Posts Tagged ‘pollen season’

Allergy and Your Immune System
`The summer used to be such a miserable time for me because I’m allergic to grass pollen. For most of

my life I have had dreadful hayfever, and my asthma would get worse during the summer as well.

Antihistamines knocked me for six, and although there were nose drops that helped a little, they

certainly did not resolve the problem completely. Exam time was always a nightmare when I was a student

- then, as now, it coincided exactly with the pollen season.’
‘Getting a job in Chicago was a turning point in my health. My colleagues were amazed to see me

snuffling through the summer and just accepting that nothing could be done to improve matters. The

whole approach to treating allergies is different there. Eventually someone marched me off to see her

allergist, who said that I should have “allergy shots” and that my health insurance would cover it. The

process was very time-consuming at first, and it took a while to work, but the change is remarkable.

I’ve never regretted having the treatment. Summer is a time I can actually enjoy now.’
Not everyone responds this well to immunotherapy, but for those allergy sufferers who do benefit, this

is an excellent treatment. It tackles allergies right at their source, by teaching the immune system to

react differently to the allergen.
Also known as Specific Immunotherapy (SIT), Incremental Immunotherapy (11T) or simply as

hyposensitisation, this form of treatment was devised by two English medical researchers, Leonard Noon

and John Freeman, who reported their successes with hayfever patients in 1911. Ironically, their

treatment is now less readily available in Britain than in any other industrialised nation. Only a

small minority of British allergy patients receive immunotherapy. The cause of this strange situation

is a ruling made in 1986 by the Committee on the Safety of Medicines (CSM). This states that

immunotherapy must only be given where there is resuscitation equipment available, and that all

patients must wait for an hour after each injection, in case of
side effects. In addition, immunotherapy cannot be used for severe asthma.
The requirement for resuscitation equipment rules out most GP surgeries, and this effectively puts

immunotherapy beyond the reach of many allergic individuals in Britain, owing to the extreme shortage

of allergists and hospital allergy clinics (see p. 89). (In the past, the lack of allergy specialists

meant that most immunotherapy in Britain was given by GPs.)
The CSM ruling was triggered by a number of deaths due to immunotherapy: there were eleven fatalities

between 1980 and 1986, with five of these in the eighteen months just before the report. But almost all

these deaths were due to very basic errors in the way the injections were given – tragic as the deaths

were, the official response to them was inappropriate. Fatal reactions to immunotherapy can be avoided

with close attention to ordinary safeguards (see p. 166-7).
Allergen immunotherapy is still freely available elsewhere in the world, and is regarded as a key part

of allergy treatment. Britain is now out of step with all other developed countries, and most doctors

feel that British restrictions are far too strict.
There are hopes that this situation may change within the next few years, and that more allergy

sufferers may be able to take advantage of this valuable treatment. This could be achieved, in part, by

investing more National Health Service money in allergy clinics and allergy specialists. In addition,

there should be a relaxation of the regulations, so that properly trained GPs can give immunotherapy to

patients who are not at high risk of a fatal reaction. For people whose lives are affected by

allergies, the reintroduction of this treatment (with appropriate safeguards) would be a huge boon.
The uses of immunotherapy
Immunotherapy is mainly used for airborne allergens such as pollen, house-dust mite and mould spores.

Allergies to animals can also be treated with immunotherapy, but the treatment cannot work miracles –

if a cat-allergic person decides to keep the cat, the high dose of allergen inhaled every day limits

the impact of immunotherapy treatment.
People with straightforward allergic reactions affecting the nose and eyes (allergic rhinitis and

conjunctivitis) respond well to immunotherapy. In patients with hayfever, for example, the success rate

(patients showing some degree of improvement) is about 80-90%. When nasal allergies are complicated by

chronic sinusitis or nasal polyps, the chance of success is a little lower.
Some studies of the long-term effects of immunotherapy suggest that, if it is given to children with

hayfever or perennial rhinitis, those children are less likely to develop asthma.
The benefits of using immunotherapy to treat established asthma are less certain. Asthma is a more

complex disease than hayfever, and allergies are only one factor among many (see p. 36), which may

limit the impact that immunotherapy can make. Experience suggests that immunotherapy can be a great

help for an asthmatic with a strong allergic reaction to a single airborne allergen, such as grass

pollen or house-dust mite, but not for other asthmatics. Asthmatics with aspirin sensitivity or chronic

sinusitis are unlikely to benefit.
The value of immunotherapy to children with asthma is a subject of great debate among doctors in the

United States. Some studies suggest that it is of little real benefit, while others are more positive.

One interesting study, that followed asthmatic children for 15 years or more, found that if they were

given a full five-year course of immunotherapy when young, they tended to have fewer asthma symptoms

and need less medication in their late teens and early twenties.
Chronic urticaria (nettle rash) is occasionally due to airborne allergens, in which case immunotherapy

may help. However, immunotherapy is not recommended for atopic eczema. When people with both eczema and

rhinitis try immunotherapy for their nasal allergies, some find that their eczema gets worse.
Insect-sting allergy is a prime candidate for immunotherapy (see pp. 167-8) but food allergy is a

different matter, and is not treated with immunotherapy at present (see p. 168).
Who can get immunotherapy?
As a result of the CSM ruling (see p. 164) remarkably few allergy sufferers in Britain receive

immunotherapy.
Those with insect-sting allergy, who have suffered anaphylaxis (see p. 58), are the most likely to be

offered this treatment. However, even with this frightening and life-threatening problem, which can be

treated with almost 100% success by immunotherapy (see p. 167-8), such treatment is not automatically

available.
A few people with severe hayfever that does not respond well to drug treatment may also be given

immunotherapy. It is worth asking your doctor about such treatment if you feel you would benefit.
How immunotherapy works
Immunotherapy consists of a series of small injections, just under the skin. The liquid that is

injected contains an extract of the offending allergen, for example house-dust mite. The injections are

given at regular intervals, usually once a week, although other schedules are possible (see p. 167-8).
At the outset, a very dilute version of the allergen extract is used, way below the threshold for an

allergic reaction. People who seem highly sensitive, on the basis of their skin tests, start on an

extract that is even more dilute.
For the next injection, a slightly higher concentration of the allergen extract is used, and the

concentration goes on increasing with each successive injection. The idea is to habituate the immune

system to the offending allergen, by very gradually raising the dose. Eventually, when the dose reaches

a level which generally gives beneficial effects, no further increases are made.
If an allergy sufferer reacts badly to immunotherapy injections (see p. 166) on several successive

occasions, the dose may be levelled off before the ideal maximum dose is reached. However, a good

allergist will persist for some time in trying to increase the dose because stopping at a lower level

often results in the treatment being ineffective.
The first stage of immunotherapy, when the concentration of allergen is being increased week by week,

is referred to as the build-up stage. The second stage, when the dose is being kept at the same level,

is called maintenance therapy, and the dose used is the maintenance dose.
There is sometimes an obvious improvement by the time the build-up stage is complete, but not always.

The benefits of the treatment generally appear within six months of reaching the maintenance dose, but

some people have to wait a year or even two before things improve. As the immunotherapy begins to take

effect, symptoms decline and there is often less need for drugs.
A great deal of research effort has gone into finding out what lies behind these changes – in other

words, what is actually happening to the immune system when immunotherapy is effective. The answer is

that a surprising number of different changes may occur and no two allergy sufferers react to

immunotherapy in quite the same way. Frequently there is a shift in the kinds of antibodies the body

produces against the offending allergen. Levels of IgG antibodies (which help to block the allergic

reaction) go up, while levels of the allergy antibody, IgE, tend to stabilise and eventually go down.

The numbers of mast cells (see box on p. 12) may also decline, and they can become less responsive to

the allergen. The balance of power between Th1 cells and Th2 cells may also shift, with the pro-allergy

Th2 cells (see p. 11) becoming less influential.
What can go wrong
The secret of safe immunotherapy is to go at exactly the right speed for the immune system of the

individual being treated. The doctor should look for feedback from the immune system – signs that show

how well it is coping with the steadily increasing dose of allergen – and use these to pace the

immunotherapy schedule.
Going too fast – getting ahead of the immune system’s ability to cope – is hazardous. A major allergic

reaction, called anaphylaxis (see p. 58), can occur, and this is the cause of deaths during

immunotherapy. However, as long as there is injectable adrenaline (see p. 150) and resuscitation

equipment available, even such an extreme crisis can be dealt with safely.
Serious reactions to immunotherapy usually occur:
•    during the initial build-up phase; maintenance therapy is much safer
•    during the pollen season, for those with pollen allergy
•    when a new vial of allergen extract is first being used, because of variations in concentration

(see p. 168-9).
Those most vulnerable to severe reactions are:
•    people with asthma, especially severe or unstable asthma
•    those who have experienced systemic allergic reactions in the past
•    anyone who appears to be extremely allergic, on the basis of skin tests
•    anyone taking beta-Mockers (see box on p. 150).
With care, these fatalities can be avoided. Patients who are given immunotherapy can ensure their own

safety by being well informed about the procedure (see p. 167).
The timing of immunotherapy
There are various different approaches to the timing of immurotherapy. The basic method (which has a

good safety record in the United States where it is very commonly used) starts with injections once a

week. After the maintenance dose has been reached, maintenance injections are given once every 2-4

weeks. The frequency of these may be increased during the pollen season, for people with pollen

allergies.
It is the regularity of the injection schedule that gradually creates, and then sustains, immune

tolerance, so the treatment is only of value to patients who can reliably keep their appointments.
When immunotherapy is successful, it can eventually be discontinued without any reappearance of the

allergic reaction. It usually takes 4-5 years of regular therapy, from the time of the first injection,

to get to this point. The benefits then persist for many years, perhaps indefinitely in some people,

even without any further injections.
Rush immunotherapy
Trying to speed up the process of immunotherapy greatly increases the risk of a severe reaction

(anaphylaxis). However, there are some situations where fast results are needed, and in such cases rush

immunotherapy, also called accelerated immunotherapy, may be used.
During the build-up stage of rush immunotherapy, injections are given every day, or even several times

a day. All the usual safety procedures (see below) are observed with particular care, to reduce the

chance of a severe reaction.
In semi-rush immunotherapy, the build-up injections are given twice a week, and the risks are lower

than with daily injections, but still higher than with weekly injections.
Minimising the risks
If you are lucky enough to be offered immunotherapy treatment under the National Health Service, you

should not feel concerned about accepting the offer. There is very little risk of a bad reaction

because safety procedures are now so stringent.
To minimise the risk of suffering a severe reaction, the doctor will ask you, at each visit, about any

reactions that occurred after your previous injection. Reactions might include redness, itching or

swelling around the injection site, or (more seriously) symptoms elsewhere on the body, such as nettle

rash (urticaria), itchy skin, sneezing, a runny nose, red or itchy eyes, tightness in the throat or

chest, coughing or wheezing. Always make a note of such symptoms, so that you don’t forget to mention

them at the next visit. This is crucially important, as such reactions can indicate that the immune

system is being hurried along too fast.
The doctor will also ask if you have an infection of any kind, as this can alter your reaction. You

should also tell the doctor about any new medicines being taken, as some, such as betablockers (see box

on p. 150), can make a bad reaction to the injection more likely to occur.
Asthmatics can expect the doctor to ask about current asthma symptoms, and to check their peak flow

both before and after an injection. If there are any symptoms, or if the peak flow is less than 70% of

the best-ever value, the injection won’t be given.
Severe reactions can sometimes begin several hours after the injection, so stay within reach of a phone

for about 24 hours. Among United States allergists (who don’t require their patients to wait after the

injection for more than 20-30 minutes) there are some who believe that everyone undergoing

immunotherapy should carry an adrenaline (epinephrine) auto-injector (see p. 150) on the day an

injection has been given, for use in the event of a severe reaction. Anyone who has suffered

anaphylaxis in response to an insect sting will probably have an adrenaline auto-injector anyway, and

this can certainly be used to treat anaphylaxis following immunotherapy. Note, however, that using the

adrenaline is just the first step in treating anaphylaxis (see p. 98) and you must then go back to your

allergist, or to the nearest hospital emergency department, without any delay.
It is sensible to avoid exercise for two hours after an injection. Be extra-cautious during the pollen

season if you are receiving immunotherapy for pollen allergies.
Immunotherapy for insect-sting allergy
`Our daughter has had two really bad reactions from being stung by a wasp. After the second one, the

doctor at the accident and emergency department told us that she nearly died. We got so anxious about

it that we worried every time we left the house in the summer, and it was even worse if she went out

without us. My wife got so upset about it that she wasn’t sleeping well. It was affecting the whole

family badly.
‘Then we heard about desensitisation treatment, and asked our GP, but he said he couldn’t do it.

According to him, they might be able to do it at the hospital, but it might not work, and it was risky

too. We accepted that at first, but then I started doing some research on the Internet, and discovered

that in America and Germany this treatment is absolutely standard – someone like our daughter would

automatically be given it. We felt very angry when we found this out, and went back to the doctor.

Eventually Ann was referred to the allergy department at a hospital, and now she is getting this

desensitisation treatment. I’m pleased about that, obviously, but I still think it shouldn’t have been

such a fight to get it.’
Immunotherapy provides highly effective protection for those with insect-sting allergy, and should be

given to anyone who has had a severe systemic reaction (see p. 60). Some United States allergists also

recommend it for adults who have had a cutaneous systemic reaction (see p. 60), on the basis that they

may well progress to a severe systemic reaction with the next sting.
Studies of people who have suffered severe systemic reactions, and are then treated with immunotherapy,

show that 97% have no systemic reaction to future insect stings. For the 3% who are not fully

protected, the severity of the reaction is much reduced and far less likely to be life-threatening. In

other words, this is an excellent treatment which can save lives.
Targeting the treatment
Choosing the right venom for immunotherapy can sometimes be difficult. Not everyone with insect-sting

allergy sees the insect that caused the reaction. Skin tests may not give the answer either, because

there are often positive reactions to several different venoms. Some of these may be false positives

(see box on p. 91) and it is impossible for the allergist to say which one(s) are actually relevant.

Most allergists will recommend immunotherapy for all of them, using a mixture of venom extracts.
Where the guilty insect was seen and identified, but other venoms also give positive skin tests, a more

difficult decision has to be made. Many allergists carry out immunotherapy for all the venoms that gave

a positive skin test, on a ‘better safe than sorry’ basis. Since there are cross-reactions between

venoms (see box on p. 113), there is some sense in this. Other allergists just give immunotherapy for

the insect that did the deed.
Will immunotherapy against one insect protect against a related insect? With two closely related

insects such as wasps and hornets, which have many allergens in common, it might do – but there is no

guarantee. The problem is that, as well as the shared allergens, each venom also has its own unique

ingredients. It’s impossible to say, with the kind of tests available at present, if an allergic

reaction was to shared allergens or unique ones. So immunotherapy against wasp venom may give

protection against hornet venom, but it will not necessarily do so – and vice versa.
In the case of bumblebee allergy (seen almost exclusively in those, such as horticulturalists, whose

work involves handling bumblebees) a more definite answer can be given – honeybee immunotherapy does

not work. Immunotherapy with bumblebee venom does work, fortunately. The bumblebee extract has to be

obtained from specialist sources.
Injections are given weekly during the build-up phase, unless protection is needed urgently, as with

work-related sting allergy, in which case rush immunotherapy may be used. Once the maximum dose has

been reached, a maintenance injection is needed every four weeks. After a year, this maintenance dose

can be given every 6-8 weeks.
After 3-5 years of immunotherapy, skin tests with insect venoms are usually tried again. If the results

are negative, the immunotherapy will stop. Research now shows that, even if skin tests are still

positive when immunotherapy ends, there’s an 8090% chance that no systemic reaction will occur to

future stings. Some people are not reassured by this, and prefer to continue with immunotherapy for

their own peace of mind. Indeed, research shows that a near-fatal systemic reaction has a long-lasting

psychological impact, and that many people continue to feel anxious despite completing immunotherapy

and reacting negatively to skin tests.
At one time, challenge stings with live insects were given to check whether immunotherapy had actually

worked. Few doctors do this now, but your allergist may be prepared to do a challenge test if you ask.

Adrenaline and resuscitation equipment would be available if a challenge test were used, so any severe

reaction could be dealt with promptly and effectively. The fact that the psychological consequences of

insect-sting allergy are so persistent suggests that challenge tests with live insects may have a

particular value, in demonstrating that immunotherapy has worked. Challenge tests are also helpful for

those who work with stinging insects, such as honeybees and bumblebees, and who need to be sure that

they can go back to work safely.
Immunotherapy for food allergy?
Attempts to use standard immunotherapy for food allergy have been made repeatedly, but without success.

The process of giving the injections is nerve-racking because of the constant risk of a severe

reaction. The risks prevent the dose of allergen being increased very much, so the beneficial effects

are small. While there may be some reduction insensitivity, it is not enough – or not reliable enough –

to be of any practical value.
What doctors are aiming for here, incidentally, is simply to protect against the effects of

accidentally eating a tiny amount of the food – no one is expecting that someone with peanut allergy

will be able to eat peanut butter sandwiches as a result.
Some of the new developments in immunotherapy may be useful for food allergy, as described in the next

section.
The future of immunotherapy
Many different research teams are working on ways of improving immunotherapy – making it more

effective, safer to give, and less time-consuming.
One approach involves altering the allergen, so that it only interacts with those parts of the immune

system whose job is to control allergic reactions (and therefore bring about tolerance). The changes

made to the allergen are designed to make it ‘invisible’ to the parts of the immune system that

actually attack the allergen. The idea is to inject something that can’t cause a bad reaction, and is

therefore 100% safe.
The modified allergens are called allergoids. Another term often used is peptide immunotherapy – this

describes a technique in which the allergens are chopped up into small pieces to make them safe

(allergens are proteins, and a fragment of a protein is called a peptide).
Already, researchers in Germany have made an allergoid from birch pollen that can reduce hayfever

symptoms with a series of just seven injections given before the pollen season.
Meanwhile, a research team in London is working on peptides made from cat allergen, with encouraging

results so far. In a group of asthmatics who were allergic to cats, a series of 4-10 injections, over a

period of 2-8 weeks, produced benefits in about half those treated. The researchers believe that they

can improve on this and help the majority of people with cat allergy, at least enough to survive

temporary exposure to cat allergen (when visiting cat-owning friends, for example). They hope to refine

the treatment sufficiently to enable some cat-allergic people to keep their pet, rather than finding it

a new home. This is a relatively safe treatment that might be given by a GP, rather than only by

specialists. The research team hopes the treatment will be available by about 2009.
Could this kind of technique work for food allergy? Doctors believe that it can, and a great deal of

research work is being done, in both Britain and the United States. A major focus of this effort is

peanut allergy, since this puts so many young lives at risk. Even if the research is successful, It

will be several years before such treatments become available.
Researchers are also working hard to produce standardised allergen extracts – in other words, allergen

extracts that always contain a standard amount of the allergen. The aim is not only to reduce the

number of treatment failures (which can occur if the extract does not contain enough allergen) but also

to avoid mishaps when a new vial of allergen extract is used (differences in strength, between one vial

and another, are sometimes a cause of anaphylactic reactions).
Standardisation is difficult, because the starting materials –skin particles from horses, for example,

or dust-mite droppings –are natural materials and therefore variable. Some samples contain far more of

a particular allergenic ingredient than others.
One way around this problem is to develop accurate methods of measuring the amount of allergen in the

extract. Another approach is to abandon the whole business of making extracts, and produce allergens

artificially, in a laboratory. This is done by inserting the gene for the allergen – the gene for the

Der p1 allergen of house-dust mite, for example – into bacteria. These bacteria then act as production

units, manufacturing large amounts of the allergen every day. With this high-tech approach, the exact

content of the allergen preparations can be controlled.
These high-tech allergen preparations are extremely pure, and therefore very effective – as long as the

person receiving immunotherapy really is sensitised to the particular allergen that is included.

Unfortunately, most natural allergenic materials contain two, three or even more separate allergens. In

house-dust mite droppings, for example, while Der p1 is the allergen that affects most people, there is

also an allergen called Der p2, and a few people are more sensitive to this than to Der pl.
Artificially produced allergen preparations usually include the main allergen only. For the minority of

people who are more severely allergic to one of the other allergens, this extract will not work.

Eventually this problem will no doubt be circumvented by means of more precise skin testing before

immunotherapy begins – skin tests with individual allergens, rather than with allergen extract

containing a mix of allergens.
A third approach is to change from injections to oral immunotherapy – giving the allergen extracts by

mouth. The best results are obtained when the allergen is held under the tongue for a while and then

swallowed. This is known as Sub-lingual immunotherapy or SLIT, and has become very popular in Italy and

France, where it is a common treatment for hayfever. A recent pilot trial among GPs in Britain suggests

that it may be useful, but is not a miracle cure. Overall, the group treated with SLIT had fewer

symptoms during the pollen season, but antihistamines were still needed. There is some evidence from

Italy that SLIT might reduce the likelihood of children with hayfever going on to develop asthma, and

reduce the chance of new sensitivities.
Side effects are unusual with this treatment, and those that do occur are mostly mild – itching in the

mouth, for example. The treatment is safe enough for routine use in children.
Might oral immunotherapy work for food allergy? Other Italian studies suggest that it could. The

objective of these studies is to reduce the risk to children with cow’s-milk allergy from accidental

encounters with ‘hidden milk’ in prepared food or drink. The immunotherapy treatment begins with

miniscule amounts of milk – the doctors start with a single drop diluted in water, each day for a week

– and increase the dose extremely slowly. Antihistamines are given to minimise the risk of a reaction.
The whole process requires enormous patience, but after seven months, the majority of the children

involved can tolerate some milk – between three tablespoonfuls and a small cupful each day.
This is a very encouraging study that should be repeated by doctors in Britain. Because of the risks of

anaphylaxis – which can, of course, be fatal – it does require full medical supervision, and you should

not attempt it at home. Whether this method would work for allergens other than milk is something that

nobody has yet investigated.
A great many other approaches to immunotherapy are currently being tried for food allergy. Many of the

new techniques are highly experimental, and some show great promise, but it will be many years before

they are in use.
One innovation that is closer to being in general use in the United States involves giving the anti-IgE

drug omalizumab (see p. 149) alongside immunotherapy injections. The drug maximises the benefits from

the immunotherapy, and may make the build-up stage (see p. 165) safer, by lowering the risk of

anaphylaxis. For British allergy sufferers, who cannot yet get omalizumab, and whose chances of getting

immunotherapy are vanishingly small, it may seem unkind even to mention such treatments, but we can

only hope that things will improve here in the near future. You might take some comfort from the

thought that, by the time immunotherapy is available again in Britain, there will be a whole host of

highly effective new techniques available for doctors to try.
All the methods described above are forms of specific immunotherapy – they treat an allergy to dust

mites or to grass pollen or some other specific allergen.
A far more radical and ambitious approach to immunotherapy is now the aim of some medical researchers:

blocking the tendency to allergies as a whole.The underlying idea here is to reverse the basic shift in

the immune response, from Th1 cells to Th2 cells. It is this shift to Th2 cells which produces the

allergic tendency (see pp. 11 –13).
Some interesting findings have already been made in this area, including the surprising discovery that

the balance of Th1 cells and Th2 cells can be adjusted even in people with longstanding allergies.

Inspired by discoveries about hygiene and allergy (see p. 21), British researchers have made a vaccine

containing inactivated cells of a harmless bacterium found in the soil, Mycobacterium vaccae. This is

given as a single injection just under the surface of the skin. It has been used for adult patients

with asthma, and for children with severe atopic eczema, with some improvement in both groups. If the

treatment proves as useful as the preliminary studies suggest, this could be a common treatment in a

few years’ time.

Asthma.
Tom works for the Post Office, sorting mail on a night shift. ‘After work, I come out of the sorting office - it’s about five or six in the morning, and really cold - and when I suddenly hit the cold air, I feel as if I just can’t breathe. My chest clamps up like anything, so much that it hurts. Then, when I get in the car and put the heater on, it’s fine again.’
What Tom is describing is bronchospasm, the key event in asthma – a sudden, but reversible, tightening of the bands of muscle that surround the airways. The narrowed airways stop air from leaving the lungs at the normal speed, which means the lungs are still half-full when it’s time for the next in-breath.
Taking more air into half-full lungs produces pain and tightness in the chest, as the lungs become over-inflated. (This can be alarming, because it can seem like pain from the heart, but it is just the rib joints and chest muscles hurting as they become stretched.)
Insufficient oxygen reaches the bloodstream because there is so much stale air in the lungs, so the asthmatic also feels breathless. Meanwhile, the air being forced through the narrowed airways makes a whistling sound called wheezing.
Those are the common symptoms of asthma, but there are others:
• Coughing, rather than wheezing, is the main symptom for some people (see box on p. 40).
• Sometimes there is vomiting during an asthma attack, especially in children, because the
overexpanded lungs put a great deal of pressure on the stomach.
• A few asthmatics suffer narrowing in the trachea (the upper part of the windpipe) rather than
in the airways lower down, and therefore feel as if they are being strangled.
Bronchospasm is just the endpoint of the disease process in asthma, a process which begins with inflammation of the lining of the airways. Although the airway muscles relax when an asthma attack is over, and you therefore feel much better, the underlying inflammation of the airways remains.
Airway inflammation may be caused, or partially caused, by allergy. Among asthmatic children, allergies are detected in 80-90%.
Inflammation makes the lining of the airways swell up, which itself narrows the airways a little. The inflamed airway lining often makes more mucus than usual, in an effort to protect itself (this is basically a healthy response – mucus works like a sponge mopping up irritating dust particles so that they can be ejected by coughing – but it’s excessive in asthma). This mucus can clog up the airways even more. Finally, the inflamed airways send nerve impulses direct to the airway muscles telling them to contract.
Mucus alert
Asthmatic mucus is white or clear, and sometimes frothy. Greenish or yellowish mucus suggests an infection and should be reported to your doctor.
In severe cases of asthma, a lump of mucus can completely block an airway, leading part of the lung to collapse. It is vital to clear mucus from the lungs, and a physiotherapist can help with this.
What causes asthma?
This question can be answered at three different levels:
1 What makes someone predisposed to asthma?
2 What starts asthma off – in other words, what starts the inflammation process in the airways?
3 What triggers asthma attacks (episodes of bronchospasm)?
What makes someone predisposed to asthma?
The predisposition to asthma is partly inherited (see p. and partly a matter of lifestyle: a poor
diet makes asthma more likely (see p. 206), as does too much cleanliness (see p. 21), obesity and lack of exercise.
What starts off the inflammation?
The predisposition to asthma sets the stage, but it does not, in itself, start the inflammation of the airways. That is often begun by an allergic reaction to something in the air – such as house-dust mite or pet allergens.
Alternatively, the initiating factor could be a viral infection, especially a kind known as Respiratory

Syncytial Virus or RSV – there are epidemics of RSV every two or three years. Those predisposed to

asthma may make an abnormal kind of immune response to chest infections caused by viruses, a response

that shifts the balance of the immune system towards Th2 cells (see p. 11) and allergy-type reactions.

Although the infection is defeated by the immune system, some inflammation of the airway lining

remains.
A heavy dose of certain irritants, such as chlorine, or the substances used in spray-painting cars, can

also initiate asthma; this mainly occurs in a workplace setting, causing occupational asthma (see box

on p. 133).
What triggers asthma attacks?
Once the inflammation of the airways has begun, the airways are ‘twitchy’ –oversensitive – and the

airway muscles contract (i.e. bronchospasm occurs) at the smallest provocation. This contraction of the

muscles – an asthma attack –can be caused by irritants in the air, such as tobacco smoke, or a great

variety of other things. The possible triggers range from cold air or the scent of hyacinths, to

thunderstorms, laughter or anxiety – see p. 39 for a full list. Exposure to the allergens that started

the inflammation will also trigger an asthma attack, as will a virus (viral) infection such as a cold

or flu.
For many asthmatics, the breathing pattern is disturbed by the asthma attacks, and may remain abnormal

between attacks. Hyperventilation or ‘over-breathing’ can begin quite easily for asthmatics, and then

adds to the overall problems. It may be difficult to tell if you hyperventilate or not, because your

habitual pattern of breathing will seem normal to you, but there may be tell-tale symptoms such as

dizziness, tingling of the hands and feet, numbness and muscle cramps. For a full list of symptoms see

p. 227.
Mind power
The muscle of the airways is the kind of muscle over which we have no conscious control, like that of

the heart. It is known as involuntary muscle, whereas muscles in the arms and legs, which contract or

relax when we tell them to, are called voluntary muscles. Studies with biofeedback have shown that

asthmatics may, with training, gain some degree of control over these involuntary muscles. Experienced

yoga practitioners are able to influence certain involuntary muscles, including those in the airways.
There are also various ways in which the mind, or a person’s social and emotional situation, can make

asthma worse (see p. 234) but the damaging idea that it is an entirely ‘psychological’ disease is now

discounted.
Allergens and irritants
Understanding the difference between allergens and irritants is important for asthmatics. Allergens are

specific — either pollen is an allergen for you or it isn’t, depending on how your immune system reacts

to it. They are also a basic cause of asthma — they start it off.
Irritants, on the other hand, are non-specific: they affect every asthmatic if sufficiently

concentrated, causing bronchospasm by aggravating the airway lining. And, at the levels usually

encountered, they only cause trouble because the inflammation of the airways has already occurred.

Irritants include cigarette smoke, other smoke and some industrial fumes, ozone (see p. 130), sulphur

dioxide (given off by some foods and drinks — see box on p. 207), fly spray, air freshener and other

aerosols.
Diagnosis
There are four separate aspects to diagnosis:
1 Is this really asthma or something else entirely?
2 Is it combined with other diseases, and how are they affecting the asthma?
3 What is the basic cause of the inflammation in the airways, and can this be avoided?
4 What sort of factors trigger the asthma attacks?
You may not get this full diagnostic programme, but you can probably help in finding answers to some of

the questions.
Is this really asthma or something else entirely?
There are no tests that can diagnose asthma with complete certainty, but the average case of adult

asthma is pretty easy to spot, and the same is true for children over five. It is also true, however,

that some patients now described as asthmatic would have been given a different diagnosis (e.g. wheezy

bronchitis) thirty years ago. To some extent, this is because asthma was under-diagnosed in the past:

doctors were hesitant about giving a diagnosis of asthma, because of the supposed overtones of

psychosomatic disease. Sweeping away that stigma has been of immense value, but certain patients

(especially young children) may now get diagnosed as asthmatic without sufficient evidence. However,

there are also many instances of asthma being missed.
There are two tests that should be carried out before you are given a diagnosis of asthma:
1 Peak flow is the top speed of the outgoing air from your lungs, usually measured with a simple

portable machine called a peak-flow meter. Because of the narrowed airways, asthmatics have a lower

peak flow than normal.
2 The reversibility test depends on measuring peak flow before and after inhaling a beta-2 reliever

drug which relaxes the airway muscles (see p. 152). If the drug improves peak flow by more than 15%,

this strongly suggests asthma.
Asthma may be difficult to diagnose in certain situations:
• In babies, who often wheeze, especially when they have colds or chest infections. This

generally clears up later and does not automatically develop into asthma. There is great controversy

about whether wheezy babies should be labelled ‘asthmatic’ or not, and how bad the wheezing should be

before they are given asthma drugs. Views on this vary, so you may want to see a different doctor for a

second opinion. For older children who wheeze only when they get chest infections, most doctors feel it

is valuable to use asthma drugs – such treatment does not ‘turn wheezing into asthma’
as is sometimes claimed. (There are several things you can do to minimise the chance of early wheezing

turning into asthma later – see pp. 244-9.)
• When the main symptom is coughing (see box on p. 40).
• When asthma occurs only at night. In some asthmatics, even intensive testing reveals no

abnormality in the airways during the day. The only way to diagnose the condition is to use a peak-flow

meter at home, morning and evening.
• When there is a sudden one-off asthma attack in response to a powerful allergen load. This

sometimes happens to hayfever sufferers at the height of the pollen season (especially during

thunderstorms). Some doctors will want to start asthma drugs immediately, but it may be better to get

the hayfever well controlled with antihistamines and see what happens. Often there are no further

asthma attacks.
Then there are conditions that can be mistaken for asthma:
• In children, an inhaled object – such as a nut or part of a toy – becoming stuck in the

airways. In babies it can also be inhalation of milk droplets; if so, the ‘asthma’ comes on mainly

after feeding.
• Post-nasal drip (see p. 29)
• Heiner’s Syndrome – (see p. 72)
• Bronchiolitis: a viral infection (generally caused by RSV –see p. 37) which affects the small

airways (the bronchioles) of babies and toddlers. Unlike asthma, it usually produces fever.
• Gastro-oesophageal reflux (GER), or the rising of acid from the stomach into the oesophagus.

(This is commonly called heartburn, after its most typical symptom, but you can suffer from GER without

having heartburn.) GER can aggravate existing asthma, and it can also be an asthma mimic. Babies,

children and adults can all suffer from this problem. There will usually be clues such as symptoms that

come on at night after a late supper, or whenever lying down.
• Hyperventilation (see p. 227) in non-asthmatics can be misdiagnosed as asthma if it causes

breathlessness.
• Aspergillosis (see box on p. 18)
• Problems with the vocal cords. Habitually contracting the vocal cords on the in-breath makes a

loud wheezing sound and can cause breathlessness. This problem can mimic asthma, but it also affects

those who really are asthmatic. The cause may be psychological.
• Low-level carbon monoxide poisoning, generally from gas fires, which can cause breathlessness

and fatigue.
• Bronchlectasis: stretching and damage to the airways caused by diseases caught in childhood,

such as pneumonia or whooping cough. This causes lifelong breathlessness.
Is it combined with other diseases, and how are they affecting the asthma?
Any allergic problems in the nose will contribute to asthmatic symptoms in the lungs, because there are

nerve-connections between the two. Long-term sinusitis can also make matters worse. Optimum treatment

for the nasal and sinus symptoms (see pp. 28-35) will help considerably with the asthma.
One unlikely source of asthmatic symptoms has only recently been recognised: allergies can develop to

the fungi causing athlete’s foot, or other diseases (see pp. 16-17).
GER (see p. 38) can contribute substantially to asthma. In some people, the reflux causes no obvious

symptoms, apart from worsening the asthma; medical tests can show that reflux is occurring. Your doctor

can advise on this, and on treatment.
For older people, especially veteran smokers, asthma may be part of a larger picture of inflammation

and damage to the air sacs of the lung (emphysema) and/or to the airways (bronchitis). This mosaic of

problems is known as chronic obstructive pulmonary disease (COPD). It may be difficult to tell if there

is asthma present, or how much it is contributing to the overall problem. Since many patients with COPD

are helped by asthma drugs, and trying out the drugs does no harm, doctors often prescribe them just to

see what happens.
What is the basic cause of airway inflammation? Skin-prick tests are usually needed here, to check for

allergic reactions. It may be difficult to get these in Britain, where there is a shortage of

allergists (see p. 89).
Simple detective work may pinpoint allergens without the need for tests. The likely suspects are all

airborne allergens – see p. 28. Remember that the reaction does not generally start as soon as exposure

to the allergen begins: there is a time-lag. So a new dog or cat, or an allergen encountered at work,

may cause no trouble for the first year or two.
Some irritants can also be a basic cause of asthma, but only if encountered in high doses, which

usually occur in the workplace. These are called asthmagens (see box on p. 133).
In all cases, removing the allergen or irritant from the airways should be a top priority. The sooner

you can end the exposure, the more likely you are to shake off the asthma, rather than have it for

ever. Once the inflammation of the airways is firmly established, it just fuels itself – so act

quickly.
In a minority of cases, food sensitivity is the initiating cause of asthma. The reaction to food is

delayed, so the link will not be obvious. Skin-prick tests for the culprit food are usually negative,

so an elimination diet (see p. 194) is needed to diagnose this problem and identify the food concerned.

Those most likely to benefit are brittle asthmatics (those most severely affected) – as many as 60%

have a food sensitivity. There are various other clues that food could be a factor (see p. 69).
When asthma begins in adulthood, there may be no clear initiating cause – it is just a question of

long-term damage and irritation to the airways. But there can be allergens playing a part, so it is

worth investigating this possibility.
What sort of factors trigger the asthma attacks?
Most asthmatics will recognise one or more of these as triggers:
• cold or dry air
• strong smells including perfume and fragrant flowers
• irritants in the air (such as cigarette smoke and other indoor pollutants, traffic fumes,

industrial pollutants); indoor pollution is often the worst, especially if you have a gas cooker

without adequate ventilation, so there is a lot you can do to improve the air you breathe (see pp.

128-30)
• sulphur dioxide given off by preservatives used in some food and drink (see box on p. 207)
• weather conditions, particularly thunderstorms
• laughing, sighing, yawning, coughing or any other altered breathing pattern
• stress or anxiety
• strong emotions such as fear, anger or excitement
• situations or people that evoke unpleasant memories –including traumatic childhood memories;

sometimes psychotherapy is needed to sort out such problems (see p. 233)
• exercise (because breathing hard dries out the airways)
• the allergens responsible for the asthma, e.g. cat allergen
• colds, flu and chest infections.
Recording your symptoms day-by-day should help to identify the triggers that are most powerful for you.

Generally speaking, such triggers should be avoided, but this is not the case for exercise which does

much more good than harm, in the long run – without exercise, your asthma will get far worse (see p.

41).
Take care with aspirin
Aspirin sensitivity can develop unexpectedly in asthmatics, especially those with allergic rhinitis

and/or nasal polyps (see box on p. 28). It can produce a severe, even fatal, asthma attack in someone

who has previously been able to take aspirin (see p. 151).
Treatment
The first and most important aspect of asthma is environmental control – to try to minimise contact

with allergens and irritants. If you are asthmatic and you smoke, you must stop, because this will only

make matters worse by stoking up the inflammation. Any other smokers in the family should accept that

from now on this is an outdoor activity.
One of the aims of good asthma treatment is to calm the airways down, so that they are less sensitive

and ‘twitchy’. This means tackling the inflammation. You can do this with preventer drugs such as

steroids or cromoglycate (see p. 157), or with the new anti - leu kotriene drugs (see p. 159), or you

can simply remove the basic cause of the trouble, if it is a domestic allergen source, such as a cat, a

dog or house-dust mites.
Treating associated diseases such as sinusitis, hayfever, perennial allergic rhinifis, gastroesophageal

reflux (GER – see p. 38) and athlete’s foot (where this is adding to the symptoms – see p. 16) can also

help in reducing the airway inflammation. Eating a better diet may make a further contribution to

calming the airways down (see p. 206).
The second strand of treatment is to deal with bronchospasm (contraction of the airway muscles) when it

occurs. This is done with reliever drugs such as Ventolin and Atrovent (see p. 152). Note that these

only relieve the symptoms of an asthma attack, and do not address the underlying problem of

inflammation. What is more, if used too frequently (more than once a day) they may increase the risk of

a fatal or near-fatal asthma attack (see p. 153).
At one time, reliever drugs were the mainstay of asthma treatment, and were perceived as entirely safe,

while preventer drugs such as steroids were only given to those with severe asthma. All this has

changed, and most asthmatics, other than those with very infrequent attacks, are now given a

pre-venter. If your drug regime has not been reviewed for some time, make an appointment with your

doctor and check that you are getting the best of the modern treatments.
Drug treatment of asthma is not something you can just hand over to the doctor – it requires a lot of

personal decision - making. If you usually get worse when you have a cold, for example, you need to
Just a cough?
For some, coughing is the main symptom of asthma. Known as cough-variant asthma, this is not always

diagnosed correctly, especially in children. For children with recurrent coughing (two or more episodes

per year of coughing without a cold) it may be a long time before the doctor considers asthma. But

other doctors may diagnose a coughing child as `asthmatic’ all too readily, without doing enough tests.

The important point is that asthma involves episodes of bronchospasm – contraction of the airway

muscles. Without this it is not asthma. Bronchospasm can be detected by medical tests such as peak-flow

readings. Wheezing is one possible symptom of bronchospasm, but coughing is another.
If there is only coughing as a symptom, and never any wheezing, this is probably not asthma. Among

children with this pattern of symptoms, allergies are unlikely to be involved. The cause of such

coughing may be:
• in children, the effects of parental smoking
• in those with perennial allergic rhinitis (see pp. 28-9) mucus from the nose running into the

lungs. This is called post-nasal drip and produces a persistent cough.
• in the middle-aged, eosinophilic bronchitis. This is caused by an influx of eosinophils (see p.

19) into the airway lining, causing inflammation. Allergies do not seem to play a part (it is no more

common in atopics than anyone else) and the airway muscles do not contract abnormally. Treatment is

with inhaled steroids.
• in atopics (those prone to allergies), a condition sometimes called atopic cough. It involves

eosinophils congregating in the trachea (windpipe) and bronchi, but not in the lower airways. There is

inflammation but no airway narrowing. Very little is known about this disease at present; it may or may

not involve allergies. Again, inhaled steroids are effective.
• for a few people, habitual coughing. This is usually an expression of some underlying emotional

difficulty and responds to psychological treatments. The cough often has a honking or barking sound.
Any of these can be misdiagnosed as asthma. For patients with eosinophilic bronchitis or atopic cough,

this is no tragedy as they will probably get the right treatment (inhaled steroids) anyway. But if more

exact diagnostic criteria are being used (e.g. a reversibility test – see p. 38) such patients will not

be classed as asthmatic – this is more of a problem because they may not get appropriate treatment.
increase your dose of preventer as soon as a cold appears, to stop airway inflammation before it

starts. You also need to know when an asthma attack is serious enough to warrant calling an ambulance.

A management plan, worked out with your doctor, is a useful aid (see p. 96). Using a peak-flow meter,

night and morning, to monitor your asthma will also be valuable (see p. 97).
The third strand of asthma treatment is to deal with associated problems:
• Panicky reactions during asthma attacks –which make matters infinitely worse – can be dealt

with by meditation, yoga, relaxation techniques or martial arts training (see p. 222).
• Hyperventilation, which plays a much larger role in asthma than previously suspected, can be

tackled by a variety of methods (see p. 228).
• The distortions of the rib-cage that develop in severe asthma can be treated with osteopathy.
• Losing weight, if you are very heavy, will help ease the burden on your breathing.
Exercise and asthma
Exercise-induced asthma is best tackled, paradoxically, by taking exercise. As your fitness improves,

you don’t pant so hard when exercising, so your airways dry out much less. Countless asthmatics will

tell you that once you overcome the first hurdle – of wheezing the minute you start to exercise –

things get a great deal easier. You will need reliever drugs, and possibly extra preventer, to help you

over this hurdle, but it’s worth it. Warming up with a few sharp sprints, separated by a rest period,

will also help. (If you get an asthma attack while exercising, however, you should always stop –

carrying on regardless can be fatal – literally. Always have your reliever inhaler with you when you

exercise and use it if you get an attack.)
Swimming is an excellent starting point for unfit asthmatics, because the moist air prevents the

airways from drying out. Swim outdoors if you can, since chlorine can be an irritant.
Once you are fitter, regular strenuous exercise makes the breathing muscles stronger, which is of great

benefit – this can also be achieved with special exercises (see p. 231).
Don’t underestimate asthma
Asthma can be fatal, so never take it too lightly. If you often wake up in the night with asthma, you

cannot keep up with most other people your age, or are frequently breathless when climbing stairs or

walking uphill, then your asthma is not under control. The same is true if you need your reliever

inhaler more than once a day, or frequently need steroid tablets. Review your treatment with your

doctor because you probably need more preventive treatment such as inhaled steroids (see p. 157) or

anti-leukotriene drugs (see p. 149).
Recognising an asthma attack and knowing when to call for help, or go to the hospital, is also crucial

(see p. 100). Remember that fatal asthma attacks often come on very quickly – half those who die do so

within two hours of the attack starting, and a quarter die within 30 minutes. Those who die are

generally people who have neglected their preventer medication, or have been exposed to very high

levels of allergens.
There is a major organisation involved in asthma prevention, by the name of Asthma UK. They work together with people with asthma, health professionals and researchers, to develop and share expertise to help people increase their understanding of asthma, and asthma prevention, allowing them to voice their concerns to the people who matter and reduce the effect of it on their lives. They are the only charity dedicated to asthma prevention by improving the health and well-being of people with asthma and are funded by voluntary donations, indeed they are responsible for nearly £3m of asthma research each year for the cause of asthma prevention.

A form of asthma prevention can be in the improvements in environmental quality to benefit everyone in the school building because pollutants have a universally negative effect. For example, for the benefit of the students, schools should undertake extensive building repairs, painting, cleaning, and extermination during long vacations. They should replace plastic furniture and carpeting, which often emit pollutants in the form of noxious gases. For further asthma prevention, they should limit use of cleaning supplies and equipment that emit toxic fumes and strong odours which again are pollutants, and require good ventilation when they are used. They should have the entire building (particularly the heating and ventilation system) cleaned regularly to eliminate dust mites, mildew, animal dander, feathers, cockroaches, and other possible asthma and allergy triggers, and make sure that leaks of water and plaster dust are stopped and quickly cleaned up. Additionally the can help in asthma prevention by regularly monitoring the air quality of schools, especially those in sealed buildings and try to increase the ventilation so that pollutants can escape. All this can help with asthma prevention. So whilst schools may not be able to eliminate other pollutants, such as chalk dust, they can, as an act of asthma prevention, find out which of them are triggers for particular students and try to limit the student’s exposure to them. Further, sensitive scheduling can keep students with specific sensitivities away from certain art supplies and animals, which may enhance the education of some students but sicken students with asthma.

As an asthma prevention in Scandinavia, cross-country skiers sometimes wear breathing masks which store the heat and moisture from the air they breathe out and then return it to the air they breathe in. This is helpful in avoiding exercise-induced asthma. Good control of your asthma, whether by breathing in a ‘preventer’ treatment or by avoiding causes of asthma such as house dust mites and pets can have a tremendously helpful effect on exercise-induced asthma. Reliever inhalers can be tremendously helpful in asthma prevention if you use them just before you exercise. This applies especially to the so-called ‘beta-2 stimulants’ such as salbutamol (albuterol) or terbutaline. The benefit should last for hours. Long-acting reliever inhalers are also very helpful; they just work for longer. If you are a competitive athlete or sportsman, you may be concerned about disqualification because you use drugs. The good news is that all the ordinary asthma medicines, used in the medically recommended way and dosage, are acceptable to sporting bodies provided you use them correctly for asthma. The wise thing is to check with your sports authority or sports doctor. Asthma prevention is good asthma management!
There are oral asthma medications that an individual can take to control their asthma, inhaled at the onset of an asthma attack. People with asthma can carry a peak flow meter; a hand-held tool for measuring their air flow to determine whether an attack is imminent, thus requiring their asthma medications. With help from medical providers and age-appropriate printed materials, children can learn to monitor their asthma and self-medicate with their asthma medications. Taking such control of their asthma medications not only decreases its symptoms, but also promotes the children’s feelings of self-confidence, with the management of their asthma and its medications.

There are dozens of asthma medications available in the UK; the most frequently prescribed of these medications being: Ventolin; Bricanyl; Becodite; Pulmicort; Intal and Tilade. The first 2 asthma medications are essentially relievers, whilst the others are preventers. The preventer drugs are taken by an inhaled route and must be taken regularly to gain maximum effect. They belong to either the steroid or anti-inflammatory groups of asthma medications. The reliever drugs do not need to be taken as often; indeed there is evidence to support that these medications are more effective when they are taken only occasionally. Naturally there will be a concern about side effects, but in the main, asthma medications are safe and free from problems.

One such treatment which can have side effects is a steroid called prednisolone; which is taken by tablet form. These asthma medications dampen down and reduces inflammation, swelling and phlegm. There is a soluble form of these medications called Prednesol, which is useful for children and people who struggle to swallow tablets. If used in short courses there should be no risks at all; it is only when these asthma medications are prescribed over a period of years that certain side effects can occur. These include skin changes, thinning of the bones, increased blood pressure, indigestion, ulcers and the development of diabetes. Once again the emphasis is on serious long term prescriptions of these asthma medications and a brief course has no history of causing any of the above side effects.

Asthma is not an allergy as such, but there are asthma triggers, which can be caused by an allergic reaction to any number of incidents. If you have asthma, your air passages are irritable. This means things which are harmless to other people may be asthma triggers to an asthma sufferer. Various asthma triggers include: (i) Emotional stress - people with asthma often say their asthma gets worse if they are upset. (ii) Cold air - if you move from warm indoor air to cold air outdoors it can affect the air passeges. (iii) Pollution, in particular tobacco smoke - e.g. in a pub, can be one of the more common asthma triggers. (iv) Grass pollen - particularly when exposed to a recently mown lawn. (v) House dust mites - often attracted by central heating. (vii) Pet fur - especially during the malting season can affect the air passeges. (viii) Exercise - can provoke narrowing of the air passages. (ix) Infections of the lining of the breathing passages - e.g. colds and ‘flu. (x) Some drugs - especially medicines called beta blockers used for high blood pressure or heart disease have been known to be asthma triggers. (xi) Indigestion - also called gastro-oesophageal reflux, with stomach acid coming up into your gullet. (xii) Laughing - so don’t laugh! (Only joking, but it can happen). All the above reflect the irritability of the air passages in asthma, even if some of them do so in somewhat different ways, they all can be asthma triggers.

There have been significant changes in air quality over the past few decades. Pollution, from the burning of coal, which resulted in emissions of sulphur dioxide and particulate matter has decreased considerably; however, the frequency of peaks of traffic related pollution and the geographical extent of it have probably increased. Episodes of pollution from secondary pollutants, notably ozone, produced by photochemical oxidation, have also increased and this is one of the chief asthma triggers. Moreover, there have also been changes in people’s diet, lifestyle, and in homes and other indoor environments. For example, homes have tended to become warmer and, in this and other ways, much more appealing to cohabitation by dust mites, a real enemy of asthma sufferers. All these can act as asthma triggers. Cinemas and theatres can also surprisingly act as asthma triggers for some people. Research carried out recently found low levels of bacteria and moulds on carpets and seats, but high concentrations of cat allergens; presumably brought in on the clothes of members of the audience. Maybe get a DVD next time!

Hayfever in Allergy

Foxtall grasses release their pollen - a potential source of hayfever symptoms.
`I gradually recognised that it was not an ordinary cold and that the symptoms were much worse on the

golf course or even during a nice day rowing on Loch Lomond.’ Dr John Morrison Smith, then a medical

student, began suffering from hayfever in the late 1930s. ‘At first I did not know what I had, and

neither did any other doctor I encountered in the next two or three years…’
All the classical allergic diseases (see box on p. 11) seem to be increasing, but none has exploded

quite so dramatically as hayfever. The physicians of Ancient Greece described asthma and food allergy,

and the Romans recorded allergy to horses, but there were no reports of hayfever. The only account –

and it is a doubtful one – comes from Persia in AD 925. Two hundred years ago, hayfever was unknown –

and careful research by medical historians has shown that this was not a case of it simply being

ignored, or misinterpreted as a cold.
The first case was reported in 1819, but even in the 1930s it was so rare that a succession of Scottish

doctors and medical students were baffled by Dr Morrison Smith’s symptoms. Today everyone knows what

hayfever is, since huge numbers of people sneeze and snuffle their way through the pollen season. There

are no certain explanations for this meteoric rise, but greater hygiene (21) may be an important

factor.
Symptoms of hayfever
The common symptoms of hayfever are well known:
• itchiness of the nose, mouth, throat and eyes – often the first sign
• a streaming and/or blocked nose
• frequent sneezing
• red, watery eyes (very rarely, hayfever affects the eyes only, with no symptoms in the nose).
Less commonly, there may be:
• dryness of the throat if the nasal blockage results in constant breathing through the mouth
• no sense of smell due to a blocked nose (but nasal polyps can also cause this – 30)
• a feverish sweaty feeling (but the body temperature is usually normal)
• swelling and inflammation of the eyelids, sometimes leading to blistering and ulceration: there

is a risk of blindness if this is not treated promptly
• recurrent sinusitis (30)
• earache, itching or a stuffy feeling in the ears, or ‘glue ear’ (29)
Some sufferers also experience:
• Oral Allergy Syndrome (an itchy tingling mouth) from certain fruits, nuts and vegetables (see

box on p. 63)
• a skin rash from pollen falling on the skin, direct contact with the leaves of the offending

plants, or with droplets of moisture from them – as when mowing a lawn or using a strimmer. If the skin

is cut or grazed, anaphylaxis can (rarely) result from direct contact with the plant (see pp. 58-9).
Even more rarely there can be:
• stomach upsets or even colitis (inflammation of the bowel) possibly due to pollen swallowed

with food or in the saliva
• irritation in the vagina
• migraine
• kidney inflammation (nephritis), leading to puffiness of the face and hands, and possibly other

symptoms
• joint pains.
The last two are probably caused by pollen allergens bound to their antibodies and carried in the blood

(13).
Diagnosis
The standard diagnostic tool here is the skin-prick test (see lo, 91). In diagnosing hayfever there are

three separate questions:
1 Is it actually hayfever?
2 Which pollen or pollens are responsible?
3 Are allergens other than pollen also involved?
Don’t be surprised if none of these questions is asked. In most countries, if you have hayfever-like

symptoms during the pollen season (i.e. when most hayfever sufferers have symptoms), the doctor will

conclude that you have hayfever - and that will be the end of that.
If hayfever seems plausible to you, and you respond to drug treatment, or manage well on pollen

avoidance (126), then -here is probably no reason to go further. Should you want a more thorough

investigation, you will need to be persistent. These are good reasons for requesting a full diagnosis:
• Your symptoms are worse in the pollen season, but they never really go away, suggesting that

you may be allergic to year-round allergens, such as house-dust mite or moulds, as well. It is worth

knowing which ones, so that you can avoid them. If you live in an area that is always warm (such as

California or Southern Australia) it may be that your culprit pollen is in the air all year round -

even so, knowing which pollen it is can help with avoidance. Around the Mediterranean, the pollen from

cypresses can keep hayfever going through the winter (or cause symptoms in winter only).
• Your symptoms are sometimes worse when they should be better, and vice versa. If you are

consistently worse indoors with the windows closed this could indicate that a seasonal indoor allergen

is the culprit - mould spores or cockroach perhaps (cockroach is often seasonal in regions with cold

winters - 118).
• Your symptoms begin before the pollen season begins, or go on long afterwards. Or the severity

of your symptoms does not match the daily pollen count for your suspect pollen. In Britain, the mould

Cladosporium herbarum produces spores in June, roughly coinciding with the grass-pollen season. Allergy

to this mould can easily be mistaken for grass-pollen allergy. You would need skin-prick tests for both

Cladosporium and grasses.
• You are much worse near home than elsewhere. It could just be a garden plant or tree. As one

California resident observed, ‘The worst offender was an olive tree on our front lawn. It’s been

removed.’
• You want to plan holidays free from the culprit pollen.
Moving house - especially to a region with different vegetation
- can be a spur to finding out exactly what your allergens are. If you are going for a full diagnosis

make sure it is done correctly. Don’t accept testing with ‘mixed tree and shrub pollens’ for example,

or ‘weed pollens’. The result tells you very little. Ask for tests with specific pollens.
Treatment
Too many people allow hayfever to spoil the summer months because they are anxious about taking drugs,

or feel that it is nobler to suffer. This book is not in any way complacent about the dangers from

drugs (see Chapter 5), but when it comes to hayfever there really is very little cause for concern. The

risks with drugs used for hayfever are absolutely minimal, and it is such a waste to miss out on the

best time of year.
Most hayfever responds very well to treatment with antihistamines (138). If they make you sleepy,

persist for a while, because this side effect often wears off - or ask for one of the new non-sedating

forms. The sleepiness is annoying, but it is only a minor side effect, and not an indication of the

drug causing any serious harm.
Cromoglycate drops (for the eyes or nose) do not work for everyone, but if they work for you, go for

them. These are absolutely the safest of the anti-allergy drugs. Steroid drops for the nose (144) are

also recommended. The dose of steroid involved is small, and very little gets into the bloodstream, so

there is no risk of serious side effects. If you suffer stinging, burning or dryness, it might be due

to preservatives in the drops, not the drug itself (see box on p. 33). Steroid drops for the eyes

should be used cautiously (144). Don’t use over-the-counter decongestant drops for more than three days

(29).
Immunotherapy is standard treatment for hayfever in many countries, but in Britain you will have a

struggle to get it (see pp. 164-8). Some hayfever sufferers feel they do well with homeopathy (215) or

acupuncture (214).
Pollen asthma
Some people with hayfever also have pollen asthma. Their asthma is worse in the pollen season but it

usually persists all year round (either because there are other allergens or irritants involved, or

just because the inflammation of the airways is self-perpetuating) whereas hayfever itself clears up.

Treating the hayfever fully with antihistamines helps considerably with the asthma symptoms.

 

In medical terms, this article covers a lot of ground.
First there are the classical allergic diseases
 such as hayfever and immediate food allergy, which are caused by the allergy

antibody, IgE .
Then there is non-IgE immune sensitivity, a category which includes a number of quite different

diseases, caused in a great variety of ways. They also vary in severity - there are serious lifelong

problems such as coeliac disease and minor short-lived problems such as contact dermatitis from garden

plants.
Finally the chapter looks at diseases where the immune system seems not to be involved, or

plays only a minor role: the intolerance reactions to food and synthetic chemicals. These are diverse

and rather mysterious in origin. They would not be described as ‘allergies’ by most doctors, though

they often are by complementary therapists (6).
These categories are not nearly as neat and tidy as they might sound. Some problems refuse to fit

anywhere, such as atopic eczema caused by food. A percentage of children with this problem have IgE to

the food concerned, while others do not - so where does it belong?
If you were expecting an answer to that question, you will be disappointed. Nor, quite often, are there

any certain and honest answers to questions such as ‘Has my baby really got asthma?’ or ‘Can you be

sure it’s irritable bowel syndrome?’ There are no answers to
such questions because most diseases do not exist in neat compartments, and the words we use to

describe them really denote rather abstract concepts.
This does not mean that the terms used to describe diseases are invalid - doctors and medical

researchers invent them to try to make sense of a complex, confusing and largely foggy reality. They

also argue over them, split them, unite them and redefine them. There is a constant desire to get the

medical picture of that foggy reality more precise and accurate (although medical politics gets

involved too - 7 -which is unfortunate).
Over time, thanks to huge amounts of research effort, things gradually get clearer. You’ll no longer

hear a doctor talk about ‘rheumatism’ or ‘arthritis’, because it was long since realised that these

categories were useless - they included a number of diverse diseases. And while doctors might say ‘food

poisoning’ or ‘heart attack’ or ’skin cancer’ to a patient, they use much narrower and more precise

terms when talking among themselves, and when ordering tests or prescribing treatment. Each of these

categories has been split into several well-defined sub-categories.
Ideally, this process of splitting continues until each disease category has a set of well-defined

symptoms (this set is known as a syndrome), plus a few simple and definitive diagnostic tests. This

will probably depend on the cause of the disease (the mechanism in medical jargon) being clearly

understood. Once the mechanism is clear, then a disease category is a truly satisfactory tool for

diagnosis and treatment.
Of the disease categories mentioned in this book only a few, such as coeliac disease and hayfever, have

reached that happy state. The majority are still somewhat arbitrary and debatable.
Some disease terms describe a set of symptoms with no clear underlying cause, for example, ‘irritable

bowel syndrome’. Others describe a well-defined response by the body, that can be caused in many

different ways - an endpoint that can be reached by various routes. This is true of ‘asthma’ or

‘urticaria’.
A third type describes a much less well-defined cluster of symptoms. Idiopathic food intolerance,

chemical intolerance and yeast overgrowth all come into this category. A few doctors don’t even see

some of these clusters as real diseases because the symptoms involved are so vague and so widely

encountered. Some of the arguments used to dismiss idiopathic food intolerance are dissected on pp.

74-7. A key point made against these diseases is that the symptoms they produce are non-specific -

common symptoms such as headache, fatigue and diarrhoea, which can arise in a great variety of ways.

Ever since Pasteur and the germ theory, medicine has been based on the idea of each disease having

specific symptoms and specific causes, and it has roared ahead on the basis of this assumption. This is

the prevailing paradigm of modern medicine, and like all
paradigms it blinds people to facts that don’t fit. Evidence is accumulating that there are diseases

which have multiple, non-specific and variable symptoms. Chronic Fatigue Syndrome (CFS - see box on p.

85) is one of these, and its recent transformation from a doubtful diagnosis to a reputable disease

recognised by conventional medicine suggests that the paradigm might be starting to crack.
To sum up, the business of identifying and naming diseases is a complex and uncertain process, in which

the concept of most diseases is only ever that - a concept, subject to change and refinement. This does

not make it worthless - quite the opposite. These concepts are the best we can do at the present time,

and accurate diagnosis is the key to getting the best treatment available now.
As regards both diagnosis and treatment, this book covers a very wide spectrum of medical opinion, from

the entirely orthodox to the frankly whacky. I have tried to give an objective view of these different

opinions and approaches, using the evidence currently available, in the hope that it will help readers

to improve their health while wasting as little as possible of their time or money. In using this

information, you should always try to work closely with your doctor (96), respecting the depth and

breadth of knowledge that conventional medicine has to offer.