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ASTHMA

The common question that I am asked by many patients with asthma is “doctor can I use other systems of medicine along with this?” Usually I do not object to this and my usual answer is to continue both but if some one is advised to stop main line therapy and use only alternative therapy I take pains to give proper advice. by explaining the importance of and definition of complimentary therapy and alternative therapy.

All of us are aware of the other medications available for asthma. But the main line therapy for asthma is inhalers and to be specific steroid inhalers. If any other system is added to this group it is not harmful. But if a person is advised to stop inhalers and use only complimentary treatment it is suicidal.

There are many terms used to describe approaches to asthma care that are out side the realm of the optimum asthma care. Complimentary and alternative medicine is a group of diverse medical and health care systems, practices and products that are not presently considered to be part of the conventional medical practice. Some scientific evidence exists for some complimentary therapies but for most key scientific evidences are lacking. For example many believe that yogas will cure asthma. In reality it only compliments main line asthma therapy. Some of the mild asthmatics would improve very well. But there is no scientific data to say that yoga and exercise can replace treatment although enough data is there to prove that they can compliment each other.

This brings us to an important question of the difference between complimentary therapy and alternative therapy. Complimentary therapy is used along with routine treatment. Alternative treatment therapy is used as an alternative to conventional medicine. An example of this to use a special diet to cure cancer instead of chemotherapy or surgery.

Complimentary asthma therapy means that non-traditional treatments such as massage, yoga and similar treatments are employed. These treatments are used in conjunction with traditional therapies in most cases. These therapies compliment the use of prescription medication and other treatment provided by your medical doctor. Alternative therapy means that herbal and other natural treatments are implemented, often in place of traditional therapies. Sometimes, however, these alternative treatments are used along with traditional therapies just as in complimentary therapies.

Tuberculosis

The very name usually brings jitters to many patients. And most of them look crestfallen at the mention of the name of the disease. Although it was once one of the greatest killers of the century, the incidence slowly decreased around the 1970s. With the discovery of the Human Immunodeficieny Virus or HIV as it is commonly known as the problem of TB began to become serious again. A common misconception about this disease is that it affects only the lungs and cough with sputum is the only manifestation. Although involvement of the lungs is the most common presentation, TB can affect any part of the body. More than the disease, the stigma associated with the disease is more damaging to the patient physically, mentally and socially.

We get a lot of questions from the patients and their relatives when they are diagnosed with tuberculosis. We have compiled a list of few frequently asked questions (FAQs) on the same. We would love to answer any other questions asked.

How is it caused?

TB is caused by a bacterium called Mycobacterium tuberculosis. It enters the body by the nasal route, when an infected person coughs out his sputum. The bacteria affect persons who have a weak immune system; affects people in both extremes of age, when your immune system is already down due to some illness or when you are on steroids. Is it a communicable disease? This is one of the common questions asked by the patients’ relatives. Yes TB is a communicable disease, but only in the initial phases. After 2 months of treatment the person becomes non infective to others. Tb spreads through the air. One cannot get TB by shaking hands, sitting on a toilet or using the same utensils of a person with TB. Is there a vaccine for TB? BCG is a vaccine given in the first week of life to infants in our country (India). It is a vaccine for tuberculosis. As a result of this you may develop a positive reaction to the Mantoux test. However this vaccine does not give you complete protection against TB.

Can TB be treated?

Yes, of course TB can be treated completely. It requires 6 – 9months of drugs depending on the disease and some effort to be regular in the treatment. Treatment of TB is a team effort. It starts from the patient, involves the relatives, friends and the health care provider.

INTERSTITIAL LUNG DISEASE

WHAT IS FIBROSING ALVEOLITIS?

Fibrosing alveolitis is a condition which is caused by cells, which are normally involved in the body’s own defense against infection, instead causing inflammation, injury and scarring in the lungs. Scars serve a good purpose in the skin where they heal injured areas but in the lung, scar tissue prevents the lung performing its normal function of taking oxygen from the air into the blood and removing carbon dioxide from the blood.

WHO CAN GET THE DISEASE?

Fibrosing alveolitis seems to be on the increase although it is not clear why this is so. It can affect people of any age but the most common age at which the disease strikes is in the 50s and men and women are equally affected. We do not know what causes Fibrosing alveolitis, but do know that it is not an infection, that it cannot be caught from others and neither is it a form of cancer. Exposure to certain occupational dusts (e.g. asbestos, hard metal alloy), can produce disease which is identical to fibrosing alveolitis and most people with the disease are or have been cigarette smokers. However, for most people the specific cause or provoking factors cannot be identified.

WHAT ARE THE SYMPTOMS?

The most common symptom is breathlessness, particularly on exercise such as walking up hills or stairs. Because it may come on in the mid 50s, patients often attribute this to middle age. It is important to stress that the onset of breathlessness should be investigated rather than to assume it is merely part of an ageing process. If it remains untreated the condition can often worsen and lead to permanent and progressive breathlessness. Less common symptoms include a dry cough, and some people may notice a change in the shape of their finger and toe nails. This feature is present in the majority of patients who develop this lung disease.

HOW IS THE DIAGNOSIS MADE?

Investigations will usually include a chest radiograph and a set of breathing tests. These require the individual to breathe in and out of a number of machines which allow an assessment to be made of how well the lungs are working. Blood tests are also usually performed. A special form of X-ray (known as a CT scan) which produces a three dimensional picture of the lungs, may be requested. It may be necessary to obtain samples of lung tissue for examination in the laboratory. This is usually done by bronchoscopy which involves passing a small flexible telescope down the breathing tubes with the patient lightly sedated. For many people these tests provide the necessary information for planning treatment, but in some people a larger sample of lung tissue, taken by a surgeon under a general anesthetic, is needed before treatment can be considered.

TREATMENT

It is very important that the disease is identified and investigated at the earliest possible stage so that treatment to reduce progressive lung scarring can be considered at a time before the patient is severely disabled. The most common form of treatment is steroids, usually a short period of high dose therapy followed by a longer period of treatment on lower doses. A few people may experience side effects: therefore a very careful balance between the potential benefit of treatment and the risk of side effects needs to be weighed up before recommendations are made. Other drugs which may be used to treat the disease are known as immunosuppressants. Once maximum response has been achieved, the aim is to maintain that response while reducing therapy. The need for treatment in fibrosing alveolitis is usually lifelong. This is because the condition is suppressed rather than cured in the majority of cases and the long term aim is to keep the disease suppressed on the smallest possible dosage of treatment. Very occasionally drugs may be discontinued completely but this is the exception rather than the rule.

PLEUROSCOPY

Medical thoracoscopy/pleuroscopy is considered to be one of the main areas of interventional pulmonology and should be included in the training programme of the chest physician. As with all technical procedures, there is a learning curve before full competence in medical thoracoscopy/pleuroscopy is achieved. Therefore, appropriate training is mandatory. This article describes the knowledge and skills required, the contraindications and potential complications and their prevention and the instruments used, as well as step-by-step information on how to perform medical thoracoscopy/pleuroscopy, which is even easier to learn than flexible bronchoscopy.

ENDOBRONCHIAL ULTRASOUND

Respiratory system is one of the organs that is not accessed easily any body. Even surgeons have their own reasons for not accessing it. Coronary by pass surgery, valvular replacements are more glamorous and sought after while surgery on lungs and mediastinum is not. This is probably because of the technical problems and the lack of people trained in this area. Physicians would not think of bronchoscopy as that involved a scope going in to an important organ and the patient also would think the same. In the process many treatable diseases were missed. Thanks to the awareness this scenario has changed. The last decade has seen many surgeons willing to go towards this field of lung surgery which is no long considered unsafe.

Another area that is not approached by physicians and chest physicians is mediastinum. Mediastinum is a cavity between two paired organs. Mediastinum contains all the principal organs of the chest except the lungs. It extends from the sternum or breast bone to the vertebral column and is bound laterally by pleura the layer that covers the lungs, pericardium the layer that covers the heart . Mediastinum is an imaginary part that houses heart, thymus. oesophagus, trachea ,bronchi, major blood vessels and nerves.

To have look into the mediastinum is only by means of chest xray, CT scans. But to get a tissue out of the chest diagnostic purpose was considered a difficult task. Only thoracic surgeons who were interested in this field used to do mediastiniscopy or mediastinotomy to get the lymph nodes, thymus and thyroid for diagnostic tissue. With the advent of interventional radiology the task became bit easier as these procedures did not involve any admission in to the hospital and were relatively safe day care procedures. The only concern about these radiological interventional were when the lesions were in mediastinum and were close to major blood vessels. In these situations there was no other option but to open and get the tissue for diagnosis.

Endobronchial Ultrasound also called EBUS can be used to aspirate the lymph nodes for diagnostic purpose, aspirate masses in the mediastinum and lungs that are close to airways and most importantly in lung cancer staging that would prevent unnecessary lung surgeries. This is done as a office procedure without any need for admission. This is just an extension of the bronchoscopy that has lots of potential not only to diagnose lung cancer but also stage the same that would help the physicians inplanning treatment strategies. This tool has been used across the world in many cancer centres to stage the lung cancer and in many centres this has become the first diagnostic step if one suspects cancer. Right now in India this is available in some centres and I am sure in years to come we will see more people trying to access the mediastinum that was considered the blind area of the radiologist and the pulmonologist.

THORACIC SURGERY

The fact that you are reading this article means that someone known to you might be suffering from a respiratory ailment for which your doctor might have advised surgery. Its always difficult news when surgery is suggested as a means of treatment. There are always lot of concerns about any kind of surgery and more so if it is a surgery on the chest. There are a lot of questions which come to your mind. How will you do the surgery? How will it affect my lifestyle and daily activities? What impact will it cause on my family? Will I be able to withstand the surgery? What are the complications? What is the cost of the procedure involved? Most of these concerns are real and thats a hard truth. The good news amongst all this is that surgery can sometimes effectively cure your disease. However the treatment can generate as much as anxiety if not more than the disease itself. Having encountered many patients like yourself we understand your concerns and help in providing proper information to go about your treatment

What is thoracic surgery?

It simply means operating inside the chest. Most of the lung diseases like asthma, COPD, pulmonary tuberculosis etc can be managed effectively by medicines. However there are still some diseases which require surgery to be performed for its resolution.

Some of them are

  • Lung cancer – In its early stages lung cancer is very much treatable by surgery and must be offered to those patients who are fit.
  • Pneumothorax – Air within the pleural cavity. Sometimes air accumulates within the pleural cavity due to rupture of a bleb or a bulla in your lung. This might lead to collapse of the lung and difficulty in breathing. Surgery might be required to remove the blebs or bullae and prevent recurrence of the condition.
  • Empyema – Pleural space infection – This is one of the commonest conditions requiring surgery in our country. It can occur as a complication of tuberculosis or other lung infections. Usually surgery is required for adequate drainage of the fluid and lung to expand properly.
  • Tumours in the chest – Most of the chest tumours are amenable to resection and surgery offers a good chance of removing the entire tumour.
  • Undiagnosed thoracic disease – Sometimes when a diagnosis cant be arrived at by other means, we may have to resort to surgery to establish the diagnosis.
  • East side to a deluxe apartment in the sky high

This list is neither complete nor exhaustive and there are a variety of other conditions in which surgery might be useful. Thoracic surgery is an advanced type of surgery and is performed by specialists who have been trained in this field.