1

Non-Evidence based treatment and elimination

methods in asthma

Dr.Fazilet KarakoçUniversity of Marmara

Division of Pediatric Pulmonology

2

Allergic diseases are becoming more common

Predictions suggets that by the year 2020 more

than 50 % of the population will suffer from some

type of allergy

Respiratory allergies predominate and many of

them will be triggered by house dut mites.

3

Increased exposure to high concentration of

indor environmental allergens such as house

dust mite, cockroach may explain the increased

prevelance and severity of asthma in children

Children spend most of their time indoor and

exposure to indoor allergens seems to be more

significant

4

CatDog

Pollen

House dust miteSensitisation to Allergens

Pet OwnershipDog owner

Smoking StatusSmoker

SexFemale

*p = <0.0001 p=0.001 - 0.0001 p=0.05 - 0.001* *

1 1.2 1.4 1.6 1.8 2 2.2 2.42.6 3.0

**

**

*

*

*

Simpson.Custovic et alClin Exp Allergy 2001;31:391-399

Sensitisation – Risk Factor for Asthma

5

Environmental risk factors in asthma controlTreatment and elimination methods

Acupuncture

Diyet/Nutritional

treatment

Herbal medicine

Homeopathy

Breathing exercise

Others

House dust mite

Cockroach

Animal allergens

Molds

ETS

6

1925

Storm van Leeuwen

Living in allergen-free room

(in the hospital) or

Moving to high altitude

Decreased the exposure to

dust mite and had beneficial

clinical effects

Control Measurements in

order to decrease dust mite

exposure

7

Environmental measurements in Asthma

Physical Measures

Control environmental humidity and temperature

Mechanical measures ( collection/filtration)

Physical barriers (impermeable covers)

Chemical measures

Pesticides (to eliminate house dust mites and substances to denature the allergens)

8

Ev tozu akarı alerjisi

One of the most significant indoor allergens

A higher incidence of mite allergy has been reported in

asthmatic children of lower socioeconomic status

Most common allergen in Turkey ( %20-70)

House dust mites feed mainly flakes of human skin

A single adult person sheds between0.5-1 gr per day,

enough to feed 100 000 house dust mites a day

9

Particles carrying house dust mite allergen are relatively large (> 10µm) and settle quicky

Bedding, carpets,clothing and furnishings are the major sources of allergen.

During cleaning dust is disturbed and available for inhalation

10

• Can effective house dust mite allergen avoidance be achieved in homes?

• Does it make any clinical difference?

11

The relationship between allergen concentrations and

symptoms does not linear and predictable

Sensitivity and response vary greatly from individual

to individual.

Children are not raised in a single house

The concentration of house dust mites in each home vary

according to series of factors such as geographic location,

humidity, temperature, decoration and the number of the

people living in the home

12

Cochrane reviewsSheikh A,2003Gotzsche PC 2004

Cochrane reviewsSheikh A,2003Gotzsche PC 2004

29 studies

15 Physical

measurement

9 Chemical methods

5 CombinationOf methods

•Asthma symptoms

•Use of asthma medication

•Morning peak expiratory flow

NO statistically significant difference

13

Physcian should give advices about ideal

environmental control measurements to the

caregivers

14

Because of the high level of mite allergen exposure

during sleep, the bed is probably the most clinically

significant exposure site.

Encasement of the matress and pillows in allergen-

impermeable covers combined with frequent hot water

washing (>55 C) of bedding is the best method in order

to reduce dust mite exposure

Allergen-impermeable bed and pillow covers

15

BHR Asthma symptoms Bronchodilator use Inflammatory markers .

Halken, 2005EhnertB,2002Murray,1983Carswell F,1996Frederick,1997

Do allergen-impermeable bed and pillow covers effect the

control of asthma?

Asthma symptoms Pulmonary function tests İnhaled steroid dose

Rijssenbeek N,2002Woodcock A,2003Luczynska C, 2003Terreehorst I,2003

16

Dust mite control measurements in bedding

The use of acaracide or antimite shampoo in addition to encasement and hot washing doe not have any benefit

Ehnert B,1992, CarswellF,1996,Frederick JM,1997

17

Kill all live mites! BUT does not reduce allergen concentration!

DRY CLEANING

18

Carpets are amajor source for many indoor allergens

Houses with carpets have more allergens than those without

The use of Acaracides alone or in addition to other dust mite avoidance measures have not been demonstrated to be useful

Removalof carpets?

Rebmann H 1996, Woodfolk 1995, Ehnert B 1992, Carswell F 1996

CARPETS

19

Frequent vacuum cleaning effectively decrease dust mite in carpets

Even with improved filtration systems, vacuum cleaning may increase aeroallergen levels

It is advisable to wear a mask and open windows during and after cleaning

Adilah N,NZ Med J 1997

20

Control of house dust mite using extreme temperature,

either by freezing with liquid nitrogen or steam cleaning

has been shown to be effective

None of these methods is completely effective, the

amount of the allergen increase following intervention

21

Respiration-gas exchange in mites is cutaneous,

And they are particularly susceptible to loss of body

moisture

The placement of carpets in direct sunlight has been

shown to effectively decrease dust mite level, since mites

are susceptible to water loss (drying)

This is a simple , safe, and inexpensive way to reduce

house dust mites,especially if alternative methods are not

available

Tovey E JACI 1995

22

ASTHMA AND COCKROACH

23

Cocroach allergens are found

İn high concentrations in,

Blag 1,Blag 2 Cockroach feces

skin

Nest debris

Highest concentration of cockroach antigens are in dust

from kitchen floors and cupboards (50-fold more than

bedrooms)

Strongest relationship between exposure and sensitisation

has been found in the bedroom

Cockroach sensitisation is 10-40 % in Türkiye

COCKROACH

24

Increased level of cockroach allergen have been associated more frequent;

•Asthma related ER visit•Hospitalisation•Days of wheezing•Missed school days

Cockroach allergen levels has been found to be a risk factor for accelerated decline in FEV1 in adults with astma

Weiss ST J Allergy Clin Immunol 1998

ASTHMA AND COCKROACH

25

Reduction in cockroach allergen exposure may be

in important in asthma control

Gergen PJ, 1999,Carter MC,2001

Intervention studies showed no or modest reduction in cockroach allergen levels

Reduction in cockroach allergen levels were not associated with clinical benefits

26

Cockroach like to live in dark, humid and warm environment

Removal of cockroach alleregen from the house is not easy

Although the effectiveness of professional cockroach

extermination remains unproven, this is probably the only

method that will help control infestation in the long term

The goal is to eradicate not only the living cockroach

population but also the residue

Reinfestation from neighboring residences is also a

problem,especially for families living in the crowded apartment

buildings

•İn additon to extermination, elimination of cockroach food and

water sources through basic sanitation

measures , clearing harborages and

blocking entry point is important

•Grocery bags, empty bottles and newspapers make

wonderful habitats for cockroach and should not be stored in

the house

27

ASTHMA AND PETS

28

All warm-blooded pets, including small rodents and birds

Produce urine,dander,feces and saliva that may cause

allergic reaction

Animal allergen particles are small (1-20µm), sticky and

adhere surfaces

10% of children own pets in Türkiye

Transfer of animal allergens from homes to public places

(including schools) via clothing has been reported

PET ALLERGY

29

The most effective environmental

control measure for animal allergen is

removal of animals from the house

Once the animal removed, elimination of allergens

requires aggressive cleaning

Decreases in allergen levels can take months; removal

of carpeting and stuffed furniture can shorten this period

30

1000

100

10

1

0.1

0.01

Cat removed

0 5 10 15 20 25 30 35 40 45

Time (weeks)

Cat removed

Fel d 1 content(FDA units/gram

dust)

Wood et al, 1989

The Effect of Cat Removal on Fel d 1 Levels

31

•Different washing protocols for animals have been effective in the elimination of animal allergens

•However animals need to be washed twice a week to maintain decreased antigen levels

32

30

25

20

15

10

5

02 3 4 5 6 7 8

Baseline + h rs

Can f 1 (ng/m )3

dog+HEPA

dog-no HEPA

no dog+HEPA

no dog, no HEPA

35

Green et al, 1999

HEPA FILTER Air-Cleaners Reduce Airborne Dog Allergen

Baseline 2 3 4 5 6 7 Baseline+hrs

33

HAVA FİLTRELERİMcDonald E, Chest 2002Meta-Analiz

Alerjene maruziyeti azaltmak amacıile hava temizleyicileri ve diğerfiltrasyon cihazlarının kullanılmasınınetkinliği NET DEĞİLDİR!

HEPA filtrasyon astım semptomlarını ve astım ile ilişkili uyku bozukluklarını azaltır.HEPA filtrasyonu sigara dumanı gibi çeşitli inhale allerjenlere maruziyeti azaltabilirÇalışmalar hangi spesifil allerjene maruziyetin azalmasının klinik fayda sağladığını göstermemektedir

34

If removal of the animal is not acceptableExpert Panle Report2 : guidelines for the diagnosis and Management of Asthma suggest,

Keep the pet out of patients room

Keep the patients bedroom dor closed

Remove upholstred furniture and carpets from the home or isolate the pet from them as much as possible

35

Avoidance from CAT & DOG Allergens

Decrease inhaled allergen

Clinical Benefit

Removal of the pet YES ?

Washing pet LITTLE Probably NO

HEPA air filter LITTLE Probably NO

High filtration vacuum cleaner

NO NO

Removal of carpet ? ?

36

Although molds were commonly considered an outdoor allergen, spores can come indoors

Alterneria, aspergillus, penicillium etc are the most common molds in Türkiye.

Allergic sensitisation to molds has been reported 4-50 % in different regions of Türkiye

Damp homes and indoor molds have been associated with adverse respiratory symptoms and higher risk of asthma

•Maintaining adry environment with simple control measures

•Repair of water leaks and insulation defects

•İncreased bathroom ventilation

•No drying of cloths indoors

•Fewer indoor plants, has been shown to be effective in reducing exposure to mold spores

MOLDS AND ASTHMA

37

ASTHMA AND ENVİRONMENTAL

TOBACCOSMOKE

38

•ETS has been associated with increased risk of death and hospital admissions for respiratory disease as well as increased risk of asthma

Among children with established asthma ETS increase

•Asthma symtom scores•Attack frequency•Medication use

Di Franza 1996, Martinez 1992,Starchan DP 1998

•Advise caregivers and other smokers in the homes of patient with asthma to stop smking or to smoke outside the home

•The asthma care team should be knowledgeable about smoking cessation and should actively refer smokers to Programs

•Active smoking status of the patient?

•Discuss the ways to reduce exposure to reduce other sources of tobacco smoke such as from relatives, friends and day care providers

Environmental tobacco Smoke Exposure

39

CLINICAL TRIALS

OF MULTIFACETED

ENVIRONMENTAL

CONTROL

INTERVENTIONS

40

Hasta sayısı 444 425Days with asthma symptom

3.39 4.20 <0.001

Days of wheeze 2.65 3.43 <0.001Days of exercise limitation

2.34 2.84 <0.001

Night woke up 1.55 2.17 <0.001School days missed 0.65 0.82 0.003ER visit 0.93 1.08 0.17FEV1 87.0 87.4 0.56

Morgan JM,NEJM,2004

Results of a home-based intervention among urbanchildren with asthma

41

SONUÇ

•The asthma care team should evaluate environmental

conditions of the patients and discuss appropiate control

measuerments in order to decrease allergen exposure

•Physician should check the environmental control

measurement in F/U visits

•Reduction of ETS is an important target for

environmental control measurements

42

ALTERNATIVE

MEDICINE IN ASTHMA

That’s all the health insurance will pay for alternative medicine

43

THE USE OF ALTERNATIVE MEDICINE IN DIFFERENT COUNTRIES

0

10

2030

4050

6070

80

90100

ENGLAND USA GERMANY SINGAPORE

59 % 41% 26.5% 27.5%

44

ACUPUNCTURE

A large number of

small, uncontrolled

trials reported that

acupuncture

improved asthmatic

symptoms

45

Gruber et al

Thorax,2000

44 çocuk

Exercise induced asthma

Akupuncture NO protection against exercise induced

bronchospasm

Shapino et al

Chest,2002

23 patients with mild-persistent

asthma

Akupuncture NO change in

PFT ,PEF, BHR

Medici et al

J Altern Complement Med

66 patients Akupuncture NO change

PEF,FEV1,

BHR,Asthma symptoms

EFFICACY OF ACUPUNCTURE IN ASTHMA

TREATMENTS: RCT TRIALS

46

Linde K, Cochrane review,2000 7 trials with 174 pts

Martine J Eur Respir J,2002 200 publications

11 Randomised controlled trials

This is the last time I go to an acupuncturist for my asthma?!

The authors did not find evidence

of an effect of acupuncture

in reducing asthma,

whatever outcome was used

47

HOW ABOUT SAFETY

125 papers reporting side

effcets of acupuncture in

the period 1981 to 1994

Norheim AJ, J Altern

Complement Med 1996

‘You gotto be kidding! His asthma is still not undercontrol?!’

‘You gotto be kidding! His asthma is still not undercontrol?!’

Pneumothorax Hepatitis Death

48

DIYET/NUTRTIONAL THERAPY

Kaur et al.

Cochrane Database,2001

Vit C supp. 6

RCT Not Beneficial

Gilliland et al.

Am J Epidemiol 2003

Antioxidant vitamin intake

2566 children PFT small but significant

improvement?

Aroraet al.

Pediatr Allergy Immunol 2002

Vit A

levels

35 Asthma

29 control

Vit A levels were lower in children

with asthma

Woods et al

Cochrane Database,2001

Fish Oil 9

RCT Not Beneficial

49

HERBAL MEDİCİNE/ TRADITIONAL CHINESE MEDICINE

50

INCIDENCE OF HERBAL MEDICINE

USAGE IN TURKEY

31% of children with asthma use herbal medicine

Orhan F, Ann Allergy Asthma Immunol 2003

51

HERBAL MEDICINE

Until now , there has been no evidence of efficacy of herbal medicine

Studies are very heterogeneous, low quality studies with small patients numbers

Only a few RCT

There is insufficient evidence to recommend herbal medicine use as first-line or even adjunctive therapy for asthma

52

HERBALMEDICINE /SIDE EFFECT?

Although widespread use

and advertising of herbal

medicine there is

insufficient data about the

safety

‘It appears to be a side effect from the herbal medicine you’re drinking!?’

Mizushima and Kobayashi

published a series of 24

cases of interstitial

pneumonitis induced by

herbal medicine

53

Cooper et al

Thorax ,2003

Buteyko

Pranayama

Placebo

No difference FEV1,BHR,ICS

Manocha et al.

Thorax ,2002

Shaja yoga Limited but significant benefit in asthma symptoms and BHR

Huntley et al,

Thorax, 2002

Kas gevşetici teknikler

Improvement in PFT

Weiser Chest,2002

Solunum kasları

Çalıştırma teknikleri

Significant reduction of perceived dyspnea and bronchodiator use

BREATHING EXERCISES AND ASTHMA

54

OTHER ALTERNATIVE TREATMENTS IN ASTHMA

REFLOXOLOGY

55

Hondras et al

Cochraine Database,2002

Manual therapy

5

RCT

NOT BENEFICIAL

Blackhall et al

Cochraine Database,2002

Air ionizers 6

RCT

NOT BENEFICIAL

Hackman et al. Hypnosis No RCT NOT BENEFICIAL

Brygge T Refloksoloji No RCT NOT BENEFICIAL

OTHER ALTERNATIVE TREATMENTS

56

‘That’s right , Kenji.Everything happens for a reason, but no one has a clue what it is!’