Asthma Awareness Month; Claudication & Vascular Problems.

The following reviews topics discussed on Let's Talk Medical with Dr. Gigi as it aired live on WTAN 1340-AM on May 25, 2012.

Asthma Awareness Month:

May is Asthma Awareness Month, so let's discuss some highlights of this disease.  It is basically inflamation of the airways, which results in sputum, spasm, & swelling.  The inflamation can be due to infections (viral, bacterial, or fungal), allergens (pets, dust mites, cockroaches), or irritants (like smoke, perfumes, chemicals, or even acid from GE reflux).  People with asthma react more vigorously to these triggers than the average person as they have a gene which causes an over-production of inflamatory substances in their airways.

Despite the advancement of medicine over the past decades, the prevalence of asthma has been steadily increasing since the 1970's.  We are not sure why this disease continues to affect more & more people, but perhaps it is related to poor air quality or perhaps the gene is being passed on to more of our relatives!  At present, approximately 20 million people have asthma, & of these 6 million are children.  In general, children have worse outcomes than adults, so they must be monitored more closely & treated more aggressively. 

There are many medications for treating asthma, but there are basically 2 types of meds:  anti-inflamatory meds & anti-spasm meds.  The anti-inflamatory meds decrease the inflamation in the airways, so they essentially treat the disease itself, & are thus considered MAINTENANCE meds as they are used daily to maintain control of asthma.  Anti-inflamatory products are either steroids (like AsmanexAzmacortQ-VarPulmicortFlovent, & Aerobid) or leukotriene inhibitors (like SingulaireAccolate, & Zyflo). 

On the other hand, the anti-spasm meds are also called beta-agonists, & they come in 2 types:  short-acting & long-acting.  Short-acting beta-agonists are meds like Albuterol & Xopenex, which start to work within several minutes but only work for about 4-6 hours.  Long-acting beta-agonists are meds like Foradil & Serevent which take a little while to start to work (15-30 minutes) but then last for about 12 hours.  The short-acting meds like Albuterol are used as EMERGENCY (or RESCUE) inhalers as they work so quickly, but if you have good control of your asthma you should not need them very often.  In fact, if you use your rescue inhaler more than 2 times per week, you should call your doctor as you might need additional evaluation or treatment.  The long-acting beta-agonists can be used as maintenance meds, & are often found combined with steroids in products such as Advair (which is a steroid plus Serevent) or Symbicort (which is a steroid plus Foradil), but as they take a while to work, they are never used as rescue inhalers!

If you take your maintenance inhaler daily but suddenly realize that you are having more shortness of breath or more wheezing (this is actually the noise made by the air passing through an airway which is in spasm), you should start to use your rescue inhaler.  Remember however that if you use it more than 2 times per week, you should call your physician.  You should consider it an emergency each time you reach for your rescue inhaler.  So would you really allow yourself to have more than 2 emergencies in 1 week without calling your doctor for help?  The doctor will likely look for factors that cause worsening of asthma such as infection or exposures to allergens or irritants.  Depending upon the cause for your worsening asthma (called an "exacerbation" of asthma), the doctor might order a chest x-rayblood tests, or sputum culture, & might treat you with antibioticsreflux meds, or oral steroids.  Severe asthmatic attacks often require hospitalization for IV fluidsnebulizer treatments, & IV antibiotics.

Many people used to use an over-the-counter rescue inhaler called Primatene Mist as treatment for asthma.  This was Epinephrine in an inhaled form.  Since January 2012 it is no longer available due to the fact that it was very potent, had many side-effects, & was over-used by people who could be better managed by seeing a physician & getting a maintenance inhaler.

There is a gadget called a peak-flow meter which can be used to assess your lung function.  It is an inexpensive plastic device which your doctor can prescribe, & which you can get from the pharmacy.  It measures the peak force exerted when you exhale forcefully.  There are standards for age & height, but more importantly, if you check your peak flow intermittently, you will be able to determine your own baseline, so you will know when you are deteriorating.

Though asthma is a treatable disease, it is still a deadly disease.  In fact during my 20+ years of practice, I have had 2 patients die from asthma.  They were only 29 & 45 years old!  So if you have asthma, become knowledgable about your diseasetake your meds as instructed, & if you have worsening, do not over-use your rescue inhaler!  Instead, call your doctor for further evaluation & treatment!  After all, if you can't breath, you can't live!!!

Claudication & Vascular Problems:

People sometimes complain of pain in their legs.  When the pain occurs with walking or similar exertion, it is generally due to a blood flow problem though sometimes it is caused by a neurologic problem.  People with back problems, in particular spinal stenosis, often have pinched nerves in the back which cause a heaviness or pain in the legs which resolves with rest AND sitting.  In fact, sometimes this "neurogenic claudication" resolves or abates with simply bending forward at the waist... which unloads pressure on the spine.  This is why many people like to lean on a shopping cart while walking, as it relieves stress on the spine.

On the other hand, people with vascular (or blood flowproblems get pain & cramps in their legs, but these resolve with rest alone... sitting is not required.  This "vascular claudication" is basically like a heart attack of the leg muscles.  The muscles are busy working, but due to blockage of an artery, the blood (& oxygen) cannot get to the muscle, so the muscle cramps up & can no longer function.  When you rest, the oxygen demands of the muscle decrease & the blood flow is adequate, so the pain resolves & you can walk a little further before the pain returns.  If you do not intervene & re-establish good blood flow, you can end up with limited mobility, but over time you can actually get pain even at rest.  This is an indication that the blood flow in that leg is so limited that the muscle does not get enough oxygen even at rest.  Usually by this time people & their doctors figure out that there is a real problem & they do a bypass surgery or an angioplasty to improve the blood flow.

Early on, vascular claudication is treated with medications like Pletal which make the red blood cells (which carry the oxygenmore pliable.  Red cells look like frisbees, but they are fairly rigid, so the Pletal allows them to be more flexible so they can fold in half, thus squeezing through the blocked arteries more easily.  It is interesting to note that although walking triggers pain, a walking program is actually prescribed as treatment for vascular claudication as the body often responds to this oxygen-deprived situation by growing its own bypasses called "collateral" blood vessels!

Though neurogenic claudication is evidence of a nerve problemvascular claudication is evidence of a circulation problem.  It is a reflection of blocked arteries, so if you have it, you should have a work-up to look for other blocked arteries.  This should include a carotid ultrasound to look for blockage that could lead to a stroke, & a stress test or heart catheterization to look for blockage that could result in a heart attack.  Remember, the vascular system is one system... if you have blockages in one place you are prone to have blockages elsewhere!  Note however, that although you should push through the pain of vascular claudication to stress the body & encourage it to create collateral circulation, never push through chest pain, as the body does not generally create its own heart bypasses!

So we'll end on that note!  Hope you learned something, & I hope you'll listen to the live radio broadcast of Let's Talk Medical with Doctor Gigi on Fridays at 1PM Eastern time on WTAN 1340-AM in the St. Pete/Tampa area.  Of course you can always catch me on the computer via where you can listen live or to the recorded podcasts.  I appreciate any input, & please don't hesitate to call or to e-mail your questions:
(727)-441-3000 local, (866)-TAN-1340 toll-free, or

Here's to our health!

Doctor Gigi