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Asthma (transcript)
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(Announcer 1)            
This week on Second Opinion Dr. Peter Salgo is joined by pulmonologist, Dr. Michael Apostolakos  



(Dr. Michael Apostolakos)    
I want to make sure he has not thrown a blood clot to his lungs.



(Announcer 1)            
Asthma experts, Dr. John Condemi and Dr. Daryl Zeldon, along with special guest, Monica Wright  



(Monica Wright)            
The chest is burning.



(Dr. Peter Salgo)        
Burning?



(Monica)            
Burning.  You feel like there is a five pound bag of flour sitting on your chest.



(Announcer 1)            
And panel regulars, Dr. Lisa Harris and Elissa Orlando, as Second Opinion takes on a serious disease that is debilitating millions of Americans each year.

(Announcer 2)        
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent Blue plans committed to better knowledge leading to better, more affordable healthcare for consumers.






(Dr. Peter Salgo)        
Welcome to Second Opinion where each week we solve a real medical mystery.  When we close this case file in half an hour from now you will not only know the outcome of this weeks case, you will be better able to take charge of your own healthcare.  I am your host, Dr. Peter Salgo and our case file today contains the story of Henry.  You have already met the healthcare team assembled to tackle this case.  Some are doctors, some are not, and no one on the panel knows the case except for our resident civilian, Elissa Orlando.



(Elissa Orlando)            
Hi Peter.



(Peter)        
Nice to see you back again.  Thanks for coming.



(Elissa)            
Thank you.



(Peter)        
Let us get right to the case shall we?  Henry is forty five years old.  He is married.  He has two college age children and it is ten p.m.  He was watching Monday night football and he mowed the lawn earlier during the day.  He suddenly becomes short of breath.  He feels like he cannot get enough air.  His wife calls 911 and the ER doc when Henry arrives, what do you do?



(Dr. Apostolakos)    
Well, I am very concerned for a relatively young man who becomes quite ill quite fast and so I want to monitor his vital signs initially.



(Peter)        
You going to do anything for him in the ER?  Are you going to do any tests?



(Dr. Apostolakos)    
Absolutely and the first thing I am going to check is his oxygen saturation and apply oxygen.



(Peter)        
So you are going to put oxygen on him.  His 02 saturation, which is the amount of oxygen



(Monica)            
Excuse me, what is oxygen saturation?



(Dr. Apostolakos)    
That is the amount of oxygen that is found in hemoglobin in the blood, it is a measure of how well you are oxygenating your blood.



(Dr. Peter Salgo)        
I can tell you because I have the number here in the chart.  It is normal.  Any other labs that you want?



(Dr. Apostolakos)    
Well, I would want a chest x ray.



(Peter)        
Chest x ray is normal.



(Dr. Michael Apostolakos)    
And I would want to examine his lungs and heart first.



(Peter)        
Okay.  His heart sounds normal, although his heart is beating rapidly and he has bilateral wheezing.  I could tell you, because they did a few other studies, his cardiogram was normal and hey actually did something called an arterial blood gas.  What is that?



(Dr. Condemi)        
Well, that is to determine the amount of oxygen and carbon dioxide in his blood.



(Peter)        
And the amount of oxygen in his blood was normal, but the amount of carbon dioxide was low.  What does that tell you?



(Dr. Lisa Harris)        
So what we want to know is how much waste is he getting rid of and how much good stuff is he getting in?



(Peter)        
Monica, You have been in this situation.



(Monica)            
I have.



(Dr. Peter Salgo)        
What does it feel like?  What is Henry thinking and feeling?



(Monica)            
He is thinking that he does not understanding why all of a sudden this has happened.  Why he cannot breathe.  The chest is burning.



(Peter)        
Burning?



(Monica Wright)            
Burning.  You feel like there is a five pound bag of flour sitting on your chest.

(Peter)        
That has got to be terrifying.



(Monica)            
Terrifying, very terrifying.



(Peter)        
Well, here is Henry.   He is terrified.  In the meantime his doctors are working.  What do you think is wrong with Henry?  What is part of the differential diagnosis here?



(Dr. Zeldin)        
Well, certainly acute onset of an asthma attack would be one of the things I would think about.  In a guy his age I would worry about heart problems.



(Dr. Apostolakos)    
In a forty five year old man before I go into a whole lot of history about asthma, etc., I want to make sure he is not having a heart attack.  You told me his electrocardiogram was normal.  I want to make sure he has not thrown a blood clot to his lungs.



(Dr. Peter Salgo)        
How long are all of you guys and women willing to let Henry sit there short of breath, wheezing, before you do something?



(Dr. Apostolakos)    
Something is going to be done immediately for him.  He is going to be placed on oxygen.



(Monica)            
So you are saying all of this?



(Dr. Apostolakos)    
Are happening simultaneously.  He is getting treatment.  A nurse is putting in an IV, he is getting oxygen treatment.  If we hear wheezing we empirically start bronchodilators to open up the lungs.



(Peter)        
Tell me about bronchodilators.  What are they?



(Dr. Daryl Zeldin)        
They are drugs that open up the airways and allow more airflow in and out and reduce wheezing and there are several categories of bronchodilators that when we typically use affects certain types of receptors called beta receptors in the lung.



(Peter)        
And so that will make the airways, which you are presuming now I guess are too small because he is wheezing.  Make them bigger.



(Dr. Zeldin)        
Right.  They are quick acting, in general.



(Peter)        
You have had a bronchodilator, Monica.



(Monica)            
Yes.



(Dr. Peter Salgo)        
Tell me what that does.  How does it make you feel?



(Monica)            
It is almost instantaneously when I take a couple of puffs and it feels like the weight is being lifted off of my chest, but it helps me with my breathing.



(Peter)        
In the emergency room they gave him a bronchodilator, so you guys and the docs who were treating Henry are all on the same page, and Henry feels better and the word here in the chart is immediately   I assume this means within minutes   and his doctor at that moment, because Henry looks good, thinks It is safe to send him home.  They send him home with a bronchodilator, a puffer, and they tell him to go see his primary care doc the next morning.



(Monica Wright)            
Just coming from my perspective is that is happening immediately and then they are giving me something and I am feeling better.  As a patient I want to know why I am feeling better.  Is this going to be lasting?  Is it going to last me until I get to my primary care physician the next day and what happened to me?



(Peter)        
My question is, is it going to last him until he gets home?



(Monica)            
To the car.



(Peter)        
To the car.  This is a real question.  Would you send somebody home?



(Dr. Lisa Harris)        
Absolutely not.  He had an abnormal ABG already so his blood gas is abnormal.  You have given him a treatment.  He needs to be observed a little bit longer than one treatment.



(Dr. Peter Salgo)        
Well, that is what they did.  Everybody unhappy with this?



(Dr. Lisa Harris)        
Very.



(Peter)        
He comes to see you.  You are his primary care doc, It is the morning after the night before.  What are you going to do?



(Dr. Lisa Harris)        
I would want to know how he did overnight.  Did he have any more chest tightness, wheezing, coughing, shortness of breath?  Anything?



(Peter)        
He is feeling pretty good.  He has had wheezing, I can tell you, in the past accompanied by chest tightness.  It is worse late in the day.  He coughs occasionally at night and sometimes with exercise.  He gets colds a lot.  He does not wheeze with strong emotions.  He does not wheeze to things that he knows are in the air as best as he knows and he has been taking lately over the counter medications for what he calls his seasonal colds.



(Monica)            
I am hearing the symptoms that he is giving and he sounds like he is inside my head and he knows exactly what I am going to say because a lot of those things sound just like me.



(Elissa)            
It sounds like a lot of people maybe.



(Peter)        
So with this history anything else you want to do?



(Dr. Lisa Harris)        
Yeah.  He worries me.  He sounds like someone who has possibly some problems with allergies. Clearly, may have some asthma, so I am going to examine him and I am going to do a spirometry in my office and a pulse ox.



(Elissa)            
It sounds to me like you are going to focus your diagnosis.  You are looking for something wrong with me in my upper respiratory area.



(Dr. Lisa Harris)        
In your lower respiratory area.



(Elissa)            
Lower respiratory area?  So you are looking at my respiratory function and you are looking at things that might be wrong there.  Is that right?



(Dr. Lisa Harris)        
Right.



(Dr. Condemi)        
The physical ability for you to get air in and out of your lung.



(Dr. Lisa Harris)        
He is not a smoker?



(Peter)        
He is not a smoker and there are no smokers in the household.



(Dr. Condemi)        
We will see patients in the office who are walking around at sixty percent of what they should be and not have any symptoms except complain they may have shortness of breath walking upstairs with the laundry.



(Elissa Orlando)            
What is a PFT?   I understand sixty percent of what they should be, but what are all these terms you are throwing around?



(Dr. Condemi)        
Well, it is this breathing test that she is talking about.  The ability of this individual to get air in and out of his lung and so you measure it.




(Elissa)            
Can you tell me what that looks like, the spirometry?



(Dr. Lisa Harris)        
I have a little portable one in my office, so It is a little square box that is basically like part of a computer and there is some tubing and a little,   almost like a horn that you hold in your mouth and you blow out as hard and fast as you can and we actually instruct the patient how to do that and the problem with many asthmatics or people with allergy or allergy induced asthma or breathing problems is that they are so used to.   they have had such decreased lung function for so long that they think that this is normal and they do not know what it feels like to take a normal deep breath and that is why we do the test.  



(Elissa)        
Some people are walking around with sixty percent and they just do not know.



(Dr. Michael Apostolakos)    
Can I ask one question about history?



(Dr. Peter Salgo)        
You may.



(Dr. Apostolakos)    
Any family history of asthma?



(Peter)        
No family history.  We do know that this is the first time he is seen by his primary care physician about this problem or any problem because he just moved.  Henry used to live in Arizona and now he has moved to Freeport, Maine and suddenly this is when he starts taking all those medicines he told you about over the counter.  So does that have any impact on what you are thinking about Henry?



(Dr. Lisa Harris)        
Actually, yeah, I am thinking about environmental allergens.  That is the first thing that popped into   Arizona is dry.  We send people there to get better.



(Peter)        
So they do some breathing tests in the doctors office and they establish that when he uses a bronchodilator his airways got better.  I have some numbers for you.  His FEV1 over FVC ratio was less than sixty five percent of predicted.  It improves better than twelve percent using a short acting bronchodilator.  That is a mouthful.  Can somebody translate all of this for Elissa who is sitting here going oh, my goodness.  



(Dr. Apostolakos)    
The spirometry gives you two essential numbers.  One is the forced expiratory volume in one second, which is how much air you can blow out after a deep inspiration in the first second over the FEC which is the forced vital capacity, which is how much air you can totally move.  For a normal person in one second you can move about seventy five percent of your total exhaled volume.  In someone who is obstructed it takes longer to get that out so there is less and the percentage goes down that comes out in the first second as compared to the total amount out.



(Peter)        
Can we say that Henry has asthma?  There is definitely silence here.  Why?  

Never known such unanimity of thought in my life here.  Does he have asthma or not?



(Dr. Lisa Harris)        
Well, asthma you have to say that he has recurrent episodes of bronchospasm and it is hard to say on one episode whether or not he truly has asthma.



(Dr. Zeldin)        
And just saying he has asthma is not as important as knowing what caused, what triggered this particular episode and what is in his environment that may trigger further episodes.



(Peter)        
I am sure they are going to investigate that, but if he leaves your office and you tell him what is wrong he is going to ask you.  Can you tell Henry he has asthma?



(Dr. Lisa Harris)        
I can tell Henry that he reacted to something that is making him have difficulty to breathe and we need to put him on some medication to keep his airway open until I can get him in to see Dr. Condemi and Daryl.



(Dr. Peter Salgo)        
That is going to make Henry really happy.  Monica, you told us you had an episode much like Henrys.  Tell me more about it.  What was it like?  How did it happen?



(Monica)            
What had happened probably five winters ago I was having episodes of chronic bronchitis and the doctor continually asked me is there a history of asthma?  Do you have a history?  Are there pets in the house?  Is there anyone smoking that is in the house?  I said to them no to all of those questions and they treated me for the bronchitis but I kept coming in.  I was having a casual conversation with my mom about my bronchitis.  I said the doctor keeps asking me if I have a history of asthma and my mother informed me that I did.  I was four years old.  I did not know and I grew out of it and I did not know that I had had asthma as a child.



(Dr. Apostolakos)    
That brings up a very important point.  As a pulmonologist I get referred a lot of patients with  recurrent  bouts of chronic bronchitis on antibiotics and their diagnosis is really asthma because no one checked their spirometry.



(Peter)        
So nobody did that breathing test.



(Dr. Michael Apostolakos)    
That is right.



(Peter)        
So can you guys now hearing these two stories give me a definition of asthma which fits?



(Dr. Condemi)        
Asthma is inflammation of the airway.  You have got fire in your lung.



(Monica)            
That is exactly what it feels like.  It feels like fire in my lungs.  It absolutely does.




(Dr. John Condemi)        
And it is a disease which prevents you from getting air out of your lung.



(Peter)        
What do you have to exclude if you want to make the diagnosis of asthma?



(Dr. Apostolakos)    
It needs to be reversible.



(Peter)        
That is the missing fortune key.



(Dr. Apostolakos)    
And asthma has an immunologic component.  There are other diseases like reversible airway dysfunction syndrome that is a non mediated disease.  It is just an irritant in your lungs, close up, tends to be more temporary so there is an immunologic basis to asthma.



(Dr. Peter Salgo)        
So what actually causes asthma?



(Dr. Condemi)        
Well, the most common cause is allergens.  Things in the air, things in your environment.  Environmental factors working on a genetic basis.



(Peter)        
What you do not know about Monica is that she is, in fact, an aerobics instructor.  You have bad asthma attacks. How on earth do you manage that?



(Monica Wright)            
I know my triggers. I know that if at the beginning of a day if I am having a difficult breathing day that if I am going to get ready to go into the studio and teach a class that I need to do some preventive things so that I do not have a severe onset of the difficulty of breathing in the middle of a class.



(Elissa)            
So what do you do?



(Monica)            
So what I might do is if I know that I am having a difficult time breathing and I am getting ready to go into a class I may take a couple puffs of my inhaler.



(Dr. Lisa Harris)        
The thing that worries me about what you just said is many patients walk around.  By the time they have symptoms their lung disease, their constriction, their obstruction is so severe that you may end up in the hospital.  So I want to know have you been allergy tested?  Are you on a controlled medication?  Is anybody doing a spirometry?  They ought to be doing it every three months, I hope, to make sure that you are not just walking around sucking down a bronchodilator. They can stop working after a while.



(Monica)            
I would say that I do remember as a child having lots of allergy testing.  I have not as an adult.  The spirometry that you said, I have never had that.  I have had the peak flow.

(Dr. Condemi)
You never had that? You never had that?



(Peter)        
Asthma sounds like a major problem in America.  How big is it?  How many people have it?  How many kids?  How many adults?



(Dr. Zeldin)        
Seven or eight percent of the population has symptomatic asthma.



(Peter)        
Is that right?



(Dr. Zeldin)        
Yeah and probably a significantly higher proportion of individuals have had asthma at some point in their lifetime.  Ten to twelve percent by most studies.



(Peter)        
Is asthma getting worse in this country?



(Dr. Condemi)        
Well, it clearly is getting worse and then you have the situation if you go to the south Bronx, which is predominantly a black Puerto Rican area.  Forty percent of children have asthma, diagnosed asthma.  Forty percent.




(Dr. Daryl Zeldin)        
The disease disproportionately afflicts certain members of the population.



(Dr. Peter Salgo)        
I hear four million kids in America have asthma.  Is that a fair number?  That is huge.  That is absolutely huge and with that how debilitating is this disease?  So you wheeze, so what?  How bad could that be for the average asthmatic whether a kid or an adult?



(Dr. Condemi)        
Well, it clearly affects your quality of life because you stop doing things that you should be doing.  It may result in death.  We still have about five thousand deaths a year due to asthma.



(Dr. Zeldin)        
It is a major cause of school absences in children, a major cause of work absences in adults, not only for them but for their kids who have asthma as well.



(Peter)        
Well, I can tell you what they told Henry.  Henry, they said, you have got asthma.  So back when he went into the emergency room they said you were having an asthma attack.  What causes an asthma attack versus just having asthma?



(Dr. John Condemi)        
Asthma attack is usually related to a trigger and a trigger can be allergic, infectious or an irritant.



(Peter)        
I want to stop here for just a second because I want to put all of this together.  We have had a lot of context floating around over here. Asthma means that the inside of your airway is very reactive to things that you may be allergic to or things that you find irritating and that causes them to narrow down.  They allow less air to flow from your lungs.  That is when you get to feel short of breath and asthma attacks are the end results of all of this.  All right, we can move forward because Henry has asthma.  Lisa, if you were his primary care physician what are you going to do for him?



(Dr. Lisa Harris)        
He needs to be on a controller medication because his spirometry is abnormal.  Controller meaning something that is helping to reduce the inflammation in the in between times when he is not having an attack.  So the first thing I am going to do is treat him for the disease that he has right now.  The second part of that is finding out what are some of the underlying causes of his asthma.  So this is a guy who had been well, apparently is allergic or reacting to something, so we need to have him see an allergist.



(Peter)        
He is in your office now.




(Dr. Condemi)        
My role now is going to be to do some skin tests.  The diagnostic phase really is to do the skin test to see is he allergic?  What is he allergic to?  What can we do with environmental controls and if you find that house dust mites is really as big a skin test, if you could really significantly alter that he might tolerate the grass and the other things that are bothering him.



(Peter)        
You want to know what Henrys allergic to?  He is allergic to dust mites and tomatoes.  So here's what Henry says.  No way.  No way do I have allergies.  My wife, he says, is a clean freak.  She is always cleaning.  I am reading here.  She uses disinfectant spray on everything.  We have a dust mite cover on our bed.  We have an air purifier in the bedroom.  We do not have pets.  What gives here?



(Dr. Lisa Harris)        
It is the fumes from the cleaning! (laugh)



(Dr. Peter Salgo)        
All the cleaning fluid?



DR. DARLY ZELDIN:        
But also, if you are allergic to something even low levels in the environment can often trigger an attack.  You cannot get the environment clean enough sometimes for some people.



(Peter)        
Are people over cleaning and is over cleaning actually causing asthma?



(Dr. Condemi)        
It is not so much over cleaning.  There is a hygiene hypothesis to asthma and it appears as if children, a little baby, when they are going to get exposed to something their first immune response is going to be this allergic response and that is a natural response to things you are inhaling.  Then as this child gets exposed to viruses, bacteria, dirt on the floor, animals, their immune system has two choices.  One, I am going to go into the non allergic response or I am going to stay in the allergic response.  So the hygiene hypothesis says that we are removing the strong stimuli that convert us from an allergic to a non allergic response, so that clean environment has allowed this to occur.



(Dr. Zeldin)        
And that is the leading hypothesis for why the prevalence of asthma may be increasing over the last two or three decades.



(Dr. Lisa Harris)        
And that peoples homes are now more air tight and you are exposed to more allergies.



(Dr. Zeldin)        
You are spending more time indoors.



(Dr. Condemi)        
They do not eat food off the floor anymore.



(Elissa)            
So you are saying we are taking away the things that allow the kids to build up their immunity?



(Dr. Lisa Harris)        
Correct.



(Peter)        
What Henry has decided to do is go home with a rescue inhaler and tough it out.  We're going to stop for a second before I tell you more about Henry and sum up where we are right now.  Allergies can create the inflammation in the airways which causes swelling and muscle contractions and this is an asthma attack.  So Henry is out there.  He got an emergency inhaler.  He got some of his own ideas on how to help himself.  It is six weeks later. Well, I have got a word here in the chart.  Henry crawled back to see me.  I have never seen the word crawled in a chart before, but is this the case of told you so?  I mean docs do this a lot, right?  I told you so.



(Dr. Apostolakos)    
We brought this up before, but what the rescue inhaler does is relax the muscle and so it is symptomatic relief but it is not treating the underlying disease.



(Peter)        
He is in your office.  What are you going to do?



(Dr. Condemi)        
I am going to make him better.



(Peter)        
How?



(Dr. John Condemi)        
I am going to give him cortical steroids.



(Dr. Peter Salgo)        
How?



(Dr. Condemi)        
By pills.



(Peter)        
You are giving him steroid pills.



(Dr. Condemi)        
You have got to capture this individual to convince him that you can make him better.



(Elissa Orlando)            

What are the steroids going to do?



(Dr. Condemi)        
Well, the steroids are clearly going to go into his bloodstream and control the inflammation.



(Peter)        
But you are going to give him something else, right?



(Dr. Condemi)        
Yeah.  We will probably give him the combination of inhaled steroids and a long acting controller.



(Peter)        
Okay.  What is a long acting controller?



(Dr. John Condemi)        
That is Serevent, a long acting beta   It is like the Albuterol inhaler, but it stays in the lung for twelve hours.



(Dr. Apostolakos)    
Peter, you told us he crawled into the office so I think we are assuming that his airflow is very obstructed and if we are very concerned about him either needing to come into the hospital or God forbid, dying from   if this inflammation gets so bad that you can not breathe at all.  So we're assuming that he needs oral cortical steroids.  If his inflammation is relatively mild then we could talk about inhaled cortical steroids, which would be effective but are going to take longer to work than the oral pills that we are talking about.



(Dr. Condemi)        
And a lot, again, depends on his PFT and the physical exam and everything else.



(Dr. Lisa Harris)        
So what we are trying to accomplish is open his airway, reduce the inflammation, so he is going to get something that is like a long acting muscle relaxant and an inhaled steroid.



(Dr. Zeldin)        
The other thing you are going to do is have a frank conversation with him about what to do if this should get worse.



(Dr. Lisa Harris)        
He needs an asthma action plan.  It is a sheet where you can teach the patient how to do their peak flow so that they can measure, so they get an idea at home how bad their asthma is.  Green light, you do X, Y, Z.  Yellow light, you do another intervention.  Red light, you need to get to the hospital.



(Dr. Daryl Zeldin)        
You give them a little inhaler, a little breathing machine to take home and measure his own breathing.



(Peter)        
What do you do at this point to control your asthma?



(Monica)            
I personally look for my triggers, what I know is an allergen and what I know will trigger the wheezing and the discomfort.



(Dr. Peter Salgo)        
Let me tell you what Henry was put on.  Henry was sent home on inhaled steroids only and told to use his rescue bronchodilator that he was already using. Is everybody happy with this?  Look at Lisa.  She is going oh, no.  I did not hear  oye  over there, but I will bet you are thinking it.



(Dr. Condemi)        
At least the treatment is beginning.



(Elissa)            
Well, you are treating the inflammation now and he got a rescue inhaler if he needs it.



(Dr. Lisa Harris)        
He crawled in, that is the caveat.  He was too sick to go home and



(Peter)        
Let me pause for a moment and sum up where we are right now.  Control of the inflammation in the airways is the key to the treatment of persistent asthma.  There are drugs that work.  They make a real difference in your quality of life.  You have got to get them.  You have got to get them the right way but these are important things to know.  So, what about Henry?  I sort of caught a whiff of this from you guys just before we summed up.  What do you think is going to happen to Henry?



(Dr. Condemi)        
One, he is not going to get better from an inhaled steroid because it takes too long so he is going to stop using it.



(Elissa)            
Because he feels bad.



(Dr. Condemi)        
No.  That is why the combination of this long acting Albuterol and the steroids is the ideal treatment.  He is going to get better from one medicine and you are sneaking in the other medicine.



(Peter)        
You want to know what happened?



(Dr. John Condemi)        
If you start him on the inhaled steroids It is going to take him two, three, four weeks to get better and then he is still going to be



(Peter)        
It is like you read Henrys mind.  Henry continued to use his rescue drugs.  Henry never used his inhaled steroids and that is basically what he decided to do.  So how are you doing?



(Monica)            
I do not know after hearing all of this.



(Peter)        
Not that you are Henry.



(Monica Wright)            
Right.  When everything is optimal like the allergens are fine and the weather is in the middle, It is moderate, I might use my rescue inhaler maybe once or twice in a month.



(Dr. Peter Salgo)        
So you are doing well.



(Dr. Condemi)        
I guarantee you have a smoldering fire.  Without doing that PFT you do not know how sick you are.  Now, the thing that is helping you is really your exercise because you have a good signal there so that really is to your advantage, but you do not know if forty years from now you are going to end up with thirty percent of your lung.



(Peter)        
You have instructed friends and relatives to call 911 if they see you in terrible shape?



(Monica)            
Yes, I have.



(Peter)        
That is an important thing to remember.  Asthma can kill you.  It is a nasty disease.  Henry, we hope, does not have to find out the hard way.  I want to thank you all for being here.  We have covered a lot of ground today so what I want to do now is just sum up one last time the things that we have discussed.  Asthma means that the inside of your airways are very reactive to things that you are allergic to or things you find irritating causing them to narrow and allow less air to flow from your lungs.  Allergies create the inflammation in the airways which causes swelling and muscle contraction and this is an asthma attack.  Control of the inflammation in the airway is the key to the treatment of persistent asthma.  There are drugs that work, drugs that make a real difference in the quality of life provided you use them.  And, of course, our final message is this.  Taking charge of your health means being informed and having quality communication with your doctor.  I am Dr. Peter Salgo and I will see you next time for another Second Opinion.





(Announcer 1)            
Search for health information and learn more about doctor/patient communication on the Second Opinion Web site.  The address is pbs.org.





(Announcer 2)        
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent Blue plans committed to better knowledge leading to better, more affordable healthcare for consumers.