A CLINICAL STUDY OF BRONCHIAL ASTHMAIN CHILDREN AND ITS HOMOEOPATHICTHERAPEUTIC STRATEGIES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA, BANGALORE DECLARATION BY THE CANDIDATE I hereby declare that this dissertation entitled “A CLINICAL STUDY OF BRONCHIAL ASTHMA IN CHI

A CLINICAL STUDY OF BRONCHIAL ASTHMA

IN CHILDREN AND ITS HOMOEOPATHIC

THERAPEUTIC STRATEGIES

by

DR BINYMOL ANEY KURIAN

Dissertation Submitted to Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

Under the Guidance of

DR SHASHI KANT TIWARI

Department of Homoeopathic Pediatrics

Father Muller Homoeopathic Medical College

Deralakatte, Mangalore

2010

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A CLINICAL STUDY

OF BRONCHIAL ASTHMA IN CHILDREN AND ITS HOMOEOPATHIC THERAPEUTIC STRATEGIES” is a bonafide and genuine research work carried out by me under the guidance of DR SHASHI KANT TIWARI

Professor, during the year 2007–2010, in partial fulfillment of requirement

for the award of DOCTOR OF MEDICINE (HOMOEOPATHIC PEDIATRICS)

I have not previously submitted this work (partial or full) to anyother university for the award of any other Degree or Diploma

Date:

Place: Mangalore DR BINYMOL ANEY KURIAN

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A CLINICAL STUDY

OF BRONCHIAL ASTHMA IN CHILDREN AND ITS HOMOEOPATHIC THERAPEUTIC STRATEGIES” is a bonafide research work done by

DR BINYMOL ANEY KURIAN under my guidance and supervision

during the year 2007 – 2010, in partial fulfillment of the requirement for

the award of the degree of “ DOCTOR OF MEDICINE” (HOMOEOPATHIC PEDIATRICS)

I have satisfied myself regarding the authenticity of herobservations noted in this dissertation and it conforms to the standards ofRajiv Gandhi University of Health Sciences, Karnataka, Bangalore It hasnot been submitted (partial or full) for the award of any other Degree orDiploma

Place: Mangalore DR SHASHI KANT TIWARI

D.M S., Dip (N.I.H ), MD (HOM)

Professor,

Fr Muller Homoeopathic Medical

College and Hospital, Deralakatte, Mangalore

ENDORSEMENT BY THE HOD, PRINCIPAL/

HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “A CLINICAL STUDY OF BRONCHIAL ASTHMA IN CHILDREN AND ITS HOMOEOPATHIC THERAPEUTIC STRATEGIES” is a bonafide research work carried out by

DR BINYMOL ANEY KURIAN under the guidance and supervision of DR SHASHI KANT TIWARI during the year 2007 – 2010, in partial fulfillment of the requirement for the award of the degree of “DOCTOR OF MEDICINE” (HOMOEOPATHIC PEDIATRICS)

We have satisfied regarding the authenticity of her observations noted in thisdissertation and it conforms the standards of Rajiv Gandhi University of Health Sciences,Karnataka, Bangalore It has not been submitted (partial or full) for the award of anyother Degree or Diploma

Head of the Department Principal

DR JYOSHNA S DR SRINATH RAO

B.H.M.S M.D (HOM) B.H.M.S M.D (HOM)

Professor, Professor and H.O.D

Dept of Homoeopathic Pediatrics Department of Materia Medica

Fr Muller Homoeopathic Medical Fr Muller Homoeopathic College, Deralakatte, Medical College, Mangalore Deralakatte, Mangalore

Place: Mangalore Place: Mangalore

Date: Date:

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore shall have the rights to preserve, use

and disseminate this dissertation / thesis in print or electronic format foracademic / research purpose

Date:

Place: Mangalore DR BINYMOL ANEY KURIAN

© Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

“My help comes from the LORD, who made heaven and earth” Psalm 121:2

I consider this as my privilege to thank the Almighty God, for

helping me to achieve this humble task through the following persons who have been of immense help and a source of encouragement in my endeavor.

I would like to express my sincere and heartfelt thanks to my

respected teacher and guide, Dr Shashi Kant Tiwari , D.M.S., Dip N.I.H.,

M.D(Hom), for providing me expert guidance, constructive criticism, timely support and encouragement throughout my post graduation course and during this dissertation work It is my good fortune to be his student and to do this work under his guidance.

It is my privilege to express sincere gratitude to Rev Fr Baptist Menezes, Former Director, FMCI, Rev Fr Patrick Rodrigues, Director, FMCI, Rev Fr Stany

Tauro, Former Administrator, FMHMC&H and Rev Fr Wilfred Prakash D’souza,

Administrator of FMHMC, Deralakatte, Mangalore for providing me an opportunity and adequate facilities to carry out this work to my satisfaction in this reputed institution.

I would like to express my gratitude to Dr Srinath Rao, Principal,

Head of the Department of Homoeopathic Materia Medica for the support during the study.

I express my sincere thanks to Dr Shivaprasad, Vice-Principal,

Head of the Department of Organon of Medicine and Homoeopathic Philosophy, and P.G Coordinator, for his support and guidance.

My sincere thanks to, Dr Sunny Mathew, Medical Superintendent

for his help and support especially at the OPD set up and dispensing section.

It is my esteemed privilege to express my gratitude to Dr Jyoshna

Shivaprasad, Professor, and Head of the Dept Pediatric for the care and

concern, valuable suggestions, timely support & encouragement throughout my post graduation course and during this dissertation work

I am grateful to Dr M.K Kamath, Dr.N.C Dhole , Dr Praveen,

Dr Guruprasad, Dr Pravas Kumar Pal, Dr Roshan Pinto, Dr Girish Navada, & Dr Kurian for their timely guidance.

I extend my gratitude to all my friends, colleagues, seniors, and juniors whose cooperation and timely help considerably eased my task

A word of gratitude to Mrs Sucharita Suresh for helping to

formulate the Research Methodologies for my synopsis and helping to carry out the statistical work of my thesis.

I would like to convey my thanks to the help, kindness and

cooperation that I have received from the staff of various departments of

FMHMC & also to the Pediatric Department of FMMC.

I thank all members of Non-teaching staff of FMHMC for their help

during the study.

I am most grateful to my own community MEDICAL SISTERS OF

ST JOSEPH has been a great source of encouragement through out these

years I thank my present & former Superior Generals, Provincial

Superiors & all my loving sisters who nurtured, loved and faithfully

supported me over the years

I would have never accomplished my goal without the support,

encouragement and prayers of my parents, brothers & sisters

Last but not the least; I owe my deep indebtedness, to all the lovely children, involved in this study for their co operation, and to their parents who showed their confidence in Homoeopathic treatment and also to

Microbits, Kankanady for making pains to complete this work in time

Dr Binymol Aney Kurian (SR Vidya M.S.J.)

“Honor physicians for their services, for the LORD created them; for their gift

of healing comes from the most high, and they are rewarded by the king The skill of physicians makes them distinguished, and in

the presence of the great they are admired.”

(Sirach 38/1-3)

LIST OF ABBREVIATIONS USED

B & B : Bladder and Bowel

CBC : Complete Blood Count

F/H : Family history

FVC : Forced Vital Capacity

FEV1 : Forced Expiratory Volume in one second FEF : Forced Expiratory Flow

LES : Lower Esophageal Sphincter

LSMC : Location, Sensation, Modality, Concomitant

M : Male

M : Mother

Mon : Month

Ms : Miss

NAD : No Abnormality Detected

N : Normal

No : Number

NK cells : Natural Killer Cells

NSAIDS : Non-steroidal anti-inflammatory drugs

Reg No : Register Number

RADAR : Rapid Aid to Drug Aimed ResearchRAST : Radio Allergo Sorbent Test

S No : Serial Number

TPB : Therapeutic Pocket Book

Objectives

1 To study the clinical manifestations and pathophysiology of Bronchial Asthma inchildren

2 To determine the causative factors of the environment in Pediatric BronchialAsthma.

3 Evaluate the different strategies of Homoeopathic treatment in case of PediatricBronchial Asthma

Methods

The data was collected by purposive sampling technique as per the inclusioncriteria and processed in a standardized case record Diagnosis of asthma was mainlybased on the history and physical examination.Thesignificance of treatment effect based

on different homoeopathic therapeutic strategies is tested by using Chi- square test(Fishers exact test).For the assessment of the clinical status before and after treatment thedisease score was used which is mentioned in annexure: 1 and‘t’ test is used for thestatistical analysis

Results:

Out of 30 patients studied, Arsenicum Album was the most useful remedy duringacute attack of asthma The improvement status is not significantly associated (notdependent) with strategies /methodologies used

Interpretation & Conclusion:

Homoeopathic remedies are very effective in treating Bronchial asthma inpediatric age group

Keywords:

Bronchial Asthma in children; Homoeopathic Therapeutic Strategies

7 Case distribution according to duration of illness 107

8 Case distribution according to F/H of Asthma/Allergy in

the study group

107

9 Case distribution according to F/H of Asthma/Allergy

and effectiveness of treatment

109

10 Case distribution according to anti - miasmatic remedies 109

12 Case distribution according to miasmatic expression 111

13 Case distribution according to line of management 113

14 Case distribution according to acute remedies and their

Effectiveness

113

15 Case distribution according to constitutional remedies

and their Effectiveness

115

16 Case distribution according to precipitating factors 116

17 Statistical analysis of different strategies/ methodologies

and their effectiveness

117

18 Statistical analysis of the effectiveness of treatment

before and after

NO.

3 Asthma Modified Predictive Index for Children 13

7 Factors that correlate with childhood Asthma persistence 23

11 Mechanisms of Early & Late phase of IgE Mediated

Bronchospasm

30

15 Diagrammatic Representation of Case distribution according

to age

106

16 Diagrammatic Representation of Case distribution according

to age and sex

106

17 Diagrammatic Representation of Case distribution according

to duration of illness

108

18 Diagrammatic Representation of Case distribution according

to F/H of Asthma/Allergy in the study group

108

19 Diagrammatic Representation of Case distribution according

to anti - miasmatic remedies

23 Diagrammatic Representation of Case distribution according

to acute remedies and their Effectiveness

114

24 Diagrammatic Representation of Case distribution according

to constitutional remedies and there effectiveness

114

25 Diagrammatic Representation of Case distribution according

to the different methodologies/strategies

Introduction

Respiratory disorders are amongst the most common diseases one encounters inclinical practice especially in children Changed life style, food habits which include a lot

of preservatives, artificial colors, increasing pollution, and compact living have allcontributed to an increase in the rate of upper as well as lower respiratory tract problemsespecially to bronchial asthma Modernization and the industrialization have contributed

to an increasing occurrence of the bronchial asthma amongst children Bronchial asthma

is a daily burden disease and it results in many inconveniences and emotionaldisturbances in the whole family It is a major health problem showing steady increase inprevalence both in developing and developed countries

Childhood bronchial asthma is important not only because it is the most commonchronic childhood disease, but also because it causes episodes of disturbed sleep,restriction of activities and school absenteeism, thus leading to a multilevel physical,

mental, social, economic, and psychological effect Here comes the importance ofHomoeopathic Therapeutic Strategies through which a Homoeopathic physician aims atcure, which shall be rapid, gentle, and permanent restoration of the health, or removal andannihilation of the disease in its whole extent, in the shortest, most harmless way, oneasily comprehensible principle

A Therapeutic Strategy can be defined as a plan of action, a methodology within aphilosophical conceptualization and structure, based on clear principles to guide decisionand action A clear therapeutic strategy is the backbone to homeopathic practice InHomeopathy symptoms are observed as a picture of disease that can be formulated into aTotality of symptoms, based on the presentation of characteristic symptoms Thispresentation of symptoms is unique to every case The perception of the totality soformed forms the basic building block indicating an appropriate remedy, plan of actionand long term management Thus it forms the Therapeutic Strategy, the construction ofappropriate homeopathic methodology is a general yet replicable action plan for casemanagement and cure A reliable therapeutic strategy is a methodology providing a clearstructure and direction for case analysis and management of a patient at every stage ofdisease The stalwarts like Boenninghausen, Boger, and Kent have established systems oftherapeutic strategies developed on clear homeopathic principles of understanding healthand disease

It has been observed that when children are treated with homoeopathy, the postinfection lethargy, anorexia are very negligible & the child enjoys good health, becomesactive and playful much faster Contrary to the common belief, Homeopathic medicines

do not affect digestion; do not lower resistance power; do not cause allergies and do not

harm, even if it is taken for long-term Homeopathic treatment being based on the

‘Constitutional Approach’ treats the disease at the root level, hence enhancing theresistance power of the child, who habitually has recurring infections due to a loweredresistance power, therefore preventing them from frequent illnesses Homeopathy is alsoconsidered child friendly

This humble work is to highlight the effect of Homoeopathic medicines inreducing the hypersensitivity of the respiratory tract leading to bronchial asthma and also

to show the effectiveness in changing the susceptibility by use of Homoeopathicmedicines By proper Homoeopathic Therapeutic Management Strategies, the frequencyand intensity of these attacks can be greatly reduced and minimize the use ofbronchodilators & steroids Thus the quality of life is improved to a great extent Theacute episodes of mild and moderate severity can be managed effectively with thesemedicines

“Failure comes only when we forget our ideals and objectives and principles.”

Jawaharlal Nehru.

Objectives

Review of Literature

REVIEW OF LITERATURE

THE RESPIRATORY SYSTEM - DEVELOPMENT

The respiratory system develops from a median diverticulum of the foregut Itslining epithelium is, therefore, of endodermal origin The connective tissue, cartilage, andmuscle, in relation to the organs of respiration, are derived from splanchnopleuricmesoderm The larynx develops from the cranial- most part of the respiratorydiverticulum The trachea develops from the part of the respiratory diverticulum, whichlies between the point of its bifurcation and the larynx The two primary divisions of therespiratory diverticulum form the right and left principal bronchi It soon subdivided in tolobar bronchi The substance of the lungs is formed by further subdivisions of the lobarbronchi.1

A respiratory system´s function is to allow gas exchange The space between the

alveoli and the capillaries, the anatomy or structure of the exchange system, and theprecise physiological uses of the exchanged gases vary depending on the organism In

humans and other mammals, for example, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles Molecules of oxygen and

carbon dioxide are passively exchanged, by diffusion, between the gaseous externalenvironment and the blood This exchange process occurs in the alveolar region of thelungs

ANATOMY OF RESPIRATORY SYSTEM

The respiratory system can be subdivided into an upper respiratory

Figure No: 1 Anatomy of Respiratory System

respiratory tract includes the nasal passages, and the larynx, while the lower respiratorytract is comprised of the trachea, the primary bronchi and lungs.2 The Bronchi or Tubes

are the two main tubes into the lung that divide from the trachea The bronchi subdivideinto the lobar bronchi three on the right side and two on the left These, in turn,

subdivide further The Bronchioles are the smallest subdivisions of the bronchi, at the ends of which are the alveoli (plural of alveolus) The Alveoli are the very small air sacs that are the destination of inhaled air The capillaries are blood vessels that are imbedded

in the walls of the alveoli The blood discharges carbon dioxide into the alveoli and takes

up oxygen from the air in the alveoli.3

• Blood supply: the bronchi and parenchymal tissue of the lungs are supplied by

bronchial arteries a branches of the descending thoracic aorta Bronchial veins, which

also communicate with pulmonary veins, drain into the azygos and hemiazygos Thealveoli receive deoxygenated blood from terminal branches of the pulmonary artery andoxygenated blood returns via tributaries of the pulmonary veins Two pulmonary veinsreturn blood from each lung to the left atrium

• Lymphatic drainage of the lungs: lymph returns from the periphery towards the hilar

tracheobronchial groups of nodes and from here to mediastinal lymph trunks

• Nerve supply of the lungs: a pulmonary plexus is located at the root of each lung The

plexus is composed of sympathetic fibres (from the sympathetic trunk) andparasympathetic fibres (from the vagus) Efferent fibres from the plexus supply thebronchial musculature and afferents are received from the mucous membranes ofbronchioles and from the alveoli.4

The respiratory system can also be divided into physiological, or functional,zones These include the conducting zone (the region for gas transport from the outsideatmosphere to just above the alveoli), the transitional zone, and the respiratory zone (thealveolar region where gas exchange occurs).2

Figure No: 2 Physiology of Respiratory System PHYSIOLOGY OF RESPIRATORY SYSTEM

Ventilation: Ventilation of the lungs is carried out by the muscles of respiration Control: Ventilation occurs under the control of the autonomic nervous system from

parts of the brain stem, the medulla oblongata and the pons This area of the brain forms

the respiration regulatory center, a series of interconnected brain cells within the lowerand middle brain stem which coordinate respiratory movements The sections are thepneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups.This section is especially sensitive during infancy, and the neurons can be destroyed if theinfant is dropped and/or shaken violently The result can be death due to "shaken baby

syndrome."

Inhalation: Inhalation is initiated by the diaphragm and supported by the external

intercostal muscles Normal resting respirations are 10 to 18 breaths per minute,with a time period of 2 seconds During vigorous inhalation (at rates exceeding

35 breaths per minute), or in approaching respiratory failure, accessory muscles

of respiration are recruited for support These consist of sternocleidomastoid,platysma, and the scalene muscles of the neck

Under normal conditions, the diaphragm is the primary driver of inhalation Whenthe diaphragm contracts, the ribcage expands and the contents of the abdomen are moveddownward This results in a larger thoracic volume and negative (suction) pressure (withrespect to atmospheric pressure) inside the thorax As the pressure in the chest falls, airmoves into the conducting zone Here, the air is filtered, warmed, and humidified as itflows to the lungs During forced inhalation, as when taking a deep breath, the externalintercostal muscles and accessory muscles aid in further expanding the thoracic cavity

Exhalation: Exhalation is generally a passive process; however, active or forced

exhalation is achieved by the abdominal and the internal intercostal muscles During thisprocess air is forced or exhaled out The lungs have a natural elasticity: as they recoilfrom the stretch of inhalation, air flows back out until the pressures in the chest and the

atmosphere reach equilibrium During forced exhalation, as when blowing out a candle,expiratory muscles including the abdominal muscles and internal intercostal musclesgenerate abdominal and thoracic pressure, which forces air out of the lungs.

Circulation: The right side of the heart pumps blood from the right ventricle through the

pulmonary semilunar valve into the pulmonary trunk The trunk branches into right andleft pulmonary arteries to the pulmonary blood vessels The vessels generally accompanythe airways and also undergo numerous branching Once the gas exchange process iscomplete in the pulmonary capillaries, blood is returned to the left side of the heartthrough four pulmonary veins, two from each side The pulmonary circulation has a verylow resistance, due to the short distance within the lungs, compared to the systemiccirculation, and for this reason, all the pressures within the pulmonary blood vessels arenormally low as compared to the pressure of the systemic circulation loop

Gas exchange: The major function of the respiratory system is gas exchange between the

external environment and an organism's circulatory system In humans and mammals,this exchange facilitates oxygenation of the blood with a concomitant removal of carbondioxide and other gaseous metabolic wastes from the circulation As gas exchange occurs,the acid-base balance of the body is maintained as part of homeostasis If properventilation is not maintained, two opposing conditions could occur: 1) respiratoryacidosis, a life threatening condition, and 2) respiratory alkalosis Upon inhalation, gasexchange occurs at the alveoli, the tiny sacs which are the basic functional component ofthe lungs The alveolar walls are extremely thin (approximately 0.2 mm) These walls arecomposed of a single layer of epithelial cells (type I and type II epithelial cells) in closeproximity to the pulmonary capillaries which are composed of a single layer of

endothelial cells The close proximity of these two cell types allows permeability to gasesand, hence, gas exchange

NON-RESPIRATORYFUNCTIONS

Vocalization: The movement of gas through the larynx, pharynx and mouth allows

humans to speak, or phonate The vibration of air flowing across the larynx (vocalchords), results sound Because of this, gas movement is extremely vital forcommunicationpurposes

Temperature control: It has less significance in humans because we can lose excess heat

through the skin in a regulated fashion by bringing heat to the surface with boosted bloodflow, and by the evaporation of secreted sweat

Coughing and sneezing: Irritation of nerves within the nasal passages or airways can

induce coughing and sneezing These responses cause air to be expelled forcefully fromthe trachea or nose, respectively In this manner, irritants caught in the mucus which linesthe respiratory tract are expelled or moved to the mouth where they can be swallowed.2

BRONCHIAL ASTHMA

The word asthma is a Greek one meaning “breathless” or “to breath with openmouth” Originally applied to shortness of breath of any cause, as in the description of themode of death of metal miners (“ from the disease the Greek call asthma”) by Agricola in

1556, it has come to be applied particularly to episodic breathlessness due to bronchialdisease Sir John Floyer in his ‘Treatise of the Asthma’ used the term in its general sensebut confined himself largely to discussing the episodic type from which he himselfsuffered.1

Asthma is a chronic inflammatory disorder of the airways mediated through manycells and cellular elements, particularly, mast cells, eosinophils, T lymphocytes,macrophages, neutrophils, and epithelial cells; along with an associated increase in thetracheal and bronchial hyper-responsiveness to a variety of stimuli; all this clinicallymanifested as recurrent episodes of wheezing, breathlessness, chest tightness, andcoughing, particularly at night or in the early morning usually associated with widespreadbut variable airflow obstruction that is often reversible either spontaneously or withtreatment.6

The clinical hallmark of asthma is wheezing, a musical, high pitched, largelyexpiratory sound made through the partially obstructed larger airways Cough also ischaracteristic of asthma and may be predominant symptom However, asthma may occurwithout discernible wheezing In the absence of recurrent episodes of overt wheezing, thediagnosis may be missed; frequently, children are considered to have recurrentpneumonia, chronic bronchitis, or recurrent colds with chest congestion.7

Typical symptoms associated with asthma include breathlessness, wheezing, chesttightness and cough But because the airway narrowing in people with asthma isreversible, many people with asthma only occasionally experience symptoms Once anepisode of airway narrowing resolves (either on its own or with treatment) the airflowinto and out of the lungs returns to normal, and symptoms improve.8

EPIDEMIOLOGY

Asthma is a common chronic disease, causing considerable morbidity Based oninformation collected by the National Center for Health Statistics of the centers for

(16% vs 10% not poor) are likely to have asthma.9 The studies proved that, asthmamorbidity and mortality is linked with ethnic minority and low-income status whereasasthma prevalence is primarily associated with urban living.

Worldwide, childhood asthma appears to be increasing in prevalence, despiteconsiderable improvements in our management and pharmacopeia to treat asthma.Childhood asthma seems particularly common in modern metropolitan locales and isstrongly linked with other allergic conditions In contrast, children living in rural areas ofdeveloping countries (e.g., rural Africa, China, India) and farming communities (e.g., inGermany, Austria, Switzerland, Finland, Quebec) are less likely to have asthma andallergy This striking variation in childhood asthma prevalence has led to investigations ofpotential environmental and lifestyle factors that may explain these differences as well asthe recent rise in asthma.10 In India, the prevalence of asthma in school-going children isreported to be 4 – 20% Thus every 5th to 25th Indian child suffers from asthma There is adefinitive increase in asthma prevalence to the tune of two – fold in the last two decades.6

AGE OF ONSET

Although asthma may occur at any age, it usually has its onset in the first 5 years of age More than 50% of children with asthma have the

onset of symptoms during the first 2 years of life, and at least 25% of this group experiences the onset of symptoms during the first year of life.11

Approximately 80% of all asthmatics report disease onset prior to 6yr of age Early childhood risk factors for persistent asthma have been identified.9

Figure No:3 Asthma Modified Predictive Index for Children

One major criterion or two minor criteria provide a high specificity and positivepredictive value (77%) for persistent asthma into later childhood.9

ETIOLOGY

Asthma is one of the first recognized diseases dating back to the time ofHippocrates There is more than 5% of population in industrialized countries affected bythe disease, but many go undiagnosed and untreated.12 Although the cause of childhoodasthma has not been pinpointed, contemporary research implicates interplay betweengenetic and environmental factors The strong association of common childhood asthmawith concomitant allergies suggests that environmental factors influence immunedevelopment toward the asthmatic phenotype in susceptible individuals

Genetics: Twin studies have revealed a 0.74 concordance of asthma between

monozygotic twins and a 0.35 concordance between dizygotic twins, implicating a

Food allergen sensitization Parent asthma

Minor criteria

genetic contribution to asthma development More than 22 loci on 15 autosomalchromosomes have been linked to asthma Although the genetic linkages to asthma havesometimes differed between cohorts, asthma has been consistently linked with locicontaining proallergic, proinflammatory genes (e.g., the IL-4 gene cluster onchromosome 5)

Environment: Environmental tobacco smoke, especially maternal cigarette smoking,endotoxin, and air pollutants (e.g., ozone, sulfur dioxide) aggravate airways inflammationand increase asthma severity Cold dry air and strong odors can triggerbronchoconstriction when airways are irritated but do not worsen airways inflammation

or hyper responsiveness.10

The hygiene hypothesis is a hypothesis about the cause of asthma and other

allergic disease, and is supported by epidemiologic data for asthma For example, asthmaprevalence has been increasing in developed countries along with increased use ofantibiotics, caesarean sections, and cleaning products All of these things may negativelyaffect exposure to beneficial bacteria and other immune system modulators that areimportant during development, and thus may cause increased risk for asthma and allergy.Antibiotic use early in life has been linked to development of asthma in several examples;

it is thought that antibiotics make one susceptible to development of asthma because theymodify gut flora, and thus the immune system

Caesarean sections have been associated with asthma when compared withvaginal birth; a meta-analysis found a 20% increase in asthma prevalence in childrendelivered by Cesarean section compared to those who were not It was proposed that this

is due to modified bacterial exposure during Cesarean section compared with vaginalbirth, which modifies the immune system

Poor air quality, from traffic pollution or high ozone levels, has been repeatedlyassociated with increased asthma morbidity Psychological stress, (leads to smoking) onthe part of a child's caregiver, has been associated with asthma.13

Figure No:4 Persistent Wheezing and Asthma ASTHMA TRIGGERS

Viral respiratory tract infections may be the predominant infection or

apparently exclusive precipitant of asthma, particularly in early life, or the child mayhave overt symptoms only in relation to exposure to certain animals or with strenuousexercise Various precipitating or aggravating factors may differ with age in children, andmay continue into adulthood.7Sensitization can to some extent be prevented by breastfeeding, and avoidance of high allergen exposure as well as exposure to tobacco smoke.14

Figure.No: 5 Asthma Triggers

1 Allergens: Allergic reactions may induce bronchoconstriction directly, may increase

tracheobronchial sensitivity in general, or may be obvious or subtle precipitating factors Allergy creates eosinophilic inflammation and in children is virtually the only mechanismfor creating eosinophilic inflammation Viral illnesses and Pollution increase the level ofpre-existing eosinophilic inflammation The most important allergens for asthma are theindoor allergens: pets, mites, moulds and insects like cockroaches (mainly by inhalationbut also by sting) Sensitivity to pollens is less important in asthma unless the asthma isalready poorly controlled Other allergens are infectious agent (especially fungi, and,occasionally drugs and foods)

2 Irritants: Numerous upper and lower respiratory irritants acts as precipitants of

asthma Eg: paint odours, hair sprays, perfumes, chemicals, air pollutants, tobacco smoke,cold air, cold water, and cough Some allergens act as irritants (eg:molds) Some irritantssuch as ozone and industrial chemicals may initiate bronchial hyperresponsiveness byinducing inflammation

Figure No: 6 Cause of Acute Asthma 15

3 Weather changes: Atmospheric changes commonly are associated with an increase in

asthmatic activity The mechanism not been defined but may be related to changes inbarometric pressure and alteration in the allergen or irritant content of the air

4 Infections: Most common infectious agents responsible for precipitating or

aggravating asthma are viral respiratory pathogens Fungal infections, bacterial infections(eg: pertussis or mycoplasma), and parasitic infestations (eg: toxocariasi sand ascariasis)can be important triggers Mechanisms underlying viruses and other allergic diseases areIgE- mediated and imbalance of T-lymphocyte responses

5 Exercise: Strenuous exercise ordinarily associated with breathlessness, such as

running and bicycle riding, may induce bronchial obstruction in as many as 80% of

Drugs: Aspirin, NSAIDS,

Infection: Colds,

sinusitis, and other viral respiratory tract infections

Exercise, cold air

Exercise, cold air

Irritants: Cigarette,

smoke, fire smoke, exhaust fumes, sprays, perfumes

Irritants: Cigarette,

smoke, fire smoke, exhaust fumes, sprays, perfumes

Acute asthma

individuals with asthma Hyperventilation of cold, dry air may cause heat and water lossfrom the airways, produce a hyperosmolar lining fluid, and result in mediator release (eg:histamine from mast cells) Cooling of the airways also results in vascular congestion anddilatation in the bronchial circulation.

6 Emotional factors: Emotional upset clearly aggravates asthma in some individuals;

however there is no evidence indicating that psychological factors are the basis forasthma The elegant studies of Kinsman and associates strongly indicate that copingstyles of patients, their families, and their physicians can intensify or lead to more rapidamelioration of asthma Psychological factors have been implicated in deaths fromasthma in children Asthma itself can strongly influence the emotional state of the parent,

of the family, and of other individuals associated with the patient

7 Gastroesophageal reflux: Reflux in gastric contents, with or without aspiration into

the tracheobronchial tree, can aggravate asthma in children as well as adults and is one ofthe cause for nocturnal asthma It causes significant increases in airway resistance ordecrease in pulmonary function in susceptible individuals because of vagal and otherneural responses GER may increase airway reactivity

8 Allergic rhinitis, Sinusitis, and Upper respiratory tract inflammation: Acute or

chronic asthma can be associated with aggravation of asthma and can be cause ofrecalcitrant asthma

9 Nonallergic Hypersensitivity to Drugs and Chemicals: Aspirin and NSAIDS, such

as indomethacin and ibuprofen, exacerbate asthma by increasing production of 5-LPOmetabolites, including leukotrienes Aspirin ingestion may diminish pulmonary functionand is contraindicated in children and adolescents due to the risk of Reye syndrome