICATIONS

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Appendix IX Management of Asthma Exacerbations— Emergency Department and Hospital-Based Care

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APPENDIX X TRAVELING WITH ALLERGIES OR ASTHMA Traveling may trigger allergy or asthma attacks because of exposure to allergens usually avoided at home, increased stress level, and other factors, including change of climate and quality of air. Persons with allergies and/or asthma should be prepared for a possible attack while away from home. • Take extra medication with you; don’t forget your inhaler or any other equipment you normally use at home. • If you are severely allergic to bee (or other insect, such as fire ant) stings, a food, or other substance and you have experienced anaphylactic shock because of one of these triggers, wear a medical alert bracelet engraved with important information about your allergy and the treatment. This will help a doctor in an emergency room offer you more immediate treatment. You may even need to carry a syringe and adrenaline for emergency use. • Travel with a companion who is aware of your condition and knows what to do in case you have an attack. • Carry a copy of your asthma chart listing episodes and treatments. Carry a letter from your doctor explaining your condition and how he or she has treated it so far.

• When children are traveling on their own, they should have a doctor’s letter, including clear instructions for medications or other treatment. • Avoid smoking sections on airplanes or trains, in restaurants, and other places if smoke irritates your respiratory system. • Avoid traveling to places notorious for air pollution, certain species of weeds, grasses, or trees, or other characteristics that could exacerbate your condition, such as going to the home of a relative who has cats. • Know the difference between hyperventilation and an asthma attack. Learn relaxation and deep-breathing techniques before you travel. They can help ward off an asthma attack or possibly relieve one. • Get in shape before you travel. Regular, appropriate exercise facilitates optimal body functioning. Losing excess weight makes it easier for you to breathe and your body to function well. If you find yourself in a strenuous situation while traveling, make sure you take your medication before exertion, if your doctor advises it. • Understand that as long as you can manage your condition, you can travel successfully. Ask your allergist for advice specific to your symptoms.

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APPENDIX XI ALTERNATIVE TREATMENTS AND REMEDIES FOR RESPIRATORY DISORDERS Asthma 1. Ginger, stramonium, elecampane, grindelia, hyssop, wild cherry bark, motherwort, almond, ephedra, and turmeric are among Ayurvedic, Chinese, and Western herbal remedies for asthma. 2. Homeopathic remedies for asthma include ipecac, arsenicum, bryonia, natrium sulfuricum (nat. sulf.), and lachesis. 3. Vitamin B6. 4. Aromatherapy includes steam inhalation of chamomile, eucalyptus, or lavender essential oils, vaporized pine oil, and bergamot, clary sage, neroli, chamomile, and roses. Bronchitis

1. Heated mustard oil compress applied to the head, and ginger, hollyhock, bitter orange, and stramonium are among Ayurvedic treatments. 2. Fritillary bulb, plantain seed, balloon flower root, honeysuckle flowers, mulberry leaves, gardenia fruit, anise, wild cherry bark, coltsfoot, garlic oil chest rub, ginseng tea, peppermint tea, honey and lemon, and onions are among Chinese, traditional, and Western herbal remedies. 3. Aromatherapy includes eucalyptus, ginger and thyme oils, juniper, myrrh, and rosemary. 4. Vitamins B, C, and A, and zinc. 5. Homeopathic remedies include pulsatilla, ipecac, bryonia, phosphorus, and aconite. Common Cold 1. Sunflower, coriander seeds, ginger, plantain seed, peppermint, mulberry, honeysuckle,

skullcap, barley water, honey and lemon, cinnamon, garlic, ginseng powder, echinacea, and a mustard poultice or foot bath are among Ayurvedic, Chinese, traditional, and Western herbal remedies. 2. Homeopathic remedies include aconite, belladonna, mercurius, gelsemium, allium, pulsatilla, natrum muriaticum (nat. mur.), dulcamara, kali bichronicum, and bryonia. 3. Vitamin C, zinc, royal jelly. 4. Aromatherapy includes tea tree, lemon, lavender, and eucalyptus oils. Cough 1. Coriander seeds, root ginger, sunflower, henbane, stramonium, fresh garlic or garlic tincture, ginseng, honey and lemon, mustard powder or onion poultice, peppermint tea, licorice root, aniseed, marshmallow, wild cherry bark, goldenseal, plantain, and thyme are among Ayurvedic, Chinese, traditional, and Western herbal remedies. 2. Aromatherapy includes eucalyptus oil, pine oil, oil of myrrh, frankincense, and sandalwood. 3. Homeopathic remedies include pulsatilla, rumex, bryonia, phosphorus, drosera, chamomilla, and antimonium tartaricum (ant. tart.). Emphysema

1. Garlic, stramonium, peppermint tea, and slippery elm bark are among Ayurvedic and herbal remedies. 2. Homeopathic treatment includes cough, asthma, and bronchitis remedies. 3. Aromatherapy includes cedarwood, peppermint, and eucalyptus oils.

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Appendix XI 373 Hiccups 1. Berilla stems, rhubarb, ginger, lemon juice, water with honey, nux vomica, arsenicum, ignatia, cicuta, and magnesia phosphorica (mag. phos.) are among Chinese and traditional herbal remedies and homeopathic treatment. Hyperventilation 1. Ayurvedic treatment involves balancing the tridoshas. 2. Chinese, traditional, and Western herbalism include ginseng, Chinese angelica, white peony root, thorowax root, oats, skullcap, valerian, lady’s slipper, and limeflowers. 3. Homeopathic remedies include aconite and constitutional treatment. 4. B vitamins; avoidance of caffeine. 5. Aromatherapy: lavender, geranium, bergamot, sweet almond and peach kernel oils. 6. Flower essences include elm and aspen. Influenza 1. Heated mustard oil compress, root ginger, honey and lime, bitter orange, sunflower, coriander, warmed apple juice, barley water, ginseng powder, hot lemon and honey in water, boneset, fenugreek, wormwood, sage, and licorice are among Ayurvedic, Chinese, traditional, and Western herbal remedies. 2. Homeopathic treatment includes gelsemium, rhus toxicodendron (rhus. tox.), bryonia, eupatorium perfoliatum, arsenicum, and baptisia. 3. Vitamin C, bioflavonoids, zinc, and royal jelly. 4. Aromatherapy: oils of eucalyptus, peppermint, tea tree, geranium, bergamot, chamomile, and melissa. Pleurisy

1. Apple cider vinegar compress, comfrey root, leaf tea, plantain leaf, sage leaf, and corn silk are among herbal remedies. 2. Homeopathic remedies include aconite, cantharis, belladonna, bryonia, sulfur, and hepar sulfuris calcarcum, or calcium sulfide (hep. sulf.).

3. Aromatherapy includes oils of bergamot, calendula, chamomile, myrrh, and lavender. Pneumonia 1. Heated mustard oil compress, root ginger, honey and lime, peach kernel, skullcap, fritillary bulb, raw garlic and onions, boneset, fenugreek, and ginseng are among Ayurvedic, Chinese, traditional, and Western herbal treatments. 2. Homeopathic treatment includes aconite, bryonia, sanguinaria, and phosphorus. 3. Vitamin C and zinc. 4. Aromatherapy: eucalyptus and tea tree oils, and niaouli or cajeput massage. Tracheitis 1. Hollyhock, comfrey root or leaf tea, and plantain leaf compress are among Ayurvedic and herbal treatments. 2. Homeopathic remedies include rumex, stannum, bryonia, phosphorus, and kali bichronicum. 3. Vitamin C and zinc. 4. Aromatherapy: bergamot, calendula, chamomile, and myrrh. Tuberculosis 1. Stramonium, licorice, garlic, Echinacea, and ginseng are included in Ayurvedic and herbal treatments. 2. Homeopathic remedies include baccillinium, arsenicum, and calcarea. 3. Aromatherapy: vaporized garlic, tea tree and lavender oils, and juniper, rosemary, bergamot or eucalyptus oils.

SOURCES Shealy, C. Norman, M.D., Ph.D., The Illustrated Encyclopedia of Natural Remedies, Element Books Limited, Boston, 1998. De Schepper, Luc, M.D., Ph.D., C.Hom, The People’s Pharmacy, Full of Life Publishing, Santa Fe, NM, 1998.

APPENDIX XII PROFESSIONAL AND LAY ORGANIZATIONS Allergy and Asthma Network Mothers of Asthmatics, Inc. 2751 Prosperity Avenue, Suite 150 Fairfax, VA 22031 (703) 641-9595 www.aanma.org Allergy/Asthma Information Association 65 Tomley Drive, Suite 10 Etobico*ke, Ontario, Canada M9B 5Y7 American Academy of Allergy, Asthma and Immunology (AAAAI) 611 East Wells Street Milwaukee, WI 53202-3889 (800) 822-2762 or (800) 822-ASMA http://www.aaaai.org American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL 60007 (800) 433-9016 or (847) 228-5005 http://www.aap.org American Association for Respiratory Care 11030 Ables Lane Dallas, TX 75229-4593 (972) 243-2272 http://www.aarc.org American College of Allergy, Asthma and Immunology (ACAAI) 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 (800) 842-7777 http://allergy.mcg.educ American Dietetic Association 216 West Jackson Boulevard Chicago, IL 60606-6995 (312) 899-0040 or (800) 366-1655 www.eatright.org

American Lung Association (ALA) 1740 Broadway New York, NY 10019 (800) LUNG-USA (800) 586-4872 www.lungusa.org Asthma and Allergy Foundation of America (AAFA) 1233 20th Street NW, Suite 402 Washington, DC 20036 (202) 466-7643 or (800) 7-ASTHMA (800) 727-8462 www.aafa.org U.S. CHAPTERS AAFA Los Angeles Chapter 5225 Wilshire Boulevard, Suite 705 Los Angeles, CA 90036 (213) 937-7859 AAFA Florida State Chapter c/o University Community Hospital 3100 East Fletcher Avenue Tampa, FL 33613 (813) 972-7872 AAFA Greater Chicago Chapter 111 North Wabash, Suite 909 Chicago, IL 60602 (312) 346-0745 AAFA Maryland Chapter 5601 Loch Raven Boulevard Baltimore, MD 21239 (301) 532-4135 AAFA Michigan State Chapter 6900 Orchard Lake Road, Suite 207 West Bloomfield, MI 48322 (313) 427-2202 AAFA Greater Kansas City Chapter 7905 East 134th Terrace Grandview, MO 64030 (816) 966-8164

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Appendix XII 375 AAFA St. Louis Area Chapter 222 South Central, Suite 600 St. Louis, MO 63105 (314) 726-6866 AAFA Community Health Place, Suite 209-D 7101 Newport Avenue Omaha, NE 69152 (402) 572-3073 AAFA New England Chapter 220 Boylston Street, Suite 305A Chestnut Hill, MA 02167 (617) 965-7771 AAFA S.E. Pennsylvania Chapter P.O. Box 249 Plymouth Meeting, PA 19402 (215) 825-0583 American Society of Health-System Pharmacists (ASHP) 7272 Wisconsin Avenue Bethesda, MD 20814 (301) 657-3000 http://www.ashp.org/public/news/breaking/asthma 2000.html breathnet the breathing experts™ A Network of Respiratory Specialists 850 Third Avenue New York, NY 10022 (646) 840-3901 www.breathnet.com Center for Environmental Health Centers for Disease Control and Prevention Mail Stop F-29 4770 Buford Highway, NE Atlanta, GA 20241-3724 (800) 311-3435 www.cdc.gov The Food Allergy and Anaphylaxis Network 10400 Eaton Place, Suite 107 Fairfax, VA 22030-2208 (703) 691-3179 or (800) 929-4040 www.foodallergy.org Food and Drug Administration Office of Consumer Affairs/HFE-88 5600 Fishers Lane Rockville, MD 20857

(888) INFO-FDA (888) 463-6332 www.fda.gov Healthy Kids: The Key to Basics Educational Planning for Students With Asthma and Other Chronic Health Conditions 79 Elmore Street Newton, MA 02159-1137 (617) 965-9637 Immune Deficiency Foundation P.O. Box 586 Columbia, MD 21045 (410) 461-3127 Indoor Air Quality Information Clearinghouse (800) 438-4318 http://www.epa.gov/iaq JAMA Asthma Information Center American Medical Association 515 North State Street Chicago, IL 60610 (312) 464-5374 www.ama.assn.org/special/asthma Joint Council of Allergy, Asthma and Immunology http://www.jcaai.org National Allergy and Asthma Network/ Mothers of Asthmatics 3554 Chain Bridge Road, Suite 200 Fairfax, VA 22030 (800) 878-4403 National Asthma Education Program National Heart, Lung, and Blood Institute Information Center P.O. Box 30105 Bethesda, MD 20824-0105 (301) 592-8573 or (301) 251-1222 http://www.nhlbi.nih.gov National Institute of Allergy and Infectious Diseases (NIAID) National Institutes of Health Office of Communications and Public Liaison 31 Center Drive MSC 2520 Building 31, Room 7A-50 Bethesda, MD 20892-2520 www.niaid.nih.gov

376 The Encyclopedia of Asthma and Respiratory Disorders National Institute of Environmental Health Sciences Office of Communications P.O. Box 12233 Research Triangle Park, NC 27709 (919) 541-3345 www.niehs.nih.gov/airborne/prevent/intro.html National Jewish Medical and Research Center (Lung Line) 1400 Jackson Street Denver, CO 80206 (800) 222-5864 http://www.njc.org

U.S. Department of Education Office of Civil Rights, Customer Service Team Mary E. Switzer Building, 330 C Street, SW Washington, DC 20202-1328 (800) 421-3481 or (202) 205-5413 http://www.ed.gov/offices/OCR U.S. Environmental Protection Agency Indoor Environments Division 401 M Street (66043) Washington, DC 20460 (202) 233-9370

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INDEX Boldface page numbers indicate major treatment of a subject. A AAAAI. See American Academy of Allergy, Asthma and Immunology AAFA. See Asthma and Allergy Foundation of America AAMA. See American Academy of Medical Acupuncture ABAI. See American Board of Allergy and Immunology ABGs. See arterial blood gases ABIM. See American Board of Internal Medicine ABP. See American Board of Pediatrics ABPA. See allergic bronchopulmonary aspergillosis abscess, lung 120 ACAAI. See American College of Allergy, Asthma and Immunology acapnia 1 accessory nasal sinuses 178 Accolate 1. See also Zafirlukast Accreditation Council for Graduate Medical Education (ACGME) 14 Accurbron. See theophylline acetaldehyde 148 acetaminophen, for bronchitis 49 acetanilide, and toxic-allergic syndrome 189 acetylsalicylic acid. See aspirin ACGME. See Accreditation Council for Graduate Medical Education

Achromycin 187 acid-base balance 1, 26 acidity-alkalinity, and arterial blood gas tests 26 acidosis carbon dioxide 1 hypercapnic 1 respiratory 1 acquired immune deficiency syndrome (AIDS) 5–6, 103 acrivistine 176 ACTH. See corticotropin Actidil. See triprolidine Actifed 198 actinomycetes, and air conditioning 6 active expiration 80 active immunity 1–2 acupressure 2 acupuncture 2, 11 acute epiglottitis 29 Adam’s apple 169 addiction 2 adenocarcinoma 121 adenoid cystic carcinomas 121 adenoidectomy 3 adenoids 2–3, 100 adenosine deaminase, and severe combined immunodeficiency disease 104 adenotonsillectomy 3 adrenal glands, and corticosteroids 67 adrenaline. See epinephrine Adrenaline Chloride. See epinephrine adrenergic agonists, for allergies 10 adrenergic nervous system 170 adult-onset asthma 331

381

adult respiratory distress syndrome (ARDS) 3 adverse drug reactions 3 Advil. See ibuprofen aeration 3 aeroallergens 3–4 aerobes 41 aerobic 4 aerobic exercise 4 AeroBid 4. See also flunisolide Aerolate Slo-Phyllin. See theophylline aeropathy 4 aerophobia 4 aerosol 4 aerotherapy 4 African Americans and asthma-related deaths 33 lung cancer and 125 Afrin 147 Afrinol. See pseudoephedrine agammaglobulinemias 103 agonist 4–5 agranulocytes 118 ague, brass founder’s 46 AIDS. See acquired immune deficiency syndrome AIDS-related complex 5 air 6 air block 45 airborne allergens 3–4 air bronchogram sign 6 air cells, of lungs 12 air conditioning 6 air curtain 6 air-filtration systems 6 air flow, laminar 6 air hunger 6, 75, 95 air pollution 7 air pump 164

382 The Encyclopedia of Asthma and Respiratory Disorders air purification 6 air quality 7 Air Quality Index, of U.S. Environmental Protection Agency 7 air sacs 169 air travel, and impaired pulmonary function 7 air vesicle 7 airway 7–8 airway edema 332 airway hyperresponsiveness 331–332 airway inflammation and asthma therapy 332–333 and lung function 331–332 airway management, in asthma 329–330 airway obstruction 332 airway remodeling 332 airway resistance 168 ALA. See American Lung Association Albalon Liquifilm 83 albuterol 8, 43, 203 for asthma 31, 71 in emergency care 369 for long-term control 366 for quick-relief 363, 364 as bronchodilating drug 50 for exercise-induced asthma 79 and insufflation 113 in Rotocaps 173 albuterol HFA 364 albuterol Rotahaler 364 alcohol 8 addiction to 2 and cancer of larynx 117 Alconefrin. See phenylephrine hydrochloride alkalosis altitude 8 respiratory 8 alkylamines 23–24 Allegra. See fexofenadine allergen(s) 8, 101 airborne 3–4 control measures for 143–144

high-molecular-weight 141–142 inhalant 3, 9 lower-molecular-weight 141–142 allergen extracts, in immunotherapy 107 allergic alveolitis 12 extrinsic (See hypersensitivity pneumonitis) allergic angiitis 61 allergic bronchopulmonary aspergillosis (ABPA) 27, 51 allergic crease 9 allergic reactions. See hypersensitivity reactions allergic rhinitis 8–9, 171. See also hay fever perennial 152 seasonal 160 allergic salute 9 allergic shiner 9 allergies 10–11 acupuncture and 2 employment opportunities for persons with 77 geographic locations best for sufferers of 119–120 growing out of 86 to medications 3 to penicillin 151–152 and sinusitis 178–179 surgery and 184–185 symptoms of 185 travel and 371 allergist 9 allergist-immunologist 9 allergoids 10 Allergy and Asthma Network/Mothers of Asthmatics, Inc. 11, 374 Allergy & Asthma Health 11 Allergy/Asthma Information Association 374 Allergy Council on Scientific Affairs, of the American Medical Association 105 allergy shots 11–12. See also immunotherapy

allergy triggers, avoidance of 10 allopurinol, and theophylline 188 alpha-adrenergic receptors 4 alpha-agonists, for vasomotor rhinitis 202 alpha1-antitrypsin, deficiency of 61 alternative pathway, in complement system 102–103 altitude alkalosis 8 altitude sickness 12 Altounyan, Roger E. C. 12 aluminosis 12 aluminum chloride 12 Alupent. See Metaproterenol alveobronchiolitis 12 alveolar air 6 alveolar cell carcinoma 56 alveolar cyst 70 alveolar hypoventilation, primary 146 alveolar macrophages 130, 170 alveolar proteinosis, pulmonary 162–163 alveolar sac 174 alveolar vent 202 alveolitis 12 allergic 12 extrinsic allergic (See hypersensitivity pneumonitis) alveolus 12, 169 amantadine 12–13, 110 Ambrosia species 166 Ambu bag 13 ambulatory; pneumonic plague 52 Ambu simulator 13 American Academy of Allergy 152 American Academy of Allergy, Asthma and Immunology (AAAAI) 13, 33, 374 American Academy of Medical Acupuncture (AAMA) 2 American Academy of Pediatrics 13, 374 American Association for Respiratory Care 374

Index 383 American Association for the Study of Allergy 13 American Association of Certified Allergists 94 American Board of Allergy and Immunology (ABAI) 13–14 American Board of Internal Medicine (ABIM) 13 American Board of Pediatrics (ABP) 13 American Cancer Society 180 American Chiropractic Association 59 American College of Allergy, Asthma and Immunology (ACAAI) 3, 11, 13, 14, 30, 374 American College of Allergy and Immunology. See American College of Allergy, Asthma and Immunology American College of Rheumatology 61 American Dietetic Association 14, 374 American leishmaniasis 118 American Lung Association (ALA) 374 on asthma 28 and asthma camps 37 on asthma prevalence 33 on cancer of larynx 117 on lung cancer 121 progress report of 217–222 State of the Air: 2000 7 American Medical Association Allergy Council on Scientific Affairs of 105 on depression 72 and education programs 14 on influenza 109 Section on Allergy 13 American Review of Respiratory Diseases 182 American Society for Information Science 2 American Society of Clinical Hypnosis 97 American Society of Health-System Pharmacists 375

American Thoracic Society 182, 217 Amherst, Sir Jeffrey 45 amide type local anesthetics 18 aminoalkyl ethers 23 aminophenols 14 aminophylline 14–15, 32, 187 aminosalicylic acid 148 Ammi visnaga 12 ammonium carbonate 15, 80 ammonium chloride 80 ammonium iodide 15 amoxicillin 20, 49, 151 amphetamine, and phenylpropanolamine 153 amphotericin B, for coccidioidomycosis 63 ampicillin 20, 49, 151 amyl nitrite, inhalation of 111 anabolic steroids, for hereditary angioedema 19 anaerobe 4 anaerobic exercise 4 analgesia, respiratory implications of 15 anaphylactic shock. See anaphylaxis anaphylactogen 176 anaphylactoid reaction 15 anaphylaxis 15–17, 101–102, 151 anapnea 17 anatomical snuffbox 180 anemia, hemolytic, and antihistamines 23 anemometer, respiratory 168 anergy 17 anesthesia 17–18 aneurysm 18 aneurysmal cough 68 angiitis, allergic 61 angioedema, hereditary 18–19 aniline, and toxic-allergic syndrome 189 animal dander, control measures for 143 Annals of Allergy, Asthma and Immunology 3, 14, 33 anosmia 176 anoxia 19 cerebral 58

anoxic anoxia 19 antasthmatic 19 anthracosilicosis 19 anthracosis 19, 131 anthrax 19–20 and bioterrorism 45 and woolsorter’s disease 211 anthrax vaccine 211 Anthrax Vaccine Immunization Program, of U.S. Department of Defense 211 antibiotics 20 in AIDS treatment 5–6 and asthma in pregnancy 37 for bronchitis 49 for Legionnaire’s disease 118 for pneumococcal meningitis 132 for Q fever 165 quinolone 165 for sinusitis 179 and theophylline 188 for tuberculosis 198 antibodies 1, 20, 102–103. See also immunoglobulin(s) antibody deficiency disorder 20 anticholinergics 20–21, 31, 32, 363, 364, 369 anticoagulants, for thrombosis 76 anticonvulsants, and theophylline 188 antifungals, in AIDS treatment 5–6 antigen A, in ragweed extract 166–167 antigenic drift 109 antigenic shift 109 antigens 21, 101, 219 antihistamines 21–24, 91 for allergies 10 for anaphylaxis 16, 22 and asthma in pregnancy 37 chemical classifications of 23–24 trade names of 23–24 anti-inflammatory 24 anti-inflammatory agents 108 for asthma 31–32, 71 during pregnancy 35, 37

384 The Encyclopedia of Asthma and Respiratory Disorders for exercise-induced asthma 79 for sinusitis 179 anti-inflammatory effects, of corticosteroids 67 antimicrobial 24 antiseptic 24 antituberculars 24 antituberculotic 24 antitussive 24 Antivert. See meclizine antiviral 24 antiviral agents, in AIDS treatment 5 antrocoanal polyps 161 anxiety 24–25, 98 apicolysis 25 apnea 25 apnea alarm mattress 134 apnea monitor 134 apneic oxygenation 25 apneumatosis 25 apneumia 25 apneusis 25 apneustic center 26 apoplexy 157, 201 appendix 100 apple-packer’s disease 26 apple-packer’s epistaxis 26 apulmonism 26 Aquaphyllin. See theophylline arachidonic acid 119 arch, pulmonary 26 Archives of Family Medicine 72 arc welder’s disease 142, 177 ARDS. See adult respiratory distress syndrome Aristocort. See azmacort; triamcinolone Arnold’s nerve 26 aromatherapy, for allergies 10 arrest, respiratory 26 arrhinia 26 arrhythmias antihistamines and 23 terfenadine and 176 Artaeus the Cappadocian 26 arterial blood gases (ABGs) 26 arthritis drugs, and anaphylaxis 16

artificial pneumothorax 27 artificial respiration. See cardiopulmonary resuscitation artificial ventilation 13, 202–203 asbestos, and mesothelioma 132 asbestosis 27 ascorbic acid 27 aspergillosis 96 allergic bronchopulmonary 27, 51 Aspergillus fumigatus 27, 51 asphyxia 27–28, 201 aspiration 28 aspirator 28 aspirin (acetylsalicylic acid) 16, 24, 49 aspirin triad 28 Association for the Study of Asthma and Allied Conditions 13 Astelin Nasal Spray 28. See also azelastine astemizole 22, 28 and arrhythmias 23 for exercise-induced asthma 79 sedative effects of 22 asthma 28–34 adult-onset 331, 360–362 age-adjusted mortality rate, by race and sex 312 alternative therapies for 372 American Lung Association on 217–222 and antihistamines 22 attack prevalence by age 317, 319 by race 319 by sex 318 baker’s 41 bronchial 47 cardiac 56, 75 causes of 28 child-onset 330–331, 360–362 chronic mild 71 chronic moderate 71 chronic severe 71 classifications of 28 crude mortality rate, by race and sex 313

deaths related to 33–34 degree of severity 71 diagnosis of by age, sex, and race 316–317 guidelines for 324–345 differential diagnosis of 338–339, 340 economic cost of 323 employment opportunities for persons with 77 episodic 78 exacerbations of, management of 367–370 exercise-induced 29, 79–80 extrinsic 28, 31 gastrointestinal reflux and 84 geographic locations best for sufferers of 119–120 growing out of 86 hospital discharges and 310–311 by age 321 by race 322 by sex 320 in infants 34, 360–362 intrinsic 28, 31 management of airway inflammation and 332–333 guidelines for 29, 324–345 partnership in 346–359 stepwise approach for 360–362 medications for 31–32, 43–44 military service and 133 monitoring of 341–345 morbidity and mortality, trends in 307–323 mortality rates with by race and sex 314 by 10-year age groups 315–316 and nasal polyps 161 natural way to control 138 nocturnal 31, 140 occupational 141–146 and pregnancy 35–37

Index 385 prevalence of 32–33, 224, 225–288, 308–310 recognition of 29–30 screening for 30 self-management of 347, 350–352, 358–359 severity of 29, 338 sexual activity and 176 spasmatic 181 squatting and 182 surgery and 184–185 travel and 371 triggers of 197 Asthma Action Plan 353–357 Asthma and Allergy Foundation of America (AAFA) 34, 374–375 Asthma and Allergy Poster Child 34–35 asthma attack airways in 7 signs and symptoms of 30–31 Asthmaattack! 217 asthma camps 37–38 Asthma Clinical Research Centers 217–218 Asthmador Cigarettes 114 asthma-friendly school 38–39 Asthma Haler. See epinephrine Asthma Nefrin. See epinephrine asthma specialist, referral to 339–340 asthmatic breathing 47 asthmatic bronchitis. See asthma astrocytes 102 Atarax 39. See also hydroxyzine atelectasis 39, 129 congenital 25 atmiatrics 39 atmotherapy 39 atomizer. See nebulizer atresia, pulmonary 39 atropine 21, 31, 183, 202 Atrovent. See ipratropium Aufrecht, Emanuel 39 Aufrecht’s sign 39 auricular therapy, for allergies 11 auscultation 39 Australian Association of Asthma Foundations 112

Australian Buteyko Asthma Trial 112 autogenic training, for allergies 11 autoimmune disease. See acquired immune deficiency syndrome autoimmune disorders 101 autonomic nervous system 170 autosomal dominant disorder 18–19 autotuberculin 39 Axid. See nizatidine Ayerza, Abel 39 Ayerza’s syndrome 39–40 Ayurvedic medicine 11, 40 azatadine 21 azelastine 21, 28 azidothymidine. See Zidovudine azithromycin 118, 214 Azmacort 40. See also triamcinolone AZT. See Zidovudine

B baby shots 1 bacilli pneumonia 158 Bacillus anthracis 19, 211 Bacillus subtilis 142 bacteria 41 bactericidal antibiotic 20 bad breath 46 bagassosis 41, 96, 159 bag-valve-mask resuscitator 13 baker’s asthma 41 baker’s rhinitis 41 bambuterol 41–42 barosinusitis 42 Barr, Y. M. 79 Barré, J. A. 86 barrel chest 42 barrel-shaped thorax 59 basic life support 42 basophils 101, 118 B cells 100 and antibodies 20, 102 and immunodeficiency disease 103 beclomethasone 42, 64, 65, 365 Beclovent. See beclomethasone

Beconase. See beclomethasone Beconase AQ. See beclomethasone behavioral changes, with corticosteroids 67 Behavioral Risk Factor Surveillance System (BRFSS) 6 Benadryl. See diphenhydramine bends 42, 54, 162 benign pneumoconiosis 42 Benylin DM 72 benzocaine 17–18 benzonatate 18 Bergstrom, Sune 174 Berotec. See fenoterol berylliosis 42–43 beta-adrenergic agonists 43–44 for allergies 10 for asthma 31, 32 for emergency care 369 for long-term control 365, 366 for quick relief 363, 364 beta1-receptors 4–5, 43 beta2-receptors 4–5, 43 as bronchodilating drugs 50 for exercise-induced asthma 79 beta-adrenergic receptors. See beta-adrenergic agonists beta-agonists. See beta-adrenergic agonists beta-blocking agents 44 beta-receptors. See beta-adrenergic agonists Bible printer’s lung 96 bicarbonate, and arterial blood gas tests 26 big nose 85 bioavailability, of corticosteroids 66 biological warfare 58 BioPort Corporation 211 biopsy 44 bioterrorism 19, 44–45, 58 bird breeder’s lung 45, 96 bitolterol 363, 364, 369 black death. See bubonic plague black lung. See coal worker’s pneumoconiosis

386 The Encyclopedia of Asthma and Respiratory Disorders Blended Medicine 110 block, air 45 Blomia tropicalis 92 blood, and pleural effusion 155 blood clot, pulmonary 76 blood disorders, and antihistamines 23 blood transfusions antihistamines and 22 and HIV 5 immunotransfusion 107 blowing exercise 45 blue baby 45 blue bloaters 77 Boeck’s sarcoid. See sarcoidosis bone marrow 100 bone marrow transplantation 103 Bonine. See meclizine booster shots 2 Bordetella pertussis 210 Bostock, John 45 botulinum 46 botulism 46 Bouchut, Jean A. E. 46 Bouchut’s respiration 46 Bovet, Daniele 46 bradykinin 46 bradypnea 46 brain, inflammation of 77 brain astrocytes 102 Branhamella (Neisseria) catarrhalis 138, 178 brass founder’s ague 46 brass poisoning 46 brassy cough 68 breast cancer, survival rates for, by race 304–305 breath, bad 46 Breath Enhancer 46 breath-holding attacks 46 breathing 47, 170 breathing exercises 47 breathnet 375 Brethaire. See terbutaline Brethine. See terbutaline Breurer, Josef 90 BRFSS. See Behavioral Risk Factor Surveillance System Bricanyl. See terbutaline

broad-spectrum antibiotic 20 Bromfed. See brompheniramine brompheniramine 47 bronchi 47, 169 cancer of age-adjusted death/mortality rates for 122, 126 by race, sex, and age 296–297 by race and sex 295–296 by state and race 298–299 by state and sex 297–298 incidence of 291, 300, 302 survival rates for, by race 304–305 inflammation of 77 bronchial asthma 47, 182 bronchial breathing 47, 47 bronchial cast 57 bronchial cough 68 bronchial crises 47 bronchial glands 48, 49, 85 bronchial inhalation challenge 111 bronchial murmur 134 bronchial pneumonia 158 bronchial ramus 167 bronchial sounds 181 bronchial spasm 181 bronchial tee 47 bronchial washing 48 bronchiarctia 48 bronchiectasis 48 bronchiloquy 48 bronchiocele 48 bronchiolectasis 48 bronchioles 48–49, 169 bronchiolitis 49 bronchiospasm. See bronchospasm bronchiostenosis 49 bronchitis 26, 49 alternative therapies for 372 asthmatic (See asthma) chronic 30, 49–50, 61 prevalence of 224, 225–288 croupous 120 hemorrhagic (See bronchospirochetosis) plastic 155

pseudomembranous 120 sputum in 182 bronchoadenitis 47 bronchoalveolar lavage 50 bronchoblennorrhea 50 bronchocele 50 bronchoconstriction 332. See also bronchospasm bronchodilating drugs 50 for anaphylaxis 16 for asthma 31, 71 during pregnancy 35 for exercise-induced asthma 79 bronchodilators. See bronchodilating drugs bronchoedema 50 bronchofiberscope 50 bronchogenic carcinoma 56 bronchogram 50 bronchography 6, 50 broncholithiasis 50 bronchomycosis 50 bronchopathy 50 bronchoplegia 50 bronchopneumonia 12, 50–51, 182 bronchoprovocation, in asthma diagnosis 338 bronchopulmonary aspergillosis, allergic (ABPA) 51 bronchopulmonary disorders 47 bronchopulmonary dysplasia 51 bronchopulmonary lavage 51 bronchopulmonary segments 169, 176 bronchopulmonary septicemia 176 bronchorrhagia 51 bronchorrhea 51 bronchoscope 47, 51 bronchoscopy 51 bronchosinusitis 51 bronchospasm 7, 51–52 bronchospirochetosis 52 bronchostaxis 52 bronchostomy 52 bronchotomy 52 bronchovesicular sounds 181

Index 387 Bronitin Mist. See epinephrine Bronkaid Mist 52. See also epinephrine Bronkephrine 52 Bronkodyl. See theophylline Bronkometer. See isoetharine Bronkosol. See isoetharine Bruton’s agammaglobulinemia 20 bubble children 103–104 bubonic plague 52 budesonide 52–53, 64, 65, 172, 365 Budgerigar fancier’s lung 96 bupivacaine, adverse reactions to 17 Burkitt’s lymphoma, and EpsteinBarr virus 79 Buteyko asthma relief system 112 byssinosis 53, 141

C cachexia 54 caisson disease 54, 162 calculi in pneumolithiasis 157 in rhinolithiasis 172 CAMP. See cyclic adenosine 3’, 5’monophosphate Camp Broncho Junction 38 Canada, hay fever in trees that cause 190–197 weeds that cause 205–210 canal, pharyngeal 54 canal of Lambert 54 cancer. See specific type of cancer Candida and bronchomycosis 50 skin tests for 17 Candida albicans 54 candidiasis 54 cannabis 54–55 Cannabis sativa 54, 88 cannula, nasal 55 capacity, vital 55 Capastat. See capreomycin sulfate Caplan, Anthony 55 Caplan’s syndrome 55 capnography 55

capreomycin sulfate 55 carbamazepine, and theophylline 188 carbenicillin 151 carbinoxamine 55 carbofuchsin 214 carbon, and anthracosis 19 carbon dioxide acidosis 1 carbon dioxide (CO2) 55 and arterial blood gas tests 26 and capnography 55 inhalation of 55 poisoning 55 in respiratory quotient 165 carbon monoxide (CO) 55 poisoning 55–56 carbon tetrachloride poisoning 56 carboplatin, for lung cancer 129 carcinogen 56 carcinoid tumors 121 carcinoma adenoid cystic 121 alveolar cell 56 bronchogenic 56 large-cell undifferentiated 121 oat cell 56 squamous cell 121 Cardarelli, Antonio 56 Cardarelli’s sign 56 cardiac asthma 56, 75 cardiac depression 120 cardiopneumograph 56 cardiopulmonary arrest 56 cardiopulmonary resuscitation (CPR) 42, 56–57 carriers 25, 57, 107–108 case-control study 57 “Case of a Periodical Affection of the Eyes and Chest” 45 caseous pneumonia 158 cast, bronchial 57 castor bean allergy 142 catarrh 57 catarrhal croup 69 catheter, pulmonary artery 57 CAT scan. See computed tomography cavernous rale 57 cavernous respiration 57

cavity, pleural 57–58 CCAC. See Consortium on Children’s Asthma Camps CCSP. See Clara cell secretory protein CDC. See Centers for Disease Control and Prevention cell-mediated hypersensitivity reactions. See hypersensitivity reactions, type IV cell-mediated immunity 58 cells, of immune system 101–102 Center for Environmental Health 375 Centers for Disease Control and Prevention (CDC) on asthma prevalence 32 on bioterrorism 44 on botulism 46 and immunizations 2 on influenza 109, 110 central nervous system, and corticosteroids 67 central pneumonia 158 cephalosporins 20, 58 Cephalosporium hypersensitivity 96 cerebral anoxia 58 Cerespan. See papaverine hydrochloride certification, from ABAI 13–14 C1-esterase inhibitor, and hereditary angioedema 18 cetirizine 214 CF. See cystic fibrosis chalcosis 58 chalicosis. See flint disease charas 88 Charcot, Jean M. 58 Charcot-Leyden crystals 58 cheese, and anaphylactoid reactions 15 cheese washer’s lung 96 chemical terrorism 19 chemical warfare 58 chemotherapy in AIDS treatment 6 for leprosy 118 for lung cancer 121–129 chest 59

388 The Encyclopedia of Asthma and Respiratory Disorders chest expansion, normal 59 chest pain 148 chest tube, for pleural effusion 155 chest X ray 199, 212 Cheyne-Stokes breathing 47 chi 2 ch’i 177 chicken breast 154 chicken handler’s lung 96 chicken pox, and corticosteroids 67 child crowing 116 child-onset asthma 330–331 children, and antihistamines 23 Children’s National Medical Center 28 chill 59 chin-lift airway technique. See cardiopulmonary resuscitation chironomids 133 chiropractic 59 Chlamydia 49, 187, 218 Chlamydia psittaci 59, 163 chloral hydrate poisoning 59 chloramphenicol 20, 52 chlorine 84 chloroformism 59–60 chlorpheniramine 22, 23 chlorpromazine 155 chlortetracycline 187 Chlor-Trimeton. See chlorpheniramine choana 60 choking 60 Choledyl. See oxitriphylline cholesterohydrothorax 60 cholohemothorax 60 chorditis 60 chorditis nordosa 60 chronic bronchitis 30, 49–50, 61 prevalence of 224, 225–288 chronic mild asthma 71 chronic moderate asthma 71 chronic obstructive lung disease (COLD) 50, 60–61 chronic obstructive pulmonary disease (COPD) 50, 60–61 chronic pharyngitis 153

chronic severe asthma 71 Churg-Strauss syndrome 61 chyle 61–62 chylopneumothorax 61–62 chylothorax. See chylopneumothorax cigarettes. See smoking cigarette smoke 62 cilia, and Kartagener’s syndrome 115 cimetidine 91, 188 Cipro. See ciprofloxacin ciprofloxacin 20, 165, 188 circulation, pulmonary 62, 120, 163, 170 cisplatin 129 Citelli, Salvatore 62 Citelli’s syndrome 62 clapping 62 Clara, Max 62 Clara cells 62 Clara cell secretory protein (CCSP) 222 clarithromycin 20 Claritin. See loratadine classic pathway, in complement system 102–103 clean air 6 Clean Air Month 7 Clean Air Science Advisory Committee, of EPA 181 clean room 62 cleft palate 62 clemastine fumarate 186 clindamycin 20 clofazamine 118 Clostridium botulinum 46 clotrimazole 54 clubbing 62 CO. See carbon monoxide CO2. See carbon dioxide coal-burning stoves 211 coal dust and anthracosilicosis 19 and Caplan’s syndrome 55 and coal worker’s pneumoconiosis 62 coal worker’s pneumoconiosis 62 cocaine, as anesthetic agent 17

cocaine hydrochloride poisoning, acute 63 coccidiodomycosis 63 coccidioidal. See coccidiodomycosis Coccidioides immitis 63 co*ckroaches, control measures for 144 codeine as painkiller, contraindications to 15 poisoning 63 coffee worker’s lung 96 cog-wheel breathing 47 coin test 63 COLD. See chronic obstructive lung disease cold, common 63, 168, 172, 372 cold-induced rhinorrhea 63, 179 colon cancer, survival rates for, by race 304–305 color therapy 11 columna nasi 63 coma 63, 201 Combivent 113 common cold 63, 168, 172, 372 communicable diseases 63 reportable 167 complement 102–103 complemental air 6 computed tomography (CT or CAT scan), for sinusitis diagnosis 178 concha, nasal 63 condensed air, in pneumatotherapy 156 congenital aspiration pneumonia 158 congestion nasal 136 pulmonary 64 coniofibrosis 64 coniosis 64 coniosporosis 64 Conium maculatum 90 conjunctival inhalation challenge 111 conjunctivitis, and occupational asthma 142 connective tissue mast cells 131 consonating rales 167

Index 389 Consortium on Children’s Asthma Camps (CCAC) 37–38 contact dermatitis, antihistamines for 22 Continuous Positive Airway Pressure mask, for snoring 183 continuous positive-pressure breathing 47 continuous positive-pressure ventilation 203 COPD. See chronic obstructive pulmonary disease corn farmer’s lung 96 cor pulmonale 64 Corruthers, John M., Jr. 33 corticosteroids 64–68 for allergic bronchopulmonary aspergillosis 27, 51 for allergies 10 for anaphylaxis 16 antiallergy effects of 64 anti-inflammatory effects of 67 for asthma 32, 71 for emergency care 369 for long-term control 365 for quick relief 363, 364 behavioral changes with 67 central nervous system effects of 67 contraindications for 67–68 for Goodpasture’s syndrome 85 hormonal changes with 67 for inflammation 108 for leprosy 118 metabolic effects of 64–67 in metered-dose inhalers 64 for nasal congestion 136 for nasal polyps 161 in nasal sprays 64 ocular effects of 67 for pulmonary fibrosis 82 for rhinitis medicamentosa 171 for sinusitis 179 uses of 67 and x-ray dyes 22 corticotropin (ACTH), and corticosteroids 67 Corynebacterium diphtheriae 73, 115

coryza spasmodica. See hay fever cotton, and byssinosis 53 cough 68, 200 alternative therapies for 372 ear 68 with measles 131 cough medicine, and asthma in pregnancy 37 cow’s milk, allergy to 89 coxicillin 151 Coxiella burnetti 165 CPR. See cardiopulmonary resuscitation cracked pot sound 69, 168, 181 crackles 69 crepitation 69 crepitus redux 69 cromolyn sodium 69, 138, 146 for allergies 10 for asthma 32, 71, 365 development of 12 for exercise-induced asthma 79 for inflammation 108 and insufflation 113 for nasal congestion 136 and Spinhaler 181 crossed finger airway technique 69 cross-reaction, of antigens, among plant families 21 croup 29, 69 spasmatic 181 croupous bronchitis 120 crowing 69 Cryptostroma corticale 130 CT scan. See computed tomography Curschmann’s spirals 69 cussinylcholine chloride, for cocaine poisoning 63 cyanosis 69, 75, 81 cyclaine 18 cyclic adenosine 3’, 5’monophosphate (CAMP, cyclic AMP) 69, 170 cyclic AMP. See cyclic adenosine 3’, 5’monophosphate cyclizine 22

cyclophosphamide, for Goodpasture’s syndrome 85 cyclosporin 69–70 cyst, alveolar 70 cystic fibrosis (CF) 29, 70 and nasal polyps 160 sweat chloride test for 185 cytokines, and mast cells 131

D Dallergy 133 Danazol. See danocrine danocrine, for hereditary angioedema 19 dapsone, for leprosy 118 Datura stramonium 183 dead space air 6 death rattle 71 deaths, asthma-related 33–34 Decadron. See dexamethasone Declomycin. See demeclocycline decompression illness 54. See also bends decongestants 71 for allergies 10 and asthma in pregnancy 37 for nasal congestion 136 for vasomotor rhinitis 202 decortication, pulmonary 71 deep breathing exercises 47 deer fly fever 199 degree of asthma severity 71 delayed hypersensitivity reactions. See hypersensitivity reactions, type IV delirium tremens (DTs) 2 Delsym 72 delta-9-tetrahydrocannabinol 54 demand valve manually cycled resuscitator 71–72 demeclocycline 187 Demerol. See meperidine De Morbis Artificum Diatriba (Ramazzini) 141 dendritic cells 102, 222 Denver, Colorado, Asthma Research Center in 217, 218–219

390 The Encyclopedia of Asthma and Respiratory Disorders Depo-Medrol 133 depressant, respiratory 72 Dermatophagoides 93 Dermatophagoides farinae 92, 94 Dermatophagoides microceras 92 Dermatophagoides pteronyssinus 92, 94 desert rheumatism. See coccidiodomycosis desquamative interstitial pneumonia 82, 158 detergent lung 96 dexamethasone 64, 72 dexchlorpheniramine 72 dextromethorphan 72, 174 diaphragm 72, 169–170 diaphragmatic hernia 90 diazepam, for cocaine poisoning 63 dicloxicillin 151 diffusion 72 Dilor. See dyphylline dimenhydrinate 22 Dimetane. See brompheniramine Dimetapp. See brompheniramine diphenhydramine 22, 72–73 diphenlyhydantoin, for Leeuwenhoek’s disease 117 diphosgene 84 diphtheria 73 diphtheria antitoxin 73 diphtherial cough 68 diphtheria-tetanus-pertussis (DTP) vaccine 73, 210 direct immunofluorescence 104 Directory of Graduate Medical Education Programs 14 “Disease Management of Drug Hypersensitivity: A Practice Parameter” 3 Diseases of Tradesmen (Ramazzini) 167 disinfectant 73 disodium cromoglycate 12. See also cromolyn sodium distress 183 Dittrich’s plugs 74 divers, and thoracic squeeze 188 Divine Husbandman’s Materia Medica 176

diving reflex 74 DNA gyrase 165 docetaxel, for lung cancer 129 documentation, of occupational asthma 142 dog nose 85 Dopram. See doxapram hydrochloride Doryx. See doxycycline dose-intensive chemotherapy, for lung cancer 121–129 double pneumonia 158 doxapram hydrochloride 74, 90 doxycycline 187 drainage negative pressure 74 postural 74 drainage tube 74 Dramamine. See dimenhydrinate Drinker, Philip 74 Drinker respirator 74 drip, postnasal 74 Dristan 147 droplet infection 74 drops, nose 74 drowning 74–75 drug-induced hypersensitivity pneumonitis 96 drugs, adverse reactions to 3 dry cough 68 dry rales 167 DTP vaccine. See diphtheriatetanus-pertussis vaccine DTs. See delirium tremens Dubos, René 20 duck fever 96 duct, thoracic 75 Duo-Medi-Haler. See isoproterenol Dura-Vent DA 133 dust-free room 173 dust mites 92–94, 93, 144 dyphylline 75 dysmaturity syndrome 211 dysplasia, bronchopulmonary 51 dyspnea 6, 75 expiratory 75 inspiratory 75 paroxysmal nocturnal 75

E ear cough 68 Eaton, Lee McKendree 76 Eaton agent pneumonia 158 Eaton-Lambert syndrome 76 echinacea, in influenza prevention 110 ECHO virus 76 ECMO. See extracorporeal membrane oxygenator eczema, antihistamines for 22 edema of airway 7, 332 of face 81 of glottis 76 laryngeal 76 pulmonary 6, 76, 91, 164 effective cough 68 Effectiveness of Asthma Camps for Inner City Families (Weisberg, Olson, & Sveum) 38 Elder valve 72 electropharynx 117 electrophrenic respiration 76 radiofrequency 166 ELISA (enzyme-linked immunoabsorbent assay) 76 Elixomin. See theophylline Elixophyllin 76 embolic pneumonia 158–159 embolism, pulmonary 76 emergency cardiac care 42 emergency care for asthma 369 for asthma exacerbations 370 breathing restoration in 171 emotion, as asthma trigger 28 emphysema 76–77, 157 alternative therapies for 372 differential diagnosis 30, 50, 61 prevalence of 224, 225–288 spontaneous mediastinal 88 employment opportunities, for individuals with asthma and allergies 77 empyema 77, 155 empyemic scoliosis 175

Index 391 E-mycin. See erythromycin encephalitis 77 endobronchial tube 198 endobronchitis 77 endorphins, in acupuncture 2 endoscope, fiberoptic 50 endothoracic fascia 81 endotracheal tube 78, 138. See also tracheostomy endotracheitis 78 Enteric Cytopathogenic Human Orphan (ECHO) virus 76 Entomophthora coronata 172 environmental conditions, and respiratory health 7 enzyme-linked immunoabsorbent assay (ELISA) 76 enzyme replacement therapy, for severe combined immunodeficiency disease 104 eosinophilic pneumonia 158, 163 eosinophils 118, 163 EPA. See U.S. Environmental Protection Agency ephedra 177 Ephedra 78 Ephedrine. See ephedrine ephedrine 43, 78 Ephedrine Sulfate. See ephedrine epidemic 78 epiglottis 78, 169 epiglottitis 29, 78 Epinal. See epinephrine epinephrine 43, 52, 78, 131, 185 for anaphylaxis 16, 22 for asthma 369 and beta-blocking agents 44 and cyclic AMP 69 and Ma Huang 43, 177 Epinephrine HCl. See epinephrine Epinephrine Pediatric. See epinephrine Epipen Jr. See epinephrine epipharynx 78 episodic asthma 78 epistaxis 78, 172 apple-packer’s 26 epitopes 101 Epitrate. See epinephrine

epoprostenol, for pulmonary hypertension 162 epoxy resin lung 96 Eppy/N. See epinephrine Epstein, M. A. 79 Epstein-Barr virus 79 erythromycin for anthrax 19 and arrhythmias 23 and astemizole 28 for bronchitis 49 for Legionnaire’s disease 118 for Mycoplasma pneumoniae infections 135 and terfenadine 176 and theophylline 188 Erythroxylon coca 63 esophageal cancer, survival rates for, by race 304–305 esophageal obturator airway 79 esophageal speech 117 ester type local anesthetics 18 The Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory 223–288 ethambutol 198 ethanol 8 ethanolamines 23 ethmoidal sinus 178 ethmoid cells, inflammation of 79 ethmoiditis 79 ethylenediamine 14, 23 ethylnorepinephrine hydrochloride 52 eupnea 79 Euroglyphus 93 Euroglyphus maynei 92 evaporative humidifiers 94 exercise aerobic 4 anaerobic 4 exercise-induced asthma 29, 79–80 expectorant 80 expectoration 80 Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma 324–345 expiration 80

expiratory center 80 expiratory dyspnea 75 expiratory reserve (supplemental) volume 6, 170, 203 exposure, to hazardous materials, permissible limits of 152 exsufflation 80 Extendryl 133 external respiration 170 extracorporeal membrane oxygenator (ECMO) 80 extracranial pneumatocele 156 extracts, allergen, in immunotherapy 107 extrinsic allergic alveolitis. See hypersensitivity pneumonitis extrinsic asthma 28, 31 eye(s) corticosteroids and 67 and respiratory hippus 91 watery 183 eyedrops antihistaminic 22 and asthma in pregnancy 37

F Fab. See fragment antigen binding face, cyanotic/flushing 81 failure, respiratory 81 falling drop 81 false croup 163 false ragweed 166 familial hypersensitivity pneumonitis 96 famotidine 91 farmer’s lung 81, 96 fascia, endothoracic 81 faucitis 81 Fc fragment 102 Feingold, Ira 11, 12 fenoterol 43 FET. See forced expiratory time fetal complications, with asthma in pregnancy 35 fetal monitoring, with asthma in pregnancy 36 fetal oxygen supply, with asthma in pregnancy 35–36

392 The Encyclopedia of Asthma and Respiratory Disorders FEV. See forced expiratory volume FEV1. See forced expiratory volume in one second fexofenadine 81 fiberoptic endoscope 50 fiberoptic rhinoscope 172 fibrin, in plastic bronchitis 155 fibrosis cystic 70 idiopathic pulmonary 88, 99 pleural 155 pulmonary 81–82 fibrothorax 82 FiO2. See fraction of inspired oxygen first-generation cephalosporins 58 fish, and anaphylactoid reactions 15 fistula, pulmonary arteriovenous 82 flames, inhalation of 82 flatness 82 flax, and byssinosis 53 “Flexible Scopes and Photodynamic Therapy” 154 flint disease 82 Flolan. See epoprostenol Flonase 82. See also fluticasone flour, and baker’s asthma 41 Flovent 82. See also fluticasone flow meter 82 Floxin. See norfloxacin Floyer, Sir John 82 flu. See influenza Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It (Kolata) 109 flunisolide 4, 64, 65, 82, 136, 365 fluoroquinolones, for Legionnaire’s disease 118 flushing, of face 81 fluticasone 64, 65, 82, 365 flu-virus A subtypes 109 food additives 184 food allergies 17, 31 The Food Allergy and Anaphylaxis Network 375

Food and Drug Administration (FDA) 184, 375 foods and asthma 31 avoidance of, in anaphylaxis prevention 16–17 forced expiratory time (FET) 83 forced expiratory volume (FEV) 83 forced expiratory volume in one second (FEV1) 203 formaldehyde 83 formalin, in allergoids 10 Fourneau, Ernest 46 4-Way Nasal Spray 83, 147 fraction of inspired oxygen (FiO2) 83 fragment antigen binding (Fab) 102 Francisella tularensis 158, 199 Frank, Bryan 2 Franseria 166 Freeman, John 83 fremitus 83 Freud, Sigmund 17 friction rub, pleural 83 Friedländer, Carl F. 83 Friedländer’s bacillus 83 frontal sinus 178 fumes 83 functional residual capacity 170 fungi, in pneumomycosis 157–158 furrier’s lung 96

G ganglia, thoracic 84 gas illuminating 99 as lung irritant 84 and pneumatocele 156 and pneumatosis 156 in pneumothorax 159 suffocating 84 in war 205 gas exchange, impaired. see arterial blood gases gasoline poisoning 84 G. A. S. syndrome. See general adaptation syndrome

gastroesophageal reflux disease (GERD) 89 gastrointestinal reflux, and asthma 84 gastropulmonary 84 gating, respiratory 84 GBS. See Guillain-Barré syndrome gemcitabine hydrochloride, for lung cancer 129 Gemzar, for lung cancer 129 general adaptation syndrome (G. A. S. syndrome) 84–85 genes, and antibodies 102 genetic carrier 108 genetic disorders, carrier screening for 25 genetic testing 25 Gen-Salbutamol. See albuterol geographic locations, for asthma and allergy patients 119–120 GERD. See gastroesophageal reflux disease glands, bronchial 85 glandular tularemia 199 Glaucon. See epinephrine glomerulonephritis, progressive. See Goodpasture’s syndrome glossitis 85 glossopharyngeal breathing 85 glottis, edema of 76 glucocorticoids 365 inhaled 85 glue sniffing 85 Glycyrrhiza glabra 119 Goodpasture, Ernest William 85 Goodpasture’s syndrome 85 goundou 85 grain allergies 85 gramicidin 20 Grancher, Jacques J. 85 Grancher’s disease 85 granulocytes 118 granulocytosis, and antihistamines 23 granuloma 86. See also coccidiodomycosis granulomatosis 61 Wegener’s 85–86 grapefruit juice, and terfenadine 176

Index 393 grapeseed oil, and toxic-allergic syndrome 189 grass pollen allergy 86 gravity principle, in postural drainage 161 green tobacco sickness 86 grepafloxacin, for Legionnaire’s disease 118 grindelia 86 grinder’s disease 177. See also silicosis grippe. See influenza growing out of allergies and asthma 86 guaifenesin 80, 86, 173 Guidelines for the Diagnosis and Management of Asthma 71 Guillain, Georges 86 Guillain-Barré syndrome (GBS) 86–87, 110 gustatory rhinits 87

H H. See hemagglutinin Habitrol. See nicotine patches hacking cough 68, 88 Haemophilus influenzae 69, 178 halitosis 46 hamartomas 121 Hamman, Louis 88 Hamman-Rich syndrome 88 Hamman’s disease 88 Hansen’s disease. See leprosy, tuberculoid H1 antihistamines 22 second-generation 23 H2 antihistamines 22 haptens 16, 101, 152 Harrison, Edwin 88 Harrison’s groove 88 harsh cough 68 Harvard School of Public Health 180 hashish 88 hay fever 88–89, 173. See also allergic rhinitis; pollinosis seasonal 175–176 trees that cause 190–197 weeds that cause 205–210

Hay Fever, a Key to the Allergic Disorders 83 headache histamine 89 sinus 178 Healthy Kids: The Key to Basics 375 heart 170 heartburn 89 heart-lung bypass 89 heart-lung machine 89 heart-lung preparation 162 Heimlich, H. J. 89 Heimlich maneuver 60, 89 Heimlich sign 89 Heiner’s syndrome 89, 97 helium 89 helper T cells 102 hemagglutinin (H) 109 hemithorax 89 hemlock poisoning 90 hemolytic anemia, and antihistamines 23 hemopleura 90 hemopneumothorax 90, 157 hemoptysis 90. See also Goodpasture’s syndrome hemorrhage, lung 90, 129, 157, 159 hemorrhagic bronchitis. See bronchospirochetosis hemosiderosis 142, 177. See also Goodpasture’s syndrome hemothorax 90, 155 hemp, and byssinosis 53 hemp plant 88. See also cannabis hen cluck stertor 183 HEPA filters. See high-efficiency particulate air filters heparin 76, 101 hepatopulmonary 90 herbalism, for allergies 11 Hering, Heinrich Ewald 90 Hering-Breur reflex 90 hernia diaphragmatic 90 of lung tissue 156 phrenic 90 pulmonary 159

heroin toxicity 90 hiccups/hiccough 90, 177, 373 high-efficiency particulate air (HEPA) filters 6, 202 high frequency jet ventilation 203 high-molecular-weight allergens 141–142 hilitis 90 Hippocrates 90–91 hippus, respiratory 91 Hirstia 93 Hismanal. See astemizole histamine 15, 16, 91, 101. See also antihistamines histamine headache 89 histamine H1 receptor antagonist 91 histamine H2 receptor antagonist 91 Histapan 133 Histoplasma capsulatum 91 histoplasmosis 91 Histor-D 133 HIV. See human immunodeficiency virus HIV-antibody test 5 hives. See urticaria H1N1 virus 109 H3N2 virus 109 hoarseness 91–92 holistic medicine 92 home care, for asthma exacerbations 367 homeopathy 10, 92 home remedies 92 Hong Kong flu 109 Hopmann’s papilloma 148 hormonal changes, with corticosteroids 67 hormone 92 horse-serum antitoxin, and anaphylaxis 15 hospital-based care, for asthma exacerbations 370 house-dust extract 107 house-dust mites 92–94, 144 H1 receptor antagonist 91 H2 receptor antagonist 91

394 The Encyclopedia of Asthma and Respiratory Disorders HSP. See hypersensitivity pneumonitis Huang-ti (Huangdi) 94 huffing 94, 111 human immunodeficiency virus (HIV) 5–6 humidifier 94 humidifier air-conditioner lung 96 humidifier fever 94 humidity 95 hunger, air 95 hyaline membrane disease 168 hydralazine, and pleural effusion 155 hydroconion 95 hydrocortisone 64–67 hydrogen 95 hydromorphone, contraindications to 15 hydropneumatosis 95 hydropneumothorax 95, 157 hydrorrhea 95 hydrothorax 95 hydrous magnesium silicate, and talcosis 186 hydroxyzine 22, 39 hygiene 107–108 hyperbaric oxygen therapy 95 hyperbarism 95 hypercapnic acidosis 1 hyperemia. See flushing hyperinflation 95 hyperpnea 95 hypersensitivity, to medications 3 hypersensitivity pneumonitis 6, 159 hypersensitivity pneumonitis (HSP) 95–96 hypersensitivity reactions type I 10, 16 antihistamines for 21 to local anesthetics 17 mast cells in 131 type II 10 type III 10 type IV 10 hypertension, primary pulmonary 162

hyperventilation 97 alternative therapies for 373 and respiratory alkalosis 8 hyperventilation syndrome 30 hypnosis 97 hypnotherapy, for allergies 10–11 hypnotics, antihistamines as 22 hypocapnia 97 hypoepinephria 97 hypogammaglobulinemia 20, 103 hypostatic lung collapse 129 hypostatic pneumonia 97, 158 hypoventilation, primary alveolar 146 hypoventilation syndrome 97, 154 hypoxemia 97 hypoxia 97 hysteria 98

I ibuprofen 16, 24 idiopathic pulmonary fibrosis 81, 88, 99 idiosyncrasy 99 ID tags. See medical alert bracelets and necklaces IgA. See immunoglobulin(s), IgA IgD. See immunoglobulin(s), IgD IgE. See immunoglobulin(s), IgE IgE-mediated reactions. See immediate hypersensitivity reaction IgG. See immunoglobulin(s), IgG IgM. See immunoglobulin(s), IgM ILD. See interstitial lung disorders illuminating gas 99 Ilosone. See erythromycin imagery 99 I’m Going to Asthma Camp 38 imipenem, for anthrax 20 immediate hypersensitivity reaction 99. See also hypersensitivity reactions, type I immotile colia syndrome. See Kartagener’s syndrome immune complex 99 immune complex assay 99

immune complex disorders 99–100 Immune Deficiency Foundation 375 immune system 100–103 immunity 103 active 1–2 cell-mediated 58 passive 103 immunizations 1–2, 11–12 immunodeficiency disease 103 severe combined 103–104 immunofluorescence direct 104 indirect 104 immunogens 101, 104. See also antigens immunoglobulin(s) 170. See also antibodies IgA 102, 104, 106, 178 IgD 102, 104, 106 IgE 102, 104–105 antibodies 101, 141 assay 105 and asthma 222 immune complexes 105 and mast cells 131 IgG 102, 105–106 IgM 102, 106 immunoglobulin E mediated hypersensitivity reaction. See hypersensitivity reactions, type I immunologic defenses, of respiratory system 170 immunologist 106 immunology 106 Immunology Unit, of World Health Organization 105 immunopathology 106 immunopolysaccharide 106 immunostimulant 106 immunosuppressant 106 immunotherapy 106–107 for allergies 10 for asthma in pregnancy 36 for baker’s asthma 41 and beta-blocking agents 44 for house-dust mite allergies 94

Index 395 for lung cancer 129 mechanism of action 106–107 oral 107 for ragweed allergy 167 treatment course 107 immunotransfusion 107 incense 152 indirect immunofluorescence 104 Indoor Air Quality Information Clearinghouse 375 infants, asthma in 34 infarction, pulmonary 107 infections carriers of 107–108 opportunistic, and AIDS 5 respiratory tract 108 upper respiratory 201 infectious bronchitis 49 infectious mononucleosis, and Epstein-Barr virus 79 inflammation 108 of lung 129 inflammatory cells, in asthma 220–221 influenza 12, 108–110, 373 influenza A virus 109 influenza B virus 110 influenza C virus 110 influenza vaccine 110 and asthma in pregnancy 36 and theophylline 188 INH. See isoniazid inhalant abuse 94, 111 inhalant allergens 3, 9 inhalant allergies 111 inhalation difficulty with 25 of glue/gas/solvents/fumes 94 of smoke/flames 82 inhalation anthrax 19 inhalation challenges 111 inhalation therapy 111 inhaled medications 111 inhaler 111, 112 Inner City Asthma Camp Initiative 37–38 insect larvae, and peenash 151 insects, ingestion of 151 insect sting anaphylaxis 15–16

inspiration 112 inspirator 112 inspiratory dyspnea 75 inspiratory reserve (supplemental) volume 6, 170, 203 Instep International 112 insufficiency pulmonary valvular 112 respiratory 112 insufflation 112–113 Intal. See cromolyn sodium interferon, in AIDS treatment 6 intermittent positive-pressure breathing 47 intermittent positive-pressure breathing apparatus (IPPB) 113 intermittent positive-pressure ventilation 203 internal respiration 170 International Health Regulations, and reportable diseases 167 interstitial lung disorders (ILD) 113 interstitial pneumonia 198 intestinal tract, in pneumonia 157 intracranial pneumatocele 156 intrauterine pneumonia 158 intrinsic asthma 28, 31 iodinated glycerol 80 iodine-containing preparations 200 Iodur 200 Iotuss 200 ipecac 80 IPPB. See intermittent positivepressure breathing apparatus ipratropium 21, 113 for asthma 31, 32, 363, 364, 369 for exercise-induced asthma 79 for vasomotor rhinitis 202 iron, inhalation of 142 iron lung 113. See also Drinker respirator irrespirable 113 irritants 113, 144 Irritative bronchitis, and infectious bronchitis 49

isoetharine 113, 184 isolation 113 isoniazid 113 and anaphylactoid reactions 15 and para-aminosalicylic acid 148 and pleural effusion 155 for tuberculosis 198, 199 isoproterenol 113, 184 isthmus, pharyngonasalis 113 Isuprel. See isoproterenol

J JAMA Asthma Information Center 375 jimson weed 114 Johns Hopkins Asthma and Allergy Center 107 Johns Hopkins School of Public Health, Pew Environmental Health Commission at 33 Joint Council of Allergy, Asthma and Immunology 375 Journal of Allergy and Clinical Immunology 13 juxtangina 114

K kaolinosis 115 Kaposi’s sarcoma, and AIDS 5 Kartagener’s syndrome 115, 160 Kenacort. See triamcinolone keratinocytes 102 kerosene heaters 211 ketoconazole and arrhythmias 23 for candidiasis 54 for coccidioidomycosis 63 and terfenadine 176 ketotifen 21, 115 Keyden, Ernst V. von 58 khella 12 Kids’ Asthma Check 30 killer T cells 102 kinesiology, for allergies 10 kissing disease 79 Klebs, T. A. Edwin 115 Klebsiella pneumoniae 15, 83, 115

396 The Encyclopedia of Asthma and Respiratory Disorders Klebsiella rhinoscleromatis 172 Klebs-Löeffler bacillus 115 Koch, Robert 115 Koch’s cultures 198 Koch’s Grundversuch 115 Koch’s phenomenon 115 Kolata, Gina 109 Koller, Karl 17 koniology 115 koniometer 115 koniosis 115 Korányi, Friedrich von 115 Korányi’s sign 115 Kronig, Georg 115 Kronig’s area 115 Kussmaul breathing 47

L laboratory technician’s lung 96 Laborde’s method 116 Laënnec’s pearl 116 la grippe 116. See also influenza Lambert, Edward Howard 76 laminar air flow 6 Langerhans cells 102 large-cell undifferentiated carcinoma 121 larvae, and peenash 151 laryngeal edema 76 laryngeal reflex 116 laryngeal vertigo 116 laryngectomy 117 laryngemphraxis 116 laryngismus 116 laryngismus stridulus 116, 163, 181 laryngitis 116 pachyderma 148 laryngoceles 116 laryngoplegia 116 laryngorhinology 117 laryngorrhea 117 laryngospasm 117 laryngotracheobronchitis 117 laryngo-tracheobronchomalacia 29 larynx 117, 169 cancer of 117 incidence of 291–292, 301–302

inflammation of 116 paralysis of 116 spasm of 181 ventricle of 203 vestibule of 203 lasers, in photodynamic therapy 153–154 laughing gas 117, 139 learning disabilities, and theophylline 117 lecithin-sphingomyelin ratio 117 Leeuwenhoek’s disease 117 Legionella pneumophila 118 legionellosis. See Legionnaire’s disease Legionnaire’s disease 6, 118 Leishman, Sir William B. 118 Leishmania 118 leishmaniasis 118 leprosy, tuberculoid 118 leukocyte histamine release assay 118 leukocytes 118–119 leukocytosis 118 leukopenia 23, 118 leukotriene(s) 101, 119, 214 C 179 D 179 D4 119, 214 leukotriene modifiers 366 Leutrol. See Zileutron levofloxacin, for Legionnaire’s disease 118 licorice 119 lidocaine 17, 18 Life Quality Test 30 ligament, pulmonary 119 lights, and sneezing 153, 180 like cures like 92 lingual tonsil 189 lingula, removal of 119 lingulectomy 119 Lipscomb, Mary 217, 221–222 live-virus vaccines 1 lobar pneumonia 119, 158 lobes, of lungs 119 lobules, of lungs 119 local anesthetics 17–18 locations (geographic), for asthma and allergy patients 119–120

Löeffler/Löeffler, Friedrich 115 Löffler’s syndrome 163 loratadine 22, 120 lower-molecular-weight allergens 141–142 lower respiratory tract 169 lozenges 149 LTD4 119, 214 Lucas-Championnière, J. M. M. 120 Lucas-Championnière’s disease 120 Lufyllin. See dyphylline lung(s) 120, 169 absence of 25, 26 air cells of 12 apoplexy of 157 atrophic diseases of 154 collapse of 6, 25, 39, 95, 129, 148 deflation of 156 evaluation of function 170 function of, airway inflammation and 331–332 hemorrhage of 90, 129, 159 inflammation of 129 (See also pneumonia) lobes of 119 lobules of 119 massive collapse of 130 maturity of 117 necrosis/death of 107 puncture of 148 removal of 156 transplantation of 129 lung abscess 120 lung cancer 54, 121–129 age-adjusted death/mortality rates for 122, 124 in African Americans 125 by race, sex, and age 296–297 by race and sex 126, 295–296 by state and race 298–299 by state and sex 297–298 diagnosis of 121 five-year survival rates for 128 hospital discharges for by age 303

Index 397 by race 304 by sex 127 incidence of 224–225, 225–288, 291, 300, 302 lifetime risk of 293, 306 morbidity and mortality trends in 289–306 photodynamic therapy for 153–154 smoking and 293, 305 survival rates for, by race 304–305 treatment of 121–129 types of 292–293 lung disease, prevalence and incidence of, by Lung Association territory 223–288 lunger 129 lung reflex 167 lung sounds, abnormal 69 lung surfactant 129 lungworm 129 lungwort 129 lupus. See systemic lupus erythematosus Luschka’s tonsils 189 Lycoperdon 129 lycoperdonosis 129 lymph 100, 155 lymphatic tissue 2–3 lymph fluid 3 lymph nodes 100 lymphocytes 3, 100–101, 118, 170 lymphoid interstitial pneumonia 82 lymphoid organs 100 lymphomas 121

M macrophages 102, 130 alveolar 170 Madura foot 139 magnetic resonance imaging (MRI), for sinusitis diagnosis 178 ma huang 43, 177 Maimonides, Moses 130 mainstream smoke 179

major histocompatibility complex (MHC) 58 Malayoglyphus 93 malignant neoplasms, of respiratory system, death rates for 123 Mallon, Mary 107–108 malt worker’s lung 96 manikin, in cardiopulmonary resuscitation training 13 Mantoux, Charles 130 Mantoux test 130 maple bark disease 130 maple bark stripper’s lung 96 The MA Report 11 Marezine. See cyclizine marijuana 88. See also cannabis Martin, Richard 217, 218 massage 130 massive collapse of lung 130 mast cells 9, 101, 131, 220 maternal complications, with asthma in pregnancy 35 Maxair. See pirbuterol Maxaquin. See norfloxacin maxillary sinus 178 maximum breathing capacity 131 maximum expiratory flow rate (MEFR) 131 McIntyre, Thomas 217, 219–221 MDIs. See metered-dose inhalers measles cough accompanying 131 mumps, and rubella (MMR) vaccine 17 meclizine 22 mediastinum 170 mediators 16, 101 medical alert bracelets and necklaces 131 medical history, in asthma diagnosis 335, 336–337 medicated vapors 39 medications hypersensitivity to 3 inhaled 111 Medihaler-Epi 131. See also epinephrine Medihaler-Iso. See isoproterenol

Mediquell 72 Medrol 133 medulla oblongata 168 MEFR. See maximum expiratory flow rate melanemia 131 melanosis 131 meliodosis 131 membrane, mucous 131 Ménière’s syndrome 22 meningitis pneumococcal 131–132 tuberculoid 132 meperidine 22 meridians 2 mesobronchitis 132 mesopneumon 132 mesothelioma 27, 132 metal fume fever 132 metallic tinkling 132 metaproterenol 31, 79, 132 metered-dose inhalers (MDIs) 32, 40 corticosteroids in 64 for exercise-induced asthma 79 spacers in 181 methacholine challenge 132 methacycline 187 methoscopolamine nitrate 133 methotrexate 132–133 methylprednisolone 133, 363, 364, 365, 369 methylxanthines 31, 32, 366 mexiletine, and theophylline 188 MHC. See major histocompatibility complex mice allergens 133 microbial pneumonia 159 microlithiasis, pulmonary alveolar 133 Micro-Nefrin. See epinephrine middle lobe syndrome. See atelectasis midge 133 migratory pneumonia 158 Mikity, Victor G. 210 mild asthma, chronic 71 miliary tuberculosis 133

398 The Encyclopedia of Asthma and Respiratory Disorders military service, and asthma 133 milk allergy 31, 89 Miller’s lung 96 minimal air 6 Minocin. See minocycline minocycline 187 minorities, and asthma-related deaths 33 mitral valve prolapse 29–30 MMR vaccine and rubella vaccine, mumps. See measles mobile home syndrome 83 moderate asthma, chronic 71 moist cough 68 moist rales 167 mold allergy to 133–134 control measures for 144 and penicillin 152 molysmophobia 134 mometasone furoate 64, 134 Monge, Carlos 134 Monges disease 134 monitor, apnea 134 monitoring, respiratory 134 monocytes 118 mononucleosis, and Epstein-Barr virus 79 montelukast 177 Morbidity and Mortality Weekly Report 109 morphine, as painkiller, contraindications to 15 Mosely, Pope 221 motion sickness 22 Motrin. See ibuprofen mountain fever. See altitude sickness; bends mountain sickness 181 chronic (See altitude sickness) mouth, vestibule of 203 MRI. See magnetic resonance imaging mucociliary transport escalator 130 mucormycosis. See zygomycosis mucosa 134 mucosal cells 134 mucous membrane 131 mucous plug formation 332

Müller, Johannes P. 134 Müller maneuver 134 multiple systems organ failure 134 mummy handler’s lung 96 mumps, skin tests for 17 murmur bronchial 134 pulmonary 134 muscles, respiratory 170 mushroom worker’s lung 96 mustard plaster 161 Mycobacterium 134 Mycobacterium leprae 118 Mycobacterium pneumoniae 49, 158 Mycobacterium tuberculosis 138, 139, 172, 198, 214 mycoderma 134 mycoplasma, and asthma 218–219 Mycoplasma pneumoniae 49, 135, 159 myoclonus, respiratory. See Leeuwenhoek’s disease myxasthenia 135 myxiosis 135 myxoviruses 149

N N. See neuraminidase NAEPP. See National Asthma Education and Prevalence Program nafcillin 151 nalbuphine, as painkiller, contraindications to 15 nalidixic acid 165 naphazoline hydrochloride 83 NAPS. See National Auxiliary Publication Service narcotics addiction to 2 as painkillers, contraindications to 15 nares 169 Nasacort 136 Nasacort AQ Nasal Spray 136 nasal allergy. See hay fever nasal cannula 55 nasal cavity 136, 169 nasal challenge 136

nasal concha 63 nasal congestion 136 Nasalcrom. See cromolyn sodium nasal douche. See nasal irrigation nasal feeding 136 Nasalide 136. See also flunisolide nasal inhalation challenge 111 nasal irrigation 136 nasal myiasis 151 nasal obstruction 136–137, 160–161 nasal polyps 160–161 nasal provocation tests 136 nasal reflex 137 nasal secretions 137 nasal septum 63, 137 nasal sinuses 169. See also nose nasal smear 137 nasal spray 137 and asthma in pregnancy 37 corticosteroids in 64 and rhinitis medicamentosa 9, 171 nasal strips, for snoring 183 nasal tampon 186 nasal tonsils 189 nasal turbinates 137 nasitis 137 nasopharyngeal airway 137 nasopharyngitis 137 nasoscope 137 nasoseptitis 137 nasosinusitis 137 nasotracheal intubation 138 nasus 138 National Allergy and Asthma Network/Mothers of Asthmatics 375 National Asthma Education and Prevalence Program (NAEPP) 324–345 National Asthma Education Program 29, 31, 38, 71, 375 National Auxiliary Publication Service (NAPS) 2 National Cancer Institute on lung cancer 121 Surveillance, Epidemiology, and End Results program of 224–225, 291

Index 399 National Health Interview Survey (NHIS) 223–225 National Heart, Lung, and Blood Institute 38, 324–345 National Heart and Lung Institute 69 National Institute of Allergy and Infectious Diseases (NIAID) 10, 375 National Institute of Environmental Health Sciences (NIEHS) 221, 376 National Institute of Occupational Safety and Health (NIOSH) 177 National Institutes of Health (NIH) on asthma diagnosis and management 324–345 on asthma in pregnancy 37 asthma panel of 32 National Jewish Center for Immunology and Respiratory Medicine 28 National Jewish Medical and Research Center 376 National Respiratory and Enteric Virus Surveillance System (NREVSS) 109 Nationwide Asthma Screening Program, of American College of Allergies, Asthma and Immunology 30 natural immunity. See active immunity natural way, to control asthma 138 naturopathy 11, 138 near-drowning 74 nebulizer 138 necropneumonia 138 nedocromil sodium 108, 138, 365 Neelsen, Friedrich Karl Adolf 214 negative pressure drainage 74 Nei ching su wen 94 Neirespin. See ephedrine Neisser, Albert 138 Neisseria meningitidis 172 Neisseria sicca 138 nematodes 129

Neo-Synephrine 138, 147. See also phenylephrine hydrochloride Nephron Inhalant. See epinephrine nephrotuberculosis 138 nerves to lungs 120 olfactory 146 neuraminidase (N) 109, 138 neuron beam radiation, for lung cancer 129 neutrophils 118, 119 New Mexico, Asthma Research Center in 217, 221–222 new tuberculin 198 NHIS. See National Health Interview Survey NIAID. See National Institute of Allergy and Infectious Diseases Nicoderm. See nicotine patches Nicorette. See nicotine gum nicotine. See also smoking addiction to 2 and green tobacco sickness 86 nicotine gum 138–139 nicotine patches 139 nicotine poisoning 139 Nicotrol. See nicotine patches NIEHS. See National Institute of Environmental Health Sciences NIH. See National Institutes of Health NIOSH. See National Institute of Occupational Safety and Health Nissen fundoplication 89 nitric acid poisoning 139 nitrogen 139 nitrogen dioxide 139 nitrogen narcosis 139 nitrogen oxide, and silo filler’s disease 177 nitrous oxide 117, 139 nizatidine 91 Nizoral. See ketoconazole N.K.A. 139 Nocard, Edmund I. E. 139 Nocardia 139 Nocardia asteroides 139 nocardiosis 139–140 nocturnal asthma 31, 140

no known allergies 139 nonsedating antihistamines 24 nonself, distinction from self, in immune system 101 non-small cell lung cancer (NSCLC) 121, 128, 292–293 nonsteroidal anti-inflammatory drugs (NSAIDs) 16, 24 Noon, Leonard 83 norfloxacin 165 Noroxin. See norfloxacin nose 140, 169 lack of 26 vestibule of 203 nosebleed 172. See also epistaxis nose drops 74 Nostril. See phenylephrine hydrochloride nostril plug 186 nostril reflex 140 nostrils 169 notifiable disease 140 Novocain. See procaine Novosalmol. See albuterol NREVSS. See National Respiratory and Enteric Virus Surveillance System NSAIDs. See nonsteroidal antiinflammatory drugs NSCLC. See nonsmall cell lung cancer NTZ 147 Nuprin. See ibuprofen Nursing Spectrum 97, 154 nystatin, for candidiasis 54

O O3. See ozone oat cell carcinoma 56. See also small cell lung cancer obesity and Pickwickian syndrome 154 and pimelorthopnea 155 occupational asthma 141–146 causes of 141–142, 144–146 control measures for 143–144 diagnosis of 142–143 evaluation and management of 143

400 The Encyclopedia of Asthma and Respiratory Disorders history of 141 medical-legal issues with 142–143 prevalence of 141 symptoms of 142 Ocean Spray 136 oculoglandular tularemia 199 ODTS. See organic dust toxic syndrome ofloxacin 118, 165 “Of the Catarrhus Aestivus, or Summer Catarrh” 45 old tuberculin 198 oleothorax 146 olfactory nerves 146 olfactory region, of nose 169 oligopnea 146 olopatadine hydrochloride 149 Olson, David H. 38 On Asthma: It’s Pathology and Treatment (Salter) 174 Ondine’s curse 146 oospores 182 Operation Desert Shield/Storm 133 Opinion Research Corporation (ORC) 11 opium, for asthma 174 opportunistic infections, and AIDS 5 Opticrom 146. See also cromolyn sodium oral cavity, cancer of age-adjusted incidence rates for 301 incidence of 291 oral contraceptives, and theophylline 188 oral immunotherapy 107 ORC. See Opinion Research Corporation organ failure, multiple systems 134 organic dust toxic syndrome (ODTS) 146 Organidin 200. See also iodinated glycerol organizations 374–376 oropharyngeal airway 146 oropharynx 169

orthopnea 26, 146 orthopneic position 146 oscitation 213 osmethesia 146 otolaryngologist 147 otorhinolaryngologist 147 overventilation. See hyperventilation oximeter 147 oxitriphylline 147 oxycodone, contraindications to 15 oxygen 147 for anaphylaxis 16 and arterial blood gas tests 26 oxygenation, apneic 25 oxygenator 147, 164 oxygen capacity 147 oxygen content 147 oxygen debt 147 oxygen saturation 175 oxygen supply, fetal, with asthma in pregnancy 35–36 oxygen tent 147 oxygen therapy 147 oxygen toxicity 147 oxymetazoline 147 oxytetracycline 187 ozone (O3) 7, 147

P PA catheter 148 pachyderma laryngitis 148 pachypleuritis 148 pachyrhinic 148 pacl*taxel, for lung cancer 129 PAF acetylhydrolase 220 pain, chest 148 paint refinisher’s disease 96 palatine tonsils 189 Palmer, Daniel David 59 Panmycin 187 pansinusitis 148 panting 148 papaverine hydrochloride 148 paper mill worker’s lung 96 Paper Radioimmunosorbent Test (PRIST) 105

papilloma, Hopmann’s 148 paprika slicer’s lung 96 para-aminobenzoic esters, adverse reactions to 17 para-aminosalicylic acid (PAS) 148 parabens, adverse reactions to 17–18 paracentesis pulmonis 148 paradoxical respiration 148 Paragonimus westermani 90 parainfluenza viruses 148 Paral. See acetaldehyde paraldehyde poisoning 148 Parameters for Medical Policies and Procedures for Children with Asthma 38 paramyxoviruses 149 paranasal sinuses 149 paranasal sinusitis 178 Paraplatin (carboplatin), for lung cancer 129 parapleuritis 149 parent-child transmission 108 paresthesias, and tetracyclines 187 Par-Glycerol 200 paroxysmal cough 68 paroxysmal nocturnal dyspnea 75 parrot fever. See psittacosis PAS. See para-aminosalicylic acid passive expiration 80 passive immunity 103 passive lung collapse 129 passive smoking 179–180 pastille 149 Patanol 149 patient education, in asthma management 346–359 Pavabid. See papaverine hydrochloride PBZ 149. See also tripelennamine PCR test. See polymerase chain reaction test PDT. See photodynamic therapy peak expiratory flow rate (PEFR) 149–151, 337 peak flow 149–151

Index 401 peak flow meters 151 in asthma monitoring 31, 142, 343–345 directions for use of 149–150 uses of 8, 142 Pearl, Laënnec’s. See Laënnec’s pearl pectoriloquy 151 peenash 151 PEEP. See positive end-respiratory pressure PEFR. See peak expiratory flow rate penicillin 151–152 and anaphylaxis 15 for anthrax 19, 20 as hapten 101 for pneumococcal meningitis 132 penicillin G 20, 151 penicillin V 151 penicillin VK 20 Penicillium 151, 152 pentazocine, contraindications to 15 Pen-Ts’ao 176 Pepcid. See famotidine Peppys, Jack 141 Peptostreptococcus 152 perennial allergic rhinitis 152 perennial hay fever 88 perfloxacin, for Legionnaire’s disease 118 perfume 152 perfusion 152, 170 peribronchial smooth muscles 170 peribronchiolitis 152 peribronchitis 152 peripleuritis 152 permissible exposure limits 152 Pertussin 72 pertussis. See whooping cough pertussis vaccine 153 Pew Environmental Health Commission, on asthma prevalence 33 Peyer’s patches 100 Peyrot’s thorax 59 PH. See pulmonary hypertension pH, and arterial blood gas tests 26

PHA. See Pulmonary Hypertension Association phagocytes 99 phagocytic white blood cells 102 pharyngalgia 153 pharyngeal canal 54 pharyngeal tonsils 189 pharyngitis, chronic 153 pharyngonasalis isthmus 113 pharyngorhinitis 153 pharynx 153, 169 cancer of, incidence of 291, 301 Phenergan. See promethazine phenobarbital, and theophylline 188 phenothiazines 24 phenylephrine hydrochloride 138, 153 phenylpropanolamine 153 phenyltoloxamine 153 phenytoin 155, 188 Phlebotomus papatasi 175 phlegm 153 phonasthesia 153 phosgene 84 phosphodiesterase 153 photic sneezing 153 photodynamic therapy (PDT) 129, 153–154 Photofrin. See porfimer sodium phrenic avulsion 154 phrenicectomy 154 phrenic hernia 90 phrenic nerve, removal of 154 phreniconeurectomy 154 phrenospasm 154 phthisis 154 physical activity, and asthma in pregnancy 36 physical defenses, of respiratory system 170 physical examination, in asthma diagnosis 335 physostigmine, for antihistamine overdose 23 Pickwickian syndrome 97, 154 picornavirus 172 pigeon breast 154

pigeon breeder’s disease 154 pigeon breeder’s lung 96 Pilot Project Program 221–222 pimelorthopnea 155 pinkeye, and occupational asthma 142 Pins, Emil 155 Pins’ sign 155 piperazines 24 piperidines 24 pirbuterol 155 for asthma 31 for emergency care 369 for quick relief 363, 364 for exercise-induced asthma 79 Pirquet, Clemens Peter Johann 10, 155, 165 Pirquet’s test 155 pituitary snuff syndrome 96 plague bubonic 52 pneumonic 155 white 155 (See also tuberculosis) plague vaccine 52 plain films, for sinusitis diagnosis 178 plant families, cross-reaction of antigens among 21 plasma cells 20, 102 plastic bronchitis 155 plastic worker’s lung 96 Platinol (cisplatin), for lung cancer 129 platinum salt exposure 141 platypnea 155 pleura 148, 155 pleural cavity 57–58, 156 pleural effusion 58, 77, 155 pleural fibrosis 58, 155 pleural friction rub 83 pleuralgia 58 pleural sinuses 178 pleura pulmonalis 58 pleurisy 120, 155, 373 pleurocentesis 188 pleuroclysis 156 pleurodesis 156

402 The Encyclopedia of Asthma and Respiratory Disorders pleuropneumonia 156 pleuroscopy 156 plombage 156 pneodynamics 156 pneopneic reflex 156 pneumangiography 156 pneumatics 156 pneumatocele 156, 159 pneumatosis 156 pneumatotherapy 156 pneumatothorax 156 pneumatype 156 pneumectomy 156 pneumocentesis 156 pneumococcal meningitis 131–132 pneumococcal pneumonia 158 pneumococcal pneumonitis 159 pneumococcal vaccine 132 pneumococcal vaccine polyvalent 156–157 pneumococcus 157 pneumoconiosis 19, 115, 157, 177 benign 42 coal worker’s 62 Pneumocystis carinii, and AIDS 5 Pneumocystitis carinii pneumonia 158 pneumoderma 157 pneumodynamics 157 pneumoenteritis 157 pneumography 157 pneumohemorrhagica 157 pneumohemothorax 157 pneumohydrothorax 157 pneumolithiasis 157 pneumology 157 pneumolysis 157 pneumomelanosis 157 pneumometer. See spirometer pneumomycosis 157–158 pneumonectasia 158 pneumonectomy 164 pneumonia 158–159 air bronchogram sign in 6 alternative therapies for 373 and asthma 218 hypostatic 97

interstitial 198 lobar 119 pneumonic plague 52, 155 pneumonitis 159 hypersensitivity 6, 95–96 pneumonocele 159 pneumopathy 159 pneumopleuritis 159 pneumopyothorax 159 pneumorrhagia 159 pneumoserothorax 159 pneumosilicosis. See silicosis pneumotaxic center 159 pneumotherapy 159 pneumothorax 159 artificial 27 treatment of 156 pneumotomy 159 pneumotyphus 160 Pneumovax. See pneumococcal vaccine polyvalent pneusis 160 Pnu-Immune. See pneumococcal vaccine polyvalent poisoning brass 46 carbon dioxide 55 carbon monoxide 55–56 carbon tetrachloride 56 chloral hydrate 59 cocaine hydrochloride 63 codeine 63 gasoline 84 hemlock 90 heroin 90 nicotine 139 nitric acid 139 paraldehyde 148 potassium chromate 161 smoke 179 tobacco 186 turpentine 199 Polaramine. See dexchlorpheniramine pollen 4 control measures for 144 pollinosis 88–89, 160. See also allergic rhinitis; hay fever pollutants 160 control measures for 144

pollution, air 7 polyblennia 160 polymerase chain reaction (PCR) test, in tuberculosis diagnosis 199 polymer fume fever 132. See also metal fume fever polymorphonuclear cells 119 polypnea 161 polyps, nasal 160–161 polys 119 polysinusitis 161 pons 25, 159, 168 Pontiac fever 118 Pontocaine. See tetracaine poppers. See inhalant abuse porfimer sodium, in photodynamic therapy 153–154 porta pulmonis 161 Portier, Paul 16 positioning, orthopneic 146 postnasal drip 74, 161 post-tussive suction 184 postural drainage 74, 161 potassium chromate poisoning 161 potassium iodide 161 potassium metabisulfite 184 Pott, Percivall 161 Pott’s disease 161 poultice 161 poverty, and asthma-related deaths 33–34 powdered soapstone, and talcosis 186 PPD test. See purified protein derivative test PPH. See primary pulmonary hypertension prednisolone 363, 364, 365, 369. See also corticosteroids prednisone 161 for allergic bronchopulmonary aspergillosis 27, 51 for asthma for emergency care 369 for long-term control 365 for quick relief 363, 364 for pulmonary fibrosis 82

Index 403 pregnancy antihistamine use during 23 asthma and 35–37, 222 rhinitis and 161–162 premature infants, respiratory distress syndrome of 168 preoxygenation 162 preparation, heart-lung 162 preservatives, adverse reactions to 17–18 preventive medicine 162 primary alveolar hypoventilation 146 primary atypical pneumonia 159 primary pulmonary hypertension (PPH) 162 Primatene Mist. See epinephrine PRIST 105 Privine HCL 83 procainamide, and pleural effusion 155 procaine, adverse reactions to 17 productive cough 68 progesterone, and snoring 183 progressive glomerulonephritis. See Goodpasture’s syndrome Prolert. See Semprex-D promethazine 22 propanolol, and theophylline 188 properdin pathway, in complement system 102–103 propylamines 23–24 prostaglandins 101 prostate cancer, survival rates for, by race 304–305 Pro Step. See nicotine patches proteases, and mast cells 131 proteinosis, pulmonary alveolar 162–163 proteolytic pathway, in complement system 102–103 Proteus morganii, and anaphylactoid reactions 15 proton beam radiation, for lung cancer 129 Proventil. See albuterol Proventil HFA. See albuterol Proventil Repetabs. See albuterol pseudocroup 163

pseudoemphysema 163 pseudoephedrine 163, 198, 202 pseudomembranous bronchitis 120 Pseudomonas mallei 131 Pseudomonas pseudomallei 131 pseudotuberculosis 163 pseudotumor cerebri 67 psittacosis 163 psychogenic halitosis 46 ptarmus 163 puffball 129 Pulmocort. See budesonide pulmometry 163 Pulmonaria officinalis 129 pulmonary alveolar microlithiasis 133 pulmonary alveolar proteinosis 162–163 pulmonary anthrax 211 pulmonary arch 26 pulmonary arterial webs 163 pulmonary arteriovenous fistula 82 pulmonary artery 163 pulmonary artery catheter 57, 148 pulmonary artery wedge pressure 163 pulmonary atresia 39 pulmonary capillary wedge pressure 163 pulmonary circulation 62, 120, 163, 170 pulmonary congestion 64 pulmonary cough 68 pulmonary decortication 71 pulmonary edema 6, 76, 91, 164 pulmonary embolism 76 pulmonary eosinophilia syndrome 163 pulmonary fibrosis 81–82 idiopathic 88, 99 pulmonary function tests 164, 170 in asthma diagnosis 335–336, 339 in asthma monitoring 343 pulmonary hernia 159

pulmonary hypertension (PH) 162 Pulmonary Hypertension Association (PHA) 162 pulmonary infarction 76, 107 pulmonary ligament 119 pulmonary mucociliary clearance 164 pulmonary murmur 134 pulmonary photodynamic therapy 153–154 pulmonary sequestration 176 pulmonary stenosis 182 pulmonary surfactant 184 pulmonary thromboembolism 163 pulmonary transpiration 189 pulmonary valve 164, 202 pulmonary valvular insufficiency 112 pulmonary veins 164, 170 pulmonary ventilation 203 pulmonectomy 164 pulmonitis 164 pulmonology 157 pulmonologist 164 pulmotor 164 pulse respiratory 164 Riegel’s 164 pulsus paradoxus 164 pump, air 164 puna. See altitude sickness purified protein derivative (PPD) test 130, 198 pyohemothorax 164 pyothorax 77, 164 pyrazinamine, for tuberculosis 198 Pyribenzamine. See tripelennamine pyridostigmine, and asthma 133 pyrilamine 164 Pyroglyphus 93 PZA. See pyrazinamine

Q Q fever 165 Q fever vaccine 165

404 The Encyclopedia of Asthma and Respiratory Disorders qi 2 quadrangular membrane 165 quanti-Pirquet 165 quarantine 113, 165 Quibron. See theophylline quinolone antibiotics 165, 188 quotient, respiratory 165

R rabbit fever 199 radiation in AIDS treatment 6 for lung cancer 121, 129 radiation-activated dyes, for lung cancer 129 radioallergosorbent test (RAST) 17, 105 radiocontrast dyes, antihistamines and 22 radiofrequency electrophrenic respiration 166 radioimmunosorbent test (RIST) 105 radiopulmonography 166 ragsorter’s disease. See anthrax ragweed 21, 160, 166–167 ragweed allergoid 10 ragweed extract 166–167 rales 69, 167, 183 Ramazzini, Bernardino 141, 167 ramus, bronchial 167 ranitidine 91 rarefied air, in pneumatotherapy 156 RAST. See radioallergosorbent test rat lung 96 rattle, death. See death rattle reaginic antibodies. See immunoglobulin(s), IgE rebreathing 167 recompression 167 rectal cancer, survival rates for, by race 304–305 red pulp 100 reflex, lung 167 reflex cough 68 rehalation 167 relaxation breathing techniques 47

relaxation techniques 167 reovirus 167 reportable diseases 167 reserpine, and rhinitis medicamentosa 171 reserve air 167 Residency Review Committee for Allergy and Immunology 14 residual air 6, 167 residual volume 167, 170, 203 resistance airway 168 to antibiotics 20 resonance 168 Respbid. See theophylline Respid. See theophylline respiration 47. See also breathing; respiratory system electrophrenic 76 external 170 internal 170 paradoxical 148 radiofrequency electrophrenic 166 vicarious 203 respirator 168 respiratory acidosis 1 respiratory alkalosis 8 respiratory anemometer 168 respiratory arrest 26 respiratory center 168 respiratory depressant 72 respiratory distress syndrome, of premature infants 168 respiratory enteric orphan virus 167 respiratory failure 81 acute 168 chronic 168 respiratory function monitoring 134, 168 respiratory gating 84 respiratory hippus 91 respiratory infection, viral 168 respiratory insufficiency 112 respiratory monitoring 134 respiratory muscles 170 respiratory myoclonus. See Leeuwenhoek’s disease

respiratory pulse 164 respiratory quotient 165 respiratory rate 169 respiratory region, of nose 169 respiratory review of systems 171 respiratory sounds 181 respiratory stimulant 183 respiratory syncytial virus (RSV) 169, 203, 222 respiratory system 169–171 malignant neoplasms of, death rates for 123 respiratory therapist 188 respiratory therapy 171 respiratory therapy technician 186 respiratory tract infection (RTI) 108 respirometer. See respiratory anemometer resuscitation, cardiopulmonary. See cardiopulmonary resuscitation retinoids, for lung cancer 129 retropharyngeal space 181 retropharyngitis 171 Retrovir. See Zidovudine review of systems, respiratory 171 Reye, R. D. K. 171 Reye’s syndrome 171 rheumatoid arthritis 55 rhinalgia 171 rhinitis 171 allergic 8–9, 171 (see also hay fever) perennial 152 seasonal 160 baker’s 41 gustatory 87 pregnancy and 161–162 vasomotor 9, 88–89, 171, 202 rhinitis medicamentosa 9, 137, 138, 153, 171, 202 rhinoanemometer 171 rhinoantritis 172 rhinocleisis 172 Rhinocort. See budesonide Rhinocort Nasal Spray 172 rhinodynia 172 Rhinolar 133

Index 405 rhinolaryngitis 172 rhinolithiasis 172 rhinomycosis 172 rhinopharyngitis 172 rhinopharynx 78 rhinophycomycosis 172 rhinoplasty, for nasal obstruction 137 rhinopneumonitis 172 rhinorrhagia 172 rhinorrhea 172 cold-induced 63, 179 rhinoscleroma 172 rhinoscope 172 rhinoscopy 172 rhinosporidiasis 172 rhinosporidiosis 172 Rhinosporidium seeberi 172 rhinostenosis 172 rhinotracheitis 172 rhinovirus 172 rhoncus 172 Rich, Arnold 88 Richet, Charles 16 Rickettsia 187 Rickettsia burnetti 165 Riegel’s pulse 164 Rifadin. See rifampin rifampin 172 for anthrax 20 for leprosy 118 and theophylline 188 for tuberculosis 198 Rimactane. See rifampin rimantadine, for influenza A infections 110 rima respiratoria 173 RIST 105 RMP. See rifampin Robertshaw valve 71–72 Robitet 187 Robitussin 173. See also guaifenesin Robitussin DM 72 Rocky Mountain spotted fever, tetracyclines for 187 Rondec 55 Rondomycin. See methacycline room, dust-free 173

rose cold 173 rose fever 173 Rotacaps 173 Rotahaler 8, 173 roundworms 129 Royal Brompton Hospital 69 RSV. See respiratory syncytial virus RTI. See respiratory tract infection Rubin, Nancy J. 72 Rufen. See ibuprofen Russia, tuberculosis epidemic in 198–199

S sac, alveolar 174 saccular bronchiectasis 48 Sacks, Susan Bendersky 97 safety, of asthma medications 43–44 salbutamol 113. See also albuterol saline nasal irrigations 136 saline solution 174 Salinex 136 salmeterol 174, 365 Salmonella typhi 108 salpingopharyngeal 174 salt 174 smelling 174 Salter, Henry H. 174 saltwater sprays. See saline solution sambucol, in influenza prevention 110 Samuelsson, Bengt I. 174 sanatarium/sanatorium 174–175 sandfly fever 175 sanitizer 175 sarcoidosis 175 sarcomas 121 saturation, oxygen 175 sauna taker’s lung 96 scaleniotomy 175 scalenus muscles 175 scarlatina anginosa 175 Scherr, Lois 38 Scherr, Merle S. 38 Schick, Bela 73 Schick test 73 Schneider, Conrad Viktor 175

Schneiderian membrane 175 school asthma-friendly 38–39 self-management of asthma in 358–359 School Asthma Education Subcommittee, and asthma-friendly schools 38 SCID. See severe combined immunodeficiency disease SCLC. See small cell lung cancer scleroderma 175 scoliosis, empyemic 175 SCOR grant. See Specialized Center of Research grant screening 175 scrofula 175 scuba. See self-contained underwater breathing apparatus seal, velopharyngeal 175 seasonal allergy 88, 160, 175–176 secondary pneumonia 158, 159 second-generation cephalosporins 58 secretory antibody. See immunoglobulin(s), IgA sedation, antihistamines and 22 SEER program. See Surveillance, Epidemiology, and End Results program segment, bronchopulmonary 176 segs 119 Seldane 81, 176. See also terfenadine self, distinction from nonself, in immune system 101 self-contained underwater breathing apparatus (SCUBA) 176 self-treatment risks 176 Selye, Hans 84 Semprex-D 176 sense of smell, loss of 176 sensibilisinogen 176 sensitivity 176 sensitogens 176 septicemia, bronchopulmonary 176 septotomy 176

406 The Encyclopedia of Asthma and Respiratory Disorders septum, nasal. See nasal septum sequestration, pulmonary 176 sequoiosis 96 Serevent. See salmeterol severe asthma, chronic 71 severe combined immunodeficiency disease (SCID) 103–104 sexual activity, and asthma 176 shallow breathing 47 Shen-Nung 176–177 shiatsu massage 130 shock 177, 201 short of breath 6, 180 sick building syndrome 177 siderosis 42, 177 sidestream smoke 179 SIDS. See sudden infant death syndrome sigh 177, 185 signs, vital 177 silicosiderosis. See siderosis silicosis 177 silicotuberculosis 177 silo filler’s disease 177 Singulair 177 singultation 177 singultus 90 S-2 Inhalant. See epinephrine sinobronchitis 178 sinopulmonary infections, and immunoglobulin A deficiency 178 sinuses 140 accessory nasal 178 nasal 169 paranasal 149 sinus headache 178 sinus infections 178–179 sinus irrigation, for sinusitis 179 sinusitis 178–179 sisal, and byssinosis 53 situs inversus 115 skier’s nose 179 skin tests and anergy 17 for food allergies 17 Skoda, Josef 179 Skoda’s rales 179 Skoda’s resonance 179

sleep apnea 25 Slo-Bid. See theophylline Slo-Phyllin. See theophylline slow-reacting substance of anaphylaxis (SRS-A) 179 slow-releasing substance (SRS) 179 small cell lung cancer (SCLC) 121, 128, 292–293 smallpox handler’s lung 96 smell, sense of, loss of 176 smog 7, 179 smoke environmental control measures for 144 inhalation of 82 smoke poisoning 179 smoker’s cancer. See lung cancer smoking 62 and cancer of larynx 117 and emphysema 61, 77 and lung cancer 121, 293, 305 of marijuana 54–55 nicotine patches for cessation of 139 and occupational asthma 142 passive 179–180 and theophylline 188 sneeze reflex, solar 180 sneezing 163, 180, 182 photic 153 sniffing. See inhalant abuse snoring 172, 183 snoring rale 180 snuff 180 snuffles 180 snuff taker’s lung 96 soapstone, powdered, and talcosis 186 sob 180 S.O.B. 180 sodium chloride 174 solar sneeze reflex 180 sonorous rale 180 soot 180–181 sore throat 181 soroche 181 sounds breath (See respiratory sounds) respiratory 181

space, retropharyngeal 181 spacers 40, 181 Spanish flu 108–109 sparfloxacin, for Legionnaire’s disease 118 spasm, bronchial 181 spasmatic asthma 181 spasmatic croup 181 Specialized Center of Research (SCOR) grant 221–222 speech 181 sphenoid sinus 178 Spinhaler 181 spirit of glyceryl trinitrate 182 spirogram 182 spirometer 47, 182 spirometry in asthma diagnosis 335–336, 339 in asthma monitoring 343 spleen 100, 131–132 splenopneumonia. See Grancher’s disease spontaneous mediastinal emphysema 88 spontaneous pneumothorax 159 spores 41, 182 sputum 153, 182 squamous cell carcinoma 121 squatting, in asthmatic children 182 SRS. See slow-releasing substance SRS-A. See slow-reacting substance of anaphylaxis St. Joseph’s Cough Syrup for Children 174 staircase breaths 182 stannosis 42 staphylitis 182 staphylococcal pneumonia 158 State of the Air: 2000 (American Lung Association) 7 Statistical Abstracts of the United States 33 status asthmaticus 29, 182 steam tent 182 steam vaporizers 94 stenosis, pulmonary 182 stenothorax 182

Index 407 sternutation 182. See also sneezing sternutator 182 steroid nasal sprays. See corticosteroids, in nasal sprays steroids 20, 182–183 stertor 183 stertorous breathing 183 stethoscope 183 stillicidium lacrimarum 183 stillicidium narium 183 Stilp, Richard 45 stimulant, respiratory 183 stomach flu 108 stonecutter’s phthisis 183 stone cutting, and flint disease 82 stoves, wood- and coal-burning 211 stramonium 114, 183 Streptococcus pneumoniae 158, 178, 183 Streptomyces 187 streptomyces hypersensitivity pneumonia 96 streptomycin 52, 148, 198 stress 28, 183 stridor 183 stroke 201 stupor 201 Sturnophagoides 93 subcrepitant 183 suberosis 96 substance abuse 2, 111 suction, post-tussive 184 Sudafed. See pseudoephedrine sudden infant death syndrome (SIDS), apnea monitoring and 25, 134 suffocation 184 sulfadiazine, for nocardiosis 139 sulfating agents 184 sulfites 184 sulfur dioxide gas 184 summer type hypersensitivity pneumonitis 96 Sumycin 187 superantigen 219 supplemental air. See reserve air suppressor T cells 102

surfactant 129 and mycoplasma 219 pulmonary 184 surgery and hereditary angioedema 19 related to allergic and asthmatic persons 184–185 Surveillance, Epidemiology, and End Results (SEER) program 224–225, 291 Sus-Phrine 185. See also epinephrine suspiration 185 suspirious 185 Sveum, Richard J. 38 sweat chloride test 185 swiss cheese, and anaphylactoid reactions 15 Symmetrel. See amantadine sympathomimetic drugs. See agonist symptoms, of allergy 185 Syngamus laryngeus 185 system, respiratory. See respiratory system systemic lupus erythematosus 100

T tabacosis 186 tachypnea 186 tactile fremitus 83 Tagamet, for gastrointestinal reflux 84 talc and occupational asthma 142 and talcosis 186 talcosis 186 talcum, and talcosis 186 tampon, nasal 186 T and A procedure 3 TAO. See troleandomycin Tapia, Garcia 186 Tapia syndrome 186 tartrazine 161 Tavist 186 Taxol (pacl*taxel), for lung cancer 129

Taxotere (docetaxel), for lung cancer 129 TB. See tuberculosis TBTO. See tributyl tin oxide T cells 58, 100, 102, 103 tea grower’s lung 96 technician, respiratory therapy 186 tension pneumothorax 159 tent, oxygen. See oxygen tent terbutaline 186 for asthma for emergency care 369 for quick relief 363, 364 for exercise-induced asthma 79 terfenadine 176, 186 and arrhythmias 23 for exercise-induced asthma 79 sedative effects of 22 and Zileutron 214 terpin hydrate 186 Terramycin. See oxytetracycline Tessalon. See benzonatate tetanus, skin tests for 17 tetracaine 17, 18 tetracyclines 186–187 for anthrax 19 for bronchitis 49 for bubonic plague 52 for Legionnaire’s disease 118 for Mycoplasma pneumoniae infections 135 for Q fever 165 thalidomide, for leprosy 118 thatched roof disease 96 THC 54 theophylline 76, 187–188 for allergies 10 in aminophylline 14 for asthma 31, 32, 71, 366 as bronchodilating drug 50 and cyclic AMP 69 and gastrointestinal reflux 84 and learning disabilities 117 and quinolone antibiotics 165 and Zileutron 214

408 The Encyclopedia of Asthma and Respiratory Disorders Theophylline Oral. See theophylline Theospan-SR. See theophylline Theovent. See theophylline therapeutic pneumothorax 159 therapist, respiratory 188 third-generation cephalosporins 58 Thommen’s five postulates 160 thoracentesis 155, 188 thoracic cage 188 thoracic cavity 188 thoracic duct 75 thoracic empyema 77 thoracic ganglia 84 thoracic outlet compression syndrome 188 thoracic squeeze 188 thoracograph 188 thoracopneumoplasty 188 thoracostenosis 188 thorax 188. See also chest thorax paralyticus 59 threadworms 129 three-pillow orthopnea 146 throat 188–189 sore 181 thrombocytopenia, and antihistamines 23 thromboembolism, pulmonary 163 thrombosis, pulmonary 76 thymus gland, abnormal/missing 103 thyroid cartilage 169 tidal air 6, 189 tidal volume 170, 204 tight building syndrome 177 Tilade. See nedocromil sodium Tilade Inhaler 189 timed vital capacity 203 tobacco 180, 189. See also smoking addiction to 2 and green tobacco sickness 86 poisoning 186 tobacco smoke, environmental control measures for 144 Todd, R. K. 174

toluene diisocyanate 143 tonsillectomy 3 tonsils 100, 189 total IgE 105 total lung capacity 170 toxic-allergic syndrome 189 T-Phyls. See theophylline trachea 169, 189, 211 cancer of age-adjusted death/mortality rates for 122, 124 by race and sex 295–296 by state and race 298–299 by state and sex 297–298 incidence of 291 inflammation of 189 trachealgia 211 tracheal sounds 181 tracheal tickle 211 tracheal tugging 211 tracheitis 189, 211, 373 tracheobronchomegaly 189 tracheocele 189 tracheoesophageal fistula 117 tracheostomy 189, 211 tracheotomy 189 trachitis 189 tract, respiratory. See respiratory system transillumination, for sinusitis diagnosis 178 transmission, of diseases 107–108 transpiration, pulmonary 189 transplantation of bone marrow 103 of lung 129 travel by air, and impaired pulmonary function 7 and allergies 371 and asthma 371 and influenza 110 Treatise on Asthma 130 tree, bronchial. See bronchi tree pollen allergy 190–197 trepopnea 197 triage 197 triamcinolone 40, 64, 136, 197

triamcinolone acetonide 65, 365 tributyl tin oxide (TBTO) 142 trigeminal cough 197 triggers of asthma 28, 197 avoidance of 10 trimethoprim-sulfamethoxazole for anthrax 20 for bronchitis 49 tripelennamine 23, 198 triprolidine 198 troche 198 troleandomycin (TAO), and arrhythmias 23 trovafloxacin, for Legionnaire’s disease 118 tube endobronchial 198 endotracheal (See tracheostomy) tuberculin 39, 198 tuberculin tests 17, 199 tuberculin tine test 198 tuberculofibrosis 198 tuberculoid leprosy 118 tuberculosis (TB) 198–199 alternative therapies for 373 and corticosteroids 68 isoniazid for 15 miliary 133 tuberculosis adenitis 175 tuberculosis spondylitis 161 tuberculous meningitis 132 tuberculous pneumonia 158 tubular sounds 181 tularemia 199 tularemic pneumonia 158 turkey handler’s lung 96 turkey raiser’s disease 199 turpentine poisoning 199 tussiculation 199 Tussi-Organdin 200 tussis 200 tussis convulsiva 200 tussis stomachalis 200 tussive syncope 116 twilight sleep 201 two-pillow orthopnea 26, 146 tylophora asthmatica 200

Index 409 typhoidal tularemia 199 typhoid fever 107–108 respiratory symptoms in 200 Typhoid Mary 107–108

U ulceroglandular tularemia 199 ultrasonic humidifiers 94 ultrasound, for sinusitis diagnosis 178 unconsciousness 201 Undine 146 Uniphyl. See theophylline United States trees that cause hay fever in 190–197 weeds that cause hay fever in 205–210 U.S. Department of Defense, Anthrax Vaccine Immunization Program of 211 U.S. Department of Education 376 U.S. Environmental Protection Agency (EPA) 7, 180–181, 376 unproductive cough 68 upper airway obstruction 201 upper respiratory infection 201 upper respiratory tract 169 urea formaldehyde foam insulation 83 urticaria (hives), antihistamines for 22 Utah, Asthma Research Center in 217, 219–221 uterine cough 68 uvulopalatopharyngoplasty 201

V vaccinations 1–2, 11–12 vaccine 202 vacuum cleaners, for allergic patients 202 vagus nerve, auricular branch of 26 Valium. See diazepam valley fever. See coccidiodomycosis valve, pulmonary 202 valvular pneumothorax 159

Vancenase. See beclomethasone Vancenase AQ. See beclomethasone Vanceril. See beclomethasone Vanceril inhaler. See beclomethasone vancomycin, for anthrax 20 Vanderpool, Gerald 94 Vane, John 174 van Leeuwenhoek, Anton 117 Vaponefrin. See epinephrine vapor, in steam tent 182 vaporizer 94. See also humidifier vapors, medicated 39 varicella pneumonia 158 varicose bronchiectasis 48 vasculitis, in Wegener’s syndrome 86 Vasocon 83 vasoconstrictor 202 vasodilator 202 vasomotor rhinitis 9, 88–89, 171, 202 Vedanthan, P. K. 213 velopharyngeal seal 175 vent, alveolar 202 ventilation 170, 202–203 ventilation coefficient 203 ventilation rate 203 ventilator 168, 203 Ventodisk. See albuterol Ventolin. See albuterol Ventolin Rotacaps. See albuterol ventricle of larynx 203 Venturi, Giovanni Battista 203 Venturi mask 203 vertebrae, in Pott’s disease 161 vertigo 22 laryngeal 116 vesicular sounds 181 vestibule, of nose, mouth, and larynx 169, 203 Vibramycin. See doxycycline vicarious respiration 203 viral respiratory infection 168 viruses 203 Vistaril. See hydroxyzine Vistaril Parenteral. See hydroxyzine

vital capacity 55, 203 vital signs 177, 203 vitamin C. See ascorbic acid vocal cord dysfunction 339 vocal cords 60, 203. See also larynx vocal fremitus 83 voice box. See larynx Vollmax 203 Volmax. See albuterol volume expiratory reserve 203 inspiratory reserve 203 residual 203 tidal 204 vomer 204

W warfarin, and Zileutron 214 war gases 205 wasp waist 188 water-filtering devices, for vacuum cleaners 202 water vapor, in steam tent 182 watery eyes 183 weed pollen allergy 205–210 Wegener, F. 85 Wegener’s granulomatosis 85–86 Weisberg, Stephen C. 38 wheat, and baker’s asthma 41 wheat weevil’s disease 96 wheeze 7–8, 210, 338 whiff 210 white blood cell differential count 119 white blood cells. See leukocytes white plague 155. See also tuberculosis white pulp 100 Whitman, Christie 180 WHO. See World Health Organization whooping cough 68, 200, 210 Wilson, Miriam G. 210 Wilson-Mikity syndrome 210–211 windpipe 211. See also trachea withdrawal symptoms, in addiction 2

410 The Encyclopedia of Asthma and Respiratory Disorders wood-burning stoves 211 wood joiner’s lung 96 wood pulp worker’s lung 96 wood trimmer’s disease 96 woolsorter’s disease 211 work-aggravated asthma. See occupational asthma work-related allergy, and sick building syndrome 177 World Health Organization (WHO) on bioterrorism 45 Immunology Unit of 105 and reportable diseases 167 Wright’s Peak Flow Meter 142

X xanthine bronchodilators, for allergies 10 xanthine derivatives, as bronchodilating drug 50

xeromycteria 212 X-linked agammaglobulinemia 20 X ray of blood vessels in lungs 156 chest 199, 212 for sinusitis diagnosis 178 for tuberculosis diagnosis 199 X-ray dyes, antihistamines and 22 Xylocaine. See lidocaine

Y yawn 213 yeast, in pneumomycosis 157–158 Yellow Emperor 94 Yersinia pestis 52 Yersinia pseudotuberculosis 163 yoga 47, 213 You Can Have A Life Without Allergies 12

Young’s syndrome, and nasal polyps 160

Z Zaditor Ophthalmic Solution. See ketotifen Zafirlukast 1, 119, 214, 366 Zantac 84. See also ranitidine zidovudine, in AIDS treatment 5 Ziehl, Franz 214 Ziehl-Neelsen method 214 Zileuton 214, 366 Zileutron 119, 214 zinc, and brass poisoning 46 zinc oxide, and brass poisoning 46 Zithromax 214 Zyflo. See Zileuton zygomycosis 214 Zyrtec 214

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