Because treating chronic laryngitis early on will lead to a better outcome than if you wait too long, it’s important to know when a bout of hoarseness may need medical attention.

What Is Acute Laryngitis?

Laryngitis occurs when your larynx, or voice box, becomes irritated and inflamed. A sore throat and a dry cough may accompany laryngitis. Acute laryngitis can develop from overusing your voice or from a common cold virus. Allergies can also lead to acute episodes of laryngitis. And if you suffer from gastroesophageal reflux disease (GERD), you may also get hoarse from time to time.

If vocal cord straining is the cause of your laryngitis, the treatment is easy. Resting your voice and drinking lots of fluids will usually get you back to normal. Rest also may be your best bet if a virus is the culprit. In rare cases, a bacterial infection can cause laryngitis; you may need antibiotics to knock out that infection and resume good health. When the underlying cause is GERD or allergies or exposure to irritants or chemicals, you’ll need to address those conditions before getting relief.

Laryngitis that resolves on its own after a short time shouldn’t need a medical evaluation unless it returns or if you notice a change in your voice.

Chronic Laryngitis

If your laryngitis lasts for at least three weeks, it’s said to be chronic and shouldn’t be ignored. Seek medical attention soon.

Prolonged strain on your vocal cords can lead to the growth of throat polyps or nodules on your larynx. Polyps tend to form on one vocal cord, and are usually benign (non-cancerous). However, they can cause permanent changes to your voice if they are not treated. And as with most medical conditions, early treatment of throat polyps is better than waiting too long.

“Nodules are not cancer; but the longer they are left there, the more scarring and changes in the voice you’ll have, and the harder it may be to treat,” says laryngologist Inna Husain, MD, with Rush University Medical Center in Chicago. “As with any condition, coming in sooner is better. Most people don’t know that there is a medical reason behind a change in voice, and a medical professional can best advise them.”

Keep in mind that both smoking and excessive alcohol consumption over a long period of time can cause hoarseness and raise the risk of throat cancer.

When You See the Doctor

If you can’t reclaim your voice from a prolonged bout of laryngitis, you should see a doctor. You may not need to see a specialist, called a laryngologist, right away. Your primary care physician or even a doctor at a walk-in clinic may be able to look at your throat and provide an initial diagnosis. If it looks like there are throat polyps or signs of vocal cord injury, you’d likely be referred to a laryngologist.

The main diagnostic test is a laryngoscopy. The doctor uses a tiny light and mirror to get a good look at the back of your throat. The doctor may also insert an endoscope into your nose or mouth to get an even more detailed view of your vocal cords. An endoscope is a thin, flexible tube-like instrument with a small camera at one end. It sends images back to a screen that the doctor looks at to see the size, location, and other details of any throat polyps, scars, or other signs of damage. A suspicious polyp may be biopsied to determine if it’s cancerous.

Whether the throat polyps are cancerous or benign, surgery is usually required to remove them and get your voice back to normal. Such an operation is usually done on an outpatient basis. Voice therapy may be recommended after surgery.

For related reading, visit these posts.

• Strep Throat Symptoms in Adults
• Bacterial Infection: Be Careful—It Can Become Deadly!
• Viruses 101: A Guide to What’s Making You Ill 

Originally posted in September 2016 and updated.

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According to the National Eating Disorders Association, binge eating disorder is the most common eating disorder in the United States. It was recently classified as an official mental illness by the American Psychiatric Association. Since this condition can be fatal, experts are happy that it’s finally getting the spotlight it deserves. The more attention binge eating disorder receives, the more likely it is to be recognized, addressed, and treated.

What Is Binge Eating Disorder?

“Eating disorders are not fads, phases, or choices,” states the Binge Eating Disorders Association. “They are very complex, serious mental illnesses. They are deadly. They have the highest mortality rate of all psychiatric disorders.”

Binge eating disorder is characterized by the act of eating extreme amounts of food. Those who suffer from this condition feel powerless to control either what or how much they’re eating. They often feel ashamed by their overeating but—even though they’re aware that it’s dangerous behavior—are unable to stop.

What Are the Signs of Binge Eating Disorder?

The following are the most common signs of a binge eating disorder, according to the National Eating Disorders Association. In order to be considered this type of ailment, the symptoms have to be observed weekly for a minimum of three months:

• A complete lack of control over eating behavior (i.e., they can’t control what or how much they’re eating)
• Recurrent episodes of binge eating
• Eating more food in a single time period (e.g., two hours) than an average person would eat in that same measure of time
• Eating more quickly than normal (i.e., “inhaling” food)
• Eating until one feels uncomfortably full
• Eating large amounts of food when not feeling hungry
• Eating alone (or hiding the eating) because of feeling embarrassed
• Feeling disgusted with oneself, depressed, or guilty after a binge eating episode
• Binge eating at least once a week for three months
• Fluctuations in weight
• Low self-esteem

What Causes Binge Eating Disorder?

While no one knows the exact cause of binge eating disorder, it is thought to be a product of a combination of biological, environmental and psychological factors. Those with other mental health disorders (e.g., depression) are at an increased risk of developing the illness. A study published in Eating Behaviors found that women veterans had higher rates of binge eating than those who didn’t serve. The researchers linked this increase to mental health conditions such as depression, anxiety, post-traumatic stress disorder (PTSD), and substance abuse.

Body dissatisfaction and low self-esteem can also be to blame for a binge eating disorder. Those who’ve suffered trauma (e.g. sexual abuse) or social pressures to be thin sometimes turn to binge eating as a coping mechanism. Another potential causal factor: genetics. Many people who suffer from this condition have families that overeat or binge. Another possible predictor is procrastination. Chinese researchers discovered a strong connection between procrastination and binge eating behavior.

Who Has Binge Eating Disorder?

According to the Binge Eating Disorder Association, “an estimated 3.5 percent of women, 2 percent of men, and 30 to 40 percent of those seeking weight loss treatments can be clinically diagnosed with binge eating disorder.” The condition affects three times the number of people diagnosed with anorexia and bulimia.

You don’t need to be overweight to have binge eating disorder. While most people with this condition are overweight or obese (about 70 percent), a small number of them are of a normal weight. Those with the illness often feel depressed, disgusted and guilty about their overeating. They may try to diet and eat a “normal” amount of food, but this restriction often results in further bingeing. While some cases of the disorder may be short-lived, others may recur or persist for years if the person doesn’t get help.

What Are the Dangers Associated with Binge Eating Disorder?

Those who suffer from binge eating disorder may develop both physical and psychological problems. They may also struggle with the following complications:

• Depression
• Obesity
• Anxiety
• High blood pressure
• Gallbladder disease
• Certain types of cancer
• Menstrual problems
• Fatigue
• Decreased mobility
• Substance use disorder
• Type 2 diabetes
• Gastroesophageal reflux disease (GERD)
• Sleep disorders
• Respiratory difficulties
• Social problems
• Difficulty functioning during normal activities (e.g. work, home or in a social situation)
• Joint problems
• Heart disease

Is There a Cure for Binge Eating Disorder?

While there’s no real way to prevent a binge eating disorder, seeking aid from a medical professional (i.e. a psychiatrist) can help reduce the effects of the illness.

Sadly, many people with this condition are so ashamed of their overeating that they won’t seek help. They’ve become so adept at hiding their symptoms that many suffer in silence, without even their closest friends or relatives knowing there’s a problem.

For those who do seek help, common treatments include psychotherapy (including cognitive and behavioral therapies), medications (e.g., antidepressants and anticonvulsants), nutrition counseling (to learn normal eating strategies), and group or family therapy. Another up-and-coming therapy, according to a study published in the Journal of Medical Internet Research, involves the use of virtual reality.

The post Binge Eating Disorder: What It Is and How It’s Treated appeared first on University Health News.

In addition, as we age, we spend more time in the lightest form of sleep (stage N1)—15 percent of the night, compared to younger people who spend 5 to 7 percent of their sleep at stage N1. Not surprisingly, both slow-wave sleep (stage N3) and REM sleep diminish as well. These changes may be related to illnesses that are more common in older age and the medications used to treat them, or due to a declining evening melatonin surge—that signal we discussed in Chapter 1 that gets the body ready to sleep.

A Circadian Shift

Many older people awaken before they want to and struggle to fall back asleep. The onset of sleep, which is regulated by our circadian rhythm and the homeostatic drive, tends to shift as we age. This results in greater sleepiness early in the evening, earlier sleep onset, and waking before dawn.

Any of these changes can cause sleep loss, which accumulates over time and can lead to irritability, memory loss, and injury from falls or other accidents caused by short bursts of “micro-sleep” during the daytime. These problems should not be interpreted as normal signs of aging.

Other factors that can affect your sleep as you age include becoming less physically or socially active or spending less time outdoors and getting less sunlight. Those who find themselves feeling sleepy earlier in the evening may want to keep bright lights on longer into the evening to reset their biological clocks and minimize early morning awakenings. Waking too early can be countered by avoiding bright outdoor light for the first few hours of the morning. Exposure to bright light in the morning tends to shift the circadian clock earlier, thereby promoting early morning awakenings.

Pain’s Impact on Sleep

According to the National Sleep Foundation’s 2015 Sleep in America Poll, chronic pain is responsible for an average 42-minute sleep debt per night and acute pain for 14 minutes. Only 45 percent of study participants with acute pain and 37 percent with chronic pain reported good or very good quality sleep, compared with 65 percent of those with no pain.

The poll found that two related concerns—stress and poor health—are key correlates of shorter sleep duration and worse sleep quality. Beyond sleep debt, self-reported sleep quality and stress levels underscore the effects of pain on sleep. In the poll, 23 percent of those with chronic pain reported higher stress levels, compared with 7 percent of those without pain.

People with acute or chronic pain are more likely to have sleep problems that impact their daily lives, as well. More than half of those with chronic pain say those difficulties interfered with their work, compared with 23 percent of people without pain. People with pain also are far more likely to report that lack of sleep interferes with their mood, activities, relationships, and enjoyment of life overall. Those with pain also feel less control over their sleep, worry more about lack of sleep affecting their health, and are more likely to say that environmental factors—for example, noise, light, room temperature, mattress quality—make it more difficult to get a good night’s sleep.

Health Issues and Sleep

Sleep disorders, such as obstructive sleep apnea (OSA, see Chapter 5) and restless legs syndrome (see Chapter 3), become more common with aging. Weight gain can contribute to breathing problems during sleep and lead to OSA. Chronic health problems may become more common as we age, and many older adults take multiple medications, some of which can cause insomnia or produce daytime sleepiness. Drug interactions, misuse, or overuse also can lead to sleep problems, and alcohol can interact with many of these drugs. Cigarette smoking also has been linked to sleep disturbances.

Heartburn can flare up at bedtime and interrupt sleep. About 80 percent of people with gastroesophageal reflux disease (GERD) say they have had nighttime heartburn. The condition is aggravated by obesity.

But sleep problems are not inevitable in older adults. For both men and women, daily routines can reduce the likelihood of insomnia and promote better sleep. In general, “routine lifestyle rhythms” may be a protective factor that contributes to quality sleep.

Frequent Urination

After middle age, many people complain that their sleep is interrupted by the frequent urge to urinate at night, which is called “nocturia.” As we age, our bodies produce less of the antidiuretic hormone that enables us to retain fluid, so we produce more urine at night. The bladder also tends to lose some holding capacity. From age 60 on, getting up to urinate twice nightly isn’t considered excessive. However, people with severe nocturia may awaken five or six times during the night to use the bathroom.

Nocturia can result from medical conditions such as urinary tract infections or overactive bladder, which affect 17 to 20 million men and women. In men, nocturia may be caused by benign prostate enlargement. Nocturia also is common in people with high blood pressure (especially those taking diuretic medications), heart failure, liver failure, and poorly controlled diabetes. It also can be a symptom of OSA.

Treating an underlying problem, such as OSA, often resolves or lessens nocturia. If the problem is overactive bladder, medications like solifenacin succinate (Vesicare), oxybutynin (Ditropan XL), or tolterodine tartrate (Detrol LA) can be helpful, as can a transdermal skin-patch version of oxybutynin (Oxytrol).

Three non-drug strategies also can help:

• Don’t drink fluids after 8 p.m.
• Take your diuretics in the morning.
• Get checked for diabetes.

Practicing Kegel exercises to strengthen the pelvic floor muscles that help support the bladder can be helpful. To perform Kegels, contract the pelvic floor muscles as if you are trying to stop the flow of urine. Hold for a count of four and then relax. Repeat 10 to 20 times, several times a day. If you’re unsure about how to do this technique, ask your primary-care doctor, gynecologist, or urologist for guidance.

Gender Differences

Men and women sleep somewhat differently starting in infancy. Men begin to exhibit less slow-wave sleep in their 20s, while the decline in women starts in their 30s. Although women have more deep sleep, the hormonal and vasomotor symptoms of menopause disrupt sleep starting in the 40s and 50s, and as many as 85 percent of women experience hot flashes, often at night.

The Impact of Poor Sleep on Men vs. Women

Studies examining the association of sleep behaviors with neuromuscular performance and daytime function in older women found that poorer sleep is associated with worse physical function during the day. Women who slept less than six hours per night walked 3.5 percent slower than those who slept six to eight hours. Women who napped for 1.8 hours during the day were more likely to have a functional limitation than those who napped for 30 minutes or less.

Poor sleep—measured by the total amount of sleep, the degree of waking during the night, and how long it takes to get to sleep—is associated with greater psychological distress and higher levels of biomarkers linked to an elevated risk of heart disease and type 2 diabetes. These associations are significantly stronger in women than in men. What’s more, poor sleep habits are linked to an increased risk of fibromyalgia. Researchers found that women over age 45 who reported having sleep problems “often” or “always” had nearly double the risk of developing fibromyalgia, compared with those between ages 20 and 44 who reported problems.

Men are not immune to disrupted sleep and its adverse effects. In their 60s, men have more frequent periods of light sleep and awakenings than women, and the amount of time they spend in REM sleep also declines. Lack of sleep also can mean that men have lower levels of testosterone, a hormone that affects libido, energy levels, and immune function. Other research suggests that men with abnormal sleep patterns have an increased risk of mortality. Although the reasons for the increased risk were not clear, the researchers say that men, like women, should try to maintain normal sleep patterns whenever possible.

Ethnic Differences

Interestingly, ethnicity plays a role in sleep habits and disorders. A 2015 study documented these differences in middle-aged and older Americans. Overall, 34 percent of the 2,230 participants had moderate or severe sleep-disordered breathing, and 31 percent slept less than six hours per night. Blacks were most likely to sleep too little and were more likely than whites to have sleep apnea, poor sleep quality, and daytime sleepiness. Hispanics and Chinese people were more likely than whites to have sleep-disordered breathing and short sleep duration, but Chinese people were least likely to report having insomnia.

A poll by the National Sleep Foundation documented many similarities and some significant differences with respect to sleep among Asians, Hispanics, blacks, and whites. The findings include:

Poor sleep brings health problems: Respondents from each ethnic group agreed that poor sleep is associated with health problems (76 to 83 percent).

Activity before bedtime: Blacks were the most likely to report performing activities in the hour before going to bed every night or almost every night, specifically watching television (75 percent) and/or praying or doing another religious practice (71 percent).

Not sleeping while in bed: Whether on weekdays/workdays or non-workdays/weekends, blacks spend much more time in bed without sleeping than the other ethnic groups (54 minutes on weekdays/workdays and 71 minutes on non-workdays/weekends).

Working before bed: Among those participants who were employed, blacks (17 percent) and Asians (16 percent) were more likely than whites (9 percent) and Hispanics (13 percent) to report doing job-related work in the hour before bed.

Sleep medications: Asians are the most likely ethnic group (84 percent) to say that they had a good night’s sleep at least a few nights or more a week. In addition, Asians are the least likely to report using sleep medication at least a few nights a week (5 percent versus 13 percent for whites, 9 percent for blacks, and 8 percent for Hispanics).

Never sleeping well: Asians are the least likely (9 percent) to say they “rarely” or “never” have a good night’s sleep, compared with 20 percent of whites, 18 percent of blacks, and 14 percent of Hispanics.

Regional Differences

Residents of Oklahoma, Arkansas, Mississippi, Alabama, and West Virginia suffer from the most sleep disturbances and daytime fatigue. This is consistent with other studies showing that many states reporting worse sleep and fatigue problems also have a higher prevalence of obesity. By contrast, residents of the West Coast report the fewest sleep problems. The researchers determined that regional differences in mental health, race/ethnicity, and access to medical care are the main factors that explained these differences.

Caffeine

A single cup of coffee contains 80 to 115 milligrams (mg) of caffeine, and it can take three to seven hours before the caffeine level in your bloodstream drops significantly. If you are vulnerable to caffeine’s effects, it’s conceivable that a mid-afternoon cup of coffee or tea might keep you wide awake at 11 p.m. or make it difficult to go back to sleep if you awaken in the middle of the night. In fact, a recent study showed that 400 mg of caffeine consumed three to six hours prior to bedtime can significantly disrupt sleep. When caffeine was consumed six hours before going to bed, sleep time was reduced by more than an hour, even though study participants weren’t aware of the effect.

Black and green tea (but not most herbals) have about half the amount of caffeine as coffee (about 30 to 40 mg). Most colas and soft drinks also have caffeine, as do coffee yogurt, coffee-flavored ice cream, and chocolate. A combination of these products may add up to a sleepless night.

Alcohol

Alcohol has a negative effect on sleep, contrary to the popular belief that alcoholic drinks relax you and help you sleep better. Although alcohol initially makes you a little drowsy, it disrupts the normal pattern of sleep cycles and interferes with hormones and brain chemicals involved in sleep and mood. Drinking alcohol may hasten the onset of your initial deep sleep, but it then inhibits the onset of REM sleep. Within two to three hours after the body metabolizes alcohol, you experience a rebound in REM sleep. You may be roused from sleep more easily and may wake abruptly, sometimes with a headache, if you’ve had too much to drink. The sleep you get after drinking is unlikely to make you feel refreshed in the morning.

In addition, alcohol affects breathing during sleep. It can swell mucous membranes in the mouth and nose and weaken the throat muscles that keep the airway open. This may cause snoring, even in people who don’t normally snore, and may worsen existing sleep apnea. Its initial sedative effects dull the body’s response to decreased oxygen and increased carbon dioxide, which can worsen breathing problems. Alcohol also can exacerbate restless legs syndrome and periodic limb movement disorder, and since it’s a diuretic, it can increase nocturia.

Alcohol’s effects may be amplified in older people. Therefore, some experts advise older adults to have no more than one alcoholic drink per day, even if they are not taking medications and have no medical conditions that may be affected by alcohol. The term “nightcap” to describe a drink at the end of the day is a misguided strategy for sleep. Avoiding alcohol close to bedtime is a sound sleep strategy.

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“Making adjustments to your diet and your eating habits can help alleviate your symptoms,” says Colleen Webb, RD, a dietitian at The Roberts Center for Inflammatory Bowel Disease at Weill Cornell. “In some cases, dietary modifications combined with other lifestyle changes are enough to eliminate symptoms altogether.”

Your Guide to GERD

As you eat, food and beverages travel down the esophagus and pass through the lower esophageal sphincter, a small band of muscle that allows food and liquids to enter the stomach. Normally, the sphincter opens only after you’ve swallowed food, and then stays closed. But with gastroesophageal reflux disease, the sphincter can relax and allow stomach acid to move up into the esophagus. The resulting irritation of the esophagus is what causes heartburn and other symptoms, such as a sore throat and a sour taste in your mouth.

Gastroesophageal reflux disease affects about 60 percent of the adult population, with women much more likely than men to suffer serious GERD episodes. It’s not always obvious why GERD develops, but obesity, smoking, and conditions such as delayed stomach emptying can raise your risk of GERD. For many people, certain foods can trigger an unhealthy level of stomach acid that can make its way up to your esophagus.

Watch What You Eat

Learning your trigger foods is a good first step in avoiding GERD symptoms and getting your GERD under control. Understand, though, that what triggers heartburn in one person may not bother you, and vice versa. Webb says GERD is a very individualized condition.

“Large meals, high-fat foods—especially animal fat and fried foods—caffeine, coffee (both decaf and caffeinated) and alcohol are well-known triggers for most everyone,” she explains. Other common culprits include chocolate, peppermint, garlic, onions, spicy foods, bell peppers, salads, and foods with a high acid content, such as soft drinks, citrus juices, and tomatoes.”

Webb recommends keeping a daily food journal, in which you write down everything you eat and drink. Make a note when you have heartburn and other GERD symptoms. Be aware that even healthy foods, such as beans and broccoli, can worsen heartburn because they are also gas-producing foods. Items that are high in added sugar, such as candy and desserts, may also be at fault. “A journal can help you identify your trigger foods and avoid unnecessary dietary restrictions,” Webb says.

A Digestion-Friendly Lifestyle

There are additional steps you can take to guard against GERD. “Don’t lie down for at least three hours after you eat; it’s one of the most important actions you can take to minimize your reflux. Reclining by itself is enough to worsen reflux, but sleep also delays gastric emptying and increases digestive secretions,” explains Webb.

If bedtime heartburn is a common occurrence, raise the head of your bed at least 6 to 8 inches by placing a foam wedge under the top part of the mattress.

Because obesity is a leading risk factor for gastroesophageal reflux disease, try to get to a healthy weight. Work with a dietitian to help you revamp your eating plan. (See our posts “How to Get a Healthy Eating Plan in Place” and “How to Eat Healthy: 3 Comprehensive Diet Plans.”) Smoking is also a common risk factor for GERD, so talk with your doctor about effective nicotine-replacement products and other therapies that can help you quit. Finally, exercising daily is beneficial for your overall health. It revs up your metabolism and helps with weight control. But don’t exercise intensely within two hours after eating. If you’ve been sedentary, start with a walking program; see our post “The Benefits of Walking” to learn more.

Gastroesophageal Reflux: When Medications are Needed

If you have exhausted your dietary options to stop heartburn and you’ve made other lifestyle changes, talk with your doctor about medications for GERD. If heartburn is only an occasional problem, and you find relief with antacids, such as Tums or Maalox, then you may never need anything stronger.

Two other types of drugs may also help: H2 blockers and proton pump inhibitors (PPIs). Such H2 blockers as famotidine (Pepcid AC) and ranitidine (Zantac) can reduce stomach acid production for several hours. PPIs are stronger drugs that reduce acid production and heal the esophagus, but they are associated with some serious side effects, such as bone fractures and interference with the absorption of certain vitamins.

As much as possible, try to treat your GERD with diet and lifestyle changes. If medications appear necessary, be sure to discuss with your doctor their risks and how to use them as safely as possible.

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When the immune system detects an infection, it produces inflammation, which triggers processes designed to promote healing. For example, inflammation creates a barrier around the infected area to prevent the germ from spreading. In addition, chemical factors are produced that attract immune system cells to the area to fight the infection. Inflammation in the lungs also can cause coughing, difficulty breathing, and other pneumonia symptoms. When the alveoli (tiny air sacs in the lungs) become inflamed, they fill with pus and other fluids. The body tries to clear this through coughing. The alveoli are the location in the lungs where oxygen passes into the bloodstream, so when the alveoli are inflamed, oxygen can’t easily enter the bloodstream. Too little oxygen combined with spreading infection, which can occur in people with a weakened immune system, can lead to death.

The lungs have five lobes, three in the right lung and two in the left. Pneumonia can affect a part of a lobe, an entire lobe, or several lobes. Pneumonia that affects one or more lobes is called lobar pneumonia. Pneumonia also can affect patches throughout a lung, in which case it is called bronchial pneumonia.

When pneumonia is contracted outside of a hospital or other health-care setting, it is called community-acquired pneumonia. In the United States, about 4 million people get this type of pneumonia each year, mostly in the winter. Pneumonia that occurs during a hospital stay for some other illness is called hospital-acquired pneumonia. People on a mechanical ventilator (a machine that helps you breathe) are especially at risk for this type of pneumonia. This can occur when bacteria passes down the breathing tube into the lungs.

What Causes Pneumonia?

Infectious agents that can cause pneumonia include bacteria, viruses, fungi, and mycoplasmas (a type of bacteria that lack a cell wall). These germs are all around us, in the air we breathe and, in the case of some types of fungi, in the soil. They generally don’t make us sick, because the body’s natural defenses eliminate or destroy them. However, if the immune system is weakened for some reason, the germs can enter the lungs, where they multiply and cause pneumonia.

Bacterial Pneumonia

The most common cause of pneumonia is infection with one of dozens of different types of bacteria. The most common bacterium responsible for bacterial pneumonia is Streptococcus pneumoniae (also called pneumococcus). Older adults, people with chronic illnesses, and other people in the high-risk categories listed above may develop bacterial pneumonia after having the flu or a cold.

Bacterial pneumonia can be serious and even life threatening, especially if bacteria pass into the bloodstream and spread to other parts of the body.

Viral Pneumonia

Viruses also can cause pneumonia. Children younger than age five are particularly susceptible to viral pneumonia. Adults with heart or lung disease and women who are pregnant are more likely than other adults to develop this type of pneumonia. In adults, influenza is the most likely cause of viral pneumonia. Other viral culprits are respiratory syncytial virus, rhinovirus, and herpes simplex virus, among others. Patients taking medications that suppress the immune system are at high risk of developing viral pneumonias, especially from a virus called cytomegalovirus.

Viral pneumonia often is milder than bacterial pneumonia, and some people get better in a few weeks, even without treatment. However, it also can be serious, require treatment, and sometimes be fatal, especially in someone with a weakened immune system due to medications or other serious medical conditions, like cancer or liver disease.

Mycoplasma Pneumonia

Mycoplasmas are bacteria that lack a cell wall. Mycoplasma pneumonia occurs most commonly in people younger than age 40. People with this type of pneumonia generally have only mild symptoms, and they respond well to treatment with antibiotics. It is rarely fatal.

Fungal Pneumonia

Certain types of fungi can cause pneumonia in susceptible people. These fungi include three found in soil: coccidioidomycosis in southern California and the desert Southwest; histoplasmosis in the Ohio and Mississippi River Valleys; and cryptococcus. Pneumocystis jiroveci (formerly called Pneumocystis carinii), a yeast-like fungus that also can cause pneumonia (often referred to as pneumocystis pneumonia).

When healthy people are exposed to these fungi, they generally do not develop pneumonia or other serious illness. People with weakened immune systems, especially people with HIV/AIDS or cancer, or those taking medications that suppress the immune system, are most at risk for developing pneumonia from these organisms.

Aspiration Pneumonia

Another type of pneumonia occurs when a substance in the mouth (such as food, drink, vomit, or saliva) is inhaled into the lungs (aspirated). Occasionally, people with gastroesophageal reflux disease (GERD) may develop aspiration pneumonia when small amounts of gastric contents are refluxed into the back of the throat or the mouth, and subsequently inhaled.

Pneumonia Symptoms

Symptoms of pneumonia vary depending on a number of factors, such as the organism causing the pneumonia, the type of pneumonia (lobar or bronchial), the person’s overall health, and whether pneumonia follows the flu or a cold.

Symptoms of pneumonia caused by a bacterial infection tend to appear suddenly, and usually include fever and difficulty breathing. In people who develop pneumonia as a consequence of the flu, symptoms like cough, fever, and sore throat generally appear suddenly, after flu symptoms have gone away.

The symptoms of viral pneumonia usually start more gradually than those of bacterial pneumonia, and often mimic flu symptoms (fever, cough, headache, muscle aches, and weakness). Difficulty breathing increases as the disease progresses. Symptoms of viral pneumonia often are milder than those of bacterial pneumonia, but they can still be severe.

Diagnosing Pneumonia

In people with the symptoms described above, the doctor will take a medical history and perform a physical examination. The doctor will then use a stethoscope to listen to the chest for characteristic crackling, bubbling, and rumbling sounds (called “rales”) that may indicate the presence of infection in the lungs.

If pneumonia is suspected, a chest x-ray will be performed. The x-ray can reveal the presence of pneumonia and its location in the lungs. It cannot be used to determine the organism causing the infection.

A blood sample most likely will be taken for a type of blood test called a complete blood count, or CBC. This shows the number of white blood cells in the blood sample. White blood cells are part of the body’s immune system response. A high number of white blood cells in the sample may indicate the presence of a bacterial infection. A blood culture also may be performed. This test determines the presence of bacteria in the bloodstream, and is used to find out if the infection has spread outside the lungs.

To identify the exact organism causing the infection, a sputum test may be performed. In this test, phlegm that is coughed up is analyzed under a microscope to identify the microorganism infecting the lungs.

Treating Pneumonia

Treatment for pneumonia depends on the cause and severity of the illness. In many cases, a person with pneumonia can rest at home while undergoing treatment. More severe cases may require a stay in the hospital.

Pneumonia caused by bacteria or mycoplasmas will be treated with antibiotics. Antibiotics may be given as pills that can be taken at home. In more serious cases, antibiotics may be administered intravenously during a stay in the hospital, or started in the hospital for a few days and continued at home. Severe cases of pneumonia also may necessitate treatment with oxygen, which will most likely be administered in the hospital.

Unfortunately, nearly one in four patients treated with antibiotics for community-acquired pneumonia do not respond to the first antibiotic used and require additional antibiotic therapy, hospitalization, or emergency care. Treatment is more likely to fail if the patient has a comorbid condition, such as hemiplegia, paraplegia, a rheumatologic disease, chronic obstructive pulmonary disease, cancer, diabetes, or asthma. Patients age 65 and older are two to three times more likely to require hospitalization than younger patients.

Overall, the failure rates with antibiotic therapy are similar across all antibiotic classes. However, varying resistance levels around the country mean that certain antibiotics are more likely to fail in certain regions of the United States than in others.

Commonly used antibiotics are not effective against viral pneumonia. Certain kinds of viral pneumonia can be treated with specific antiviral medications, but in many cases, viral pneumonia is treated with rest and plenty of fluids. Antifungal medications are used to treat pneumonia caused by fungal infection.

After a few days of taking antibiotics or antiviral medications, a person with pneumonia should start to feel better. The length of time for full recovery will depend on the severity of the pneumonia, and the overall health of the individual. In otherwise healthy people, the acute infectious phase of pneumonia is cured in one to two weeks. However, complete healing of the damaged lung may take an additional two to four weeks. It is extremely important to continue taking any prescribed medications for the entire length of time prescribed, even if symptoms subside. Failure to do so may allow the microorganism to reestablish itself, and lead to a recurrence of pneumonia.

Everyone with pneumonia should get plenty of rest, eat a healthy diet, and drink lots of fluids, since fluids help to loosen the mucus in the lungs.

Complications from Pneumonia

Pneumonia is usually treated and cured with antibiotics in young and healthy adults, but it is more common and can be harder to cure in people age 65 and older. One study found that older adults hospitalized for pneumonia are at increased risk for cognitive impairment, depression, and physical disability, meaning that effective prevention and treatment are especially important.

Pneumonia also is harder to cure in infants and young children, people with chronic health problems (such as heart disease, lung disease, or diabetes), and anyone with a weakened immune system. Several diseases can weaken the immune system, including HIV/AIDS. People taking chemotherapy for cancer, or taking drugs to suppress the immune system after an organ or bone marrow transplant, also have weakened immune systems.

Preventing Pneumonia

Because pneumonia tends to occur in people with a weakened immune system, staying as healthy as possible is the best way to prevent it. Eat a nutritious diet, exercise regularly, avoid smoking, and try to reduce stress. Also ask your doctor if you should get vaccinated against pneumonia.

Regular dental care also will cut the risk of bacterial pneumonia. People who never see a dentist have twice the risk of bacterial pneumonia than those who get dental checkups twice a year. The link between dental care and pneumonia in critically ill patients is well known and not surprising, since the direct conduit between the mouth and the lungs makes it easy to aspirate bacteria. Those most likely to be affected are Caucasian, older, and have more comorbidities and cognitive limitations.

Who Should Get the Pneumonia Shot?

Vaccines are available against the most common cause of pneumonia (Streptococcus pneumoniae). A vaccine called Prevnar 13 protects against 13 subtypes of these bacteria. A different vaccine, called Pneumovax 23, protects against 23 subtypes. All adults age 65 and older should receive both of these vaccines, but they can’t be given at the same time. Prevnar 13 is usually given first, and Pneumovax 23 is given one year later. Prevnar 13 is also recommended for infants and children ages two months to five years. Pneumovax 23 is recommended for adults ages 19 to 64 who smoke or have asthma. Unlike the flu shot, which must be given every year, pneumococcal vaccination provides protection for at least five years and can be given at any time of the year.

People at high risk of developing pneumonia as a complication of influenza should get a yearly flu shot.

Who Should Not Get the Pneumonia Shot?

The Centers for Disease Control and Prevention recommends that the following people avoid pneumonia vaccinations:

• People who have previously had a life-threatening allergic reaction to Prevnar 13, to an earlier pneumococcal vaccine (PCV7), or to any vaccine containing diphtheria toxoid (for example, DTaP), should not get Prevnar 13.
• Anyone who has had a life-threatening allergic reaction to Pneumovax 23 should not get another dose.
• Children under the age of two years should not receive Pneumovax 23.

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Asthma causes inflammation in the airways, producing episodes of coughing, wheezing, breathlessness, and chest tightness. Inflammation also causes the airways to secrete excess mucus, which clogs the airway, restricting the flow of air. In addition, the muscles surrounding the airways sometimes suddenly contract, causing the airway to narrow.

Asthma attacks usually occur in response to a specific trigger, such as pollen, house-dust mites, animal dander (shed skin flakes), or mold, all of which also can cause allergies. One study found that about 75 percent of 20 to 40 year olds with asthma, and 65 percent of adults aged 55 and older with asthma, have at least one allergy. Exposure to cold air, exercise, a viral infection, airborne irritants (chemicals, tobacco, or wood smoke), stress, or strong emotions also can spark an asthma attack.

For most people with asthma, airway narrowing is reversible. The airway will return to normal spontaneously or with the aid of a bronchodilator drug. In some people with long-standing or severe asthma, however, the constant inflammation causes permanent changes to the airways. For these people, the condition may not be completely reversible, even with medication. It is often very difficult or impossible to distinguish this form of asthma from chronic obstructive pulmonary disease (COPD)—consequently, the treatment of severe persistent asthma and COPD often closely resemble each other.

Why some people with asthma are prone to exacerbations and others are not is a key question. In a large study conducted by the National Heart, Lung, and Blood Institute’s Severe Asthma Research Program-3, 41 percent of 709 patients had no exacerbations, and 24 percent had three or more. Those who were exacerbation-prone did not exhibit the factors associated with asthma severity. However, bronchodilator responsiveness, blood eosinophil level, and body-mass index were associated with more frequent exacerbations, as were chronic sinusitis and gastroesophageal reflux. This led the researchers to conclude that exacerbation-prone asthma is likely a distinct phenotype from typical asthma.

Asthma is on the increase among children younger than 18, and it is more common in boys than girls. Women are more prone to adult-onset asthma than men, and more adult women than adult men have asthma. It can first appear in older age. The diagnosis of asthma in older adults may be missed when other health problems with similar symptoms (such as heart disease or COPD) coexist.

What Causes Asthma?

The exact cause of asthma is not fully known, but it is believed to result from a combination of genetic and environmental factors. In other words, some people inherit genes that make them susceptible to developing asthma. Numerous genes have been identified that appear to play some role in asthma. When people with these genes are exposed to environmental factors, such as tobacco smoke, during a crucial time in their development, their immune system is altered in a way that produces chronic inflammation in the airways and sensitivity to certain stimuli. This leads to asthma attacks.

Immunity Gone Awry

Inflammation is part of the normal protective response of the body’s immune system. The highly complex immune system defends the body against harmful substances such as bacteria, viruses, and irritants that can enter through any opening, such as the mouth, the nostrils, or a wound. The immune system generates inflammation for a variety of reasons, including to serve as a barrier against the spread of infection, and to promote healing.

Normally, inflammation subsides after the harmful invader has been eliminated. But sometimes, inflammation becomes chronic and can be problematic, as happens in people with asthma.

The immune system is not static. It is continuously responding and evolving based on what the body encounters from the external environment, which can include bacteria, viruses, and pollutants, among other things. It also responds to internal factors, such as stress.

One theory is that for asthma to develop, very specific combinations of genes and environmental factors must be present. Environmental exposures that have been most clearly linked to the development of asthma are airborne allergens and viral respiratory infections (such as pneumonia, a cold, or flu). One study found that children who had a lung infection such as pneumonia before age three had nearly double the risk of asthma or wheezing later on.

Smoking

One study suggests that cigarette smoking may increase the risk for developing asthma. In addition, cigarette smoking during pregnancy has been linked to a greater risk for the child to experience bouts of wheezing, although it is not certain that this leads to asthma.

Air Pollution

Air pollution in general, and high ozone levels in particular, can aggravate asthma. Some research suggests that young children exposed to traffic-related pollution are more likely to develop respiratory problems, such as wheezing. Some evidence suggests that babies born to women exposed to air pollution during pregnancy may be at greater risk for asthma.

Obesity

The CDC recently reported that more overweight and obese adults have asthma than adults of normal weight. As obesity rates in the United States have climbed, so have asthma rates. About 7 percent of normal-weight people have asthma, compared with 11 percent of obese adults, and 15 percent of obese women. The reason for the connection is unknown.

Interestingly, underweight women also have an increased risk for asthma, and both obese and underweight women who drink and smoke have twice the risk for asthma than women of normal weight who don’t drink or smoke.

Gaining control of asthma is more difficult for obese patients than for those with normal body weight. Bariatric surgery can help, but so can exercise. In studies, patients who participated in weight-loss programs that incorporated aerobic exercise and muscle strength training lost more weight, gained more aerobic capacity, and saw improvements in lung function, anti-inflammatory biomarkers, vitamin D levels, and airway and systemic inflammation than those whose weight-loss program did not include exercise.

Stress

Several studies have found that children who suffer adversity, such as physical abuse, the death of a parent, divorced or separated parents, or living with someone who has a drug or alcohol problem, mental illness, or has served time in jail, are at increased risk for developing asthma. The reason for this association is not known, but it is possible that childhood adversity causes chronic stress, which can lead to asthma.

Mold Exposure

A few studies have found that infants who live in homes with mold are more likely to develop asthma than those who are not exposed to mold.

Anemia

One study found that the children of women who were anemic during pregnancy are at increased risk for asthma.

Birth Country

Simply being born in the United States appears to increase the risk for asthma. Children and teenagers who are born in other countries and immigrate to the United States are about half as likely to have asthma and allergies as children born in the United States. The “Westernization Theory” may be responsible. This theory postulates that an exceptionally clean environment in childhood may prevent a child’s immune system from fully developing. Such children are more likely to have asthma and allergies than children raised in countries where less-sanitary living standards are the norm. However, it is also possible that children from Western backgrounds see physicians more frequently, and have common medical conditions such as asthma recognized earlier in life. This leads to more diagnoses, which may account in part for why asthma seems more common in industrialized countries.

Breastfeeding

Some studies have found that breastfeeding may help protect children from asthma, but the reason for a potential link between breastfeeding and better lung function is not known. The World Health Organization recommends breastfeeding exclusively for the first six months of life.

Asthma Symptoms

The most common symptom of asthma is a cough, although wheezing (a high-pitched whistling sound, especially when exhaling), chest tightness, and shortness of breath also are common.

In people with asthma, respiratory symptoms worsen in response to particular stimuli. The symptoms may occur, and often seem to worsen, at night. In some people, especially young children, the only symptom of asthma will be a cough that is worse at night.

More than one-third of adults with asthma suffer from insomnia, and, as a result, are sleepy during the daytime. This can lead to depression, anxiety, and diminished quality of life.

An asthma attack may occur suddenly or may begin slowly, with gradually worsening symptoms. It may end quickly or last for several hours. In some cases, an initial asthma attack will ease up, but then be followed by a second, possibly more severe, attack. Some severe asthma attacks will cause significant difficulty breathing, and the lips and fingernails may assume a gray or blue tinge from lack of oxygen (cyanosis). In the event of a severe asthma attack, it may be necessary to call Emergency Services or go to a hospital emergency room or a physician’s office for immediate treatment.

Research suggests that people who are obese (categorized as a body mass index of 30 or greater) may experience worse asthma symptoms than people of normal weight, due to dynamic hyperinflation. This means that air that is breathed in gets trapped in the lungs and is not exhaled, and the result is a greater feeling of breathlessness.

Asthma Triggers

People with asthma may suffer an asthma attack if they are exposed to certain triggers, including allergens like pollen and mold, pets, and smoke, among others. Triggers tend to vary from person to person.

Pollen and Mold

Outdoor allergens include pollen and mold. Allergy season, when pollen counts are highest, varies depending on where you live. To limit your exposure to pollen and outdoor mold during allergy season, keep windows closed as much as possible and try to stay indoors around midday, when pollen and some mold spore counts are highest. It may be necessary to increase your medication dose just before and during allergy season if you are sensitive to pollen and outdoor mold.

Indoor mold can grow wherever there is dampness or wetness. To keep the house as dry as possible, make sure faucets, pipes, and other sources of water are not leaking. Clean any surfaces that have mold. Basements, which can be damp, should be dehumidified if possible.

Pets

For people who have an allergic response to cats, dogs, or other animals with fur, it is the animals’ flakes of skin (dander) or dried saliva that cause the reaction. The best option for people with asthma triggered by animal dander is not to have a pet, or to have a hypoallergenic pet. For those who do not wish to deprive themselves of pet ownership, some precautions may help. The pet may be kept outdoors, or at minimum, out of the bedroom. Carpets can attract animal hair, dander, and dried saliva, so replace them with wood or tile floors, or keep the pet out of carpeted rooms.

Insects

Some people with asthma are allergic to the dried droppings and remains of cockroaches. To make your home as unappealing as possible to cockroaches, never leave food out, keep garbage in a closed container, and fix plumbing leaks. Use poison baits, powders, gels, or pastes to kill cockroaches if you see them.

Dust mites also are a common culprit. Dust mites are microscopic bugs that can live in carpets, furniture, mattresses, and bedding. The mites are harmless to humans, but can trigger allergies and asthma attacks.

Smoke, Strong Odors, and Sprays

Smoke from cigarettes, cigars, pipes, or a wood-burning stove or fireplace can trigger an asthma attack in some people. It is best to stay away from people who are smoking, and to keep your home smoke-free. A person with asthma who smokes should quit, and should encourage other people living in the home who smoke to stop as well. Smoking increases the risk for numerous diseases, including cancer and heart disease, as well as COPD.

Strong odors and sprays, such as perfume, aftershave, scented body lotions, hair spray, talcum powder, paint, new carpet, and others also can be problematic for some people with asthma. Exposure to these irritants should be limited as much as possible.

Exercise

To minimize the chance of experiencing symptoms while exercising or engaging in sports, be sure to spend about 10 minutes warming up before engaging in vigorous exercise. Check the air quality and pollen levels if you are allergic to pollen, and try to exercise during times when air quality is good and pollen levels are low.

Many people with asthma also use their rescue inhaler 10 minutes prior to exercising, which decreases the chances of an attack during exercise and also improves exercise performance for many.

Medications

Some people with asthma are sensitive to certain medications. Drugs that can trigger asthma symptoms include beta-blockers (used to treat high blood pressure), aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are used for pain relief and include common over-the-counter drugs such as ibuprofen (Advil, Motrin) and naproxen (Aleve). Aspirin and NSAIDs trigger asthma symptoms in about 3 to 5 percent of adults with asthma.

For people who are bothered by any of these medications there are alternatives. Your physician can make specific recommendations.

Sulfites in Foods

Some foods and drinks contain sulfite compounds. These compounds work as a preservative to prevent discoloration, and can be found in beer, wine, processed potatoes, dried fruit, sauerkraut, and shrimp. About 5 percent of people with asthma have a worsening of symptoms when they eat foods containing sulfites. The only remedy for these individuals is to avoid sulfite-containing foods. Foods and beverages that contain sulfites must indicate this on the label.

Other Triggers

Some people find that viral infections, changes in weather, strong emotions, or their menstrual cycle worsen asthma symptoms, or even trigger an attack.

Diagnosing Asthma

A physician will suspect asthma in a person who has characteristic symptoms that recur and are triggered or worsened by certain stimuli, such as the triggers mentioned above.

To make the diagnosis, a physician will take a detailed medical history, conduct a physical examination that includes listening to the chest for wheezing sounds, and perform a spirometry test. This often involves bronchodilator reversibility testing to determine if the airflow obstruction is reversible, which is typical in asthma. The spirometry test also may be used to rule out other possible causes of symptoms, such as COPD.

Treating Asthma

Asthma can’t be cured, but it can be effectively managed by preventing asthma attacks as much as possible, and treating them when they occur. The goals of asthma treatment are to reduce the intensity and frequency of asthma attacks, and to prevent any adverse effects of asthma (such as the need for hospitalization), as well as any side effects of asthma medications. Ideally, if asthma is well managed:

• There will be few bothersome symptoms. This means that symptoms will occur in the daytime no more than twice each week, and symptoms in the night will be limited to no more than twice each month.
• Use of an inhaled bronchodilator will be necessary a maximum of two times per week. (This does not include use of a bronchodilator prior to exercise).
• Normal daily activities, such as work, school attendance, exercise, and participation in athletics, will not be hindered.
• Airflow, as measured with a peak flow meter, will be normal.
• The need for hospitalization or use of oral steroids for asthma symptoms will occur no more than once a year.

Achieving these goals involves eliminating or minimizing asthma triggers and using appropriate drug therapy (usually inhaled beta-agonists and inhaled corticosteroids).

Drugs to Treat Asthma

Most people with asthma will need medications. Many of the bronchodilator and anti-inflammatory drugs used for asthma are the same ones used to treat COPD. However, they are used differently for asthma.

There are three general types of asthma medications:

• Long-term control medications are the mainstay of asthma treatment for most people. They must be taken daily to prevent symptoms, generally by reducing inflammation. They will not provide quick relief when symptoms do occur.
• Quick-relief (“rescue”) medications are usually fast-acting bronchodilators that work by relaxing airway muscles, promptly relieving symptoms. They are used to open airways during an asthma attack or just before exposure to a known trigger, such as exercise.
• Medications for allergy-induced asthma reduce sensitivity to a particular allergen.

For the most part, long-term control medications should keep asthma symptoms under control, with only occasional need of a rescue medication for quick relief. If quick-relief medications are needed on more than two days each week (not including prior to exercise), this indicates that a change in long-term control medication may be needed.

Oral drugs sometimes used for asthma include the leukotriene receptor antagonists montelukast (Singulair) and zafirlukast (Accolate), theophylline (Theolair, Uniphyl), cromolyn (Intal), nedocromil (Tilade), and zileuton (Zyflo). Leukotriene receptor antagonists are taken in pill form, rather than inhaled. Leukotrienes are chemicals that are part of the body’s natural immune system. In people with allergies and asthma, the body mistakenly perceives harmless substances, such as pollen and other allergens, as a threat. Exposure to allergens sparks leukotrienes to produce inflammation. Leukotriene receptor antagonists block the action of leukotrienes to prevent inflammation.

For people with asthma that is triggered by allergies, immunotherapy (“allergy shots”) or a monoclonal anti-IgE antibody drug called omalizumab (Xolair) may be used. For those with asthma related to an inflammatory cell called eosinophils, new monoclonal antibody therapies called mepolizumab (Nucala), reslizumab (Cinqair), and benralizumab (Fasenra) are now available. Everyone with asthma should follow the recommended schedule for influenza and pneumonia vaccinations.

People with severe asthma may be treated with a newer class of drugs known as biologics. These drugs target the cells causing inflammation, and include omalizumab (Xolair), mepolizumab (Nucala), reslizumab (Cinqair), and benralizumab (Fasenra). Biologics are considered a major advance in asthma treatment. Omalizumab binds an antibody that causes allergic reactions, thereby reducing the body’s sensitivity to allergens. Omalizumab is used only in people who have moderate-to-severe asthma that is triggered by allergies. Mepolizumab, reslizumab, and benralizumab reduce levels of cells called eosinophils, which play a role in allergic reactions and contribute to inflammation. All are given by injection in a doctor’s office every few weeks.

The severity of asthma can change over time, either for better or worse. Therefore, treatment may require periodic adjustment, either to improve control of the disease or, if it is well controlled, to reduce medications so the risk of drug side effects can be managed.

Asthma Treatment Regimens

All medications used in asthma, and the frequency of their use, depends largely on the severity of the disease. Asthma is classified as intermittent or persistent, and persistent asthma is further classified as mild, moderate, or severe.

Intermittent Asthma

People with intermittent asthma generally only require a quick-relief medication. In most cases, this will be a bronchodilator—specifically a short-acting inhaled beta-agonist, such as albuterol (AccuNeb, Ventolin HFA, Proventil HFA, ProAir HFA), levalbuterol (Xopenex HFA), pirbuterol (Maxair Autoinhaler, or metaproterenol, a generic). The medication is taken as needed for immediate relief when symptoms arise. People with asthma who experience symptoms during exercise may be instructed to use a short-acting inhaled beta-agonist about 10 minutes before exercising to prevent symptoms.

If a bronchodilator is needed on more than two days a week (not including exercise), it may signal that asthma is worsening or not under good control. If this happens, asthma may be classified as persistent, and a change in treatment may be warranted.

Mild Persistent Asthma

For people with persistent asthma, daily treatment with a long-term controller-type medication is used. For those with mild persistent asthma, this will most likely be a low dose of an inhaled corticosteroid. In addition, a short-acting beta-agonist will be used for immediate symptom relief.

Four other options for long-term controller medications in people with mild persistent asthma are leukotriene receptor antagonists, theophylline, cromolyn (Intal), and nedocromil (Tilade). Cromolyn and nedocromil, which are inhaled, are called mast cell stabilizers. Mast cells are part of the body’s immune system. In the presence of a foreign invader, mast cells break down and release large amounts of histamine, which contributes to the production of inflammation. Cromolyn and nedocromil work by preventing mast cells from breaking down. This stops histamine from being released, and prevents inflammation.

Moderate Persistent Asthma

For moderate persistent asthma, there are two options for long-term controller therapy:

• A medium dose of an inhaled corticosteroid, or
• A low dose of an inhaled corticosteroid, plus a long-acting beta-agonist (LABA).

If a LABA is used, it should not be used as the only medication (see “Long-Acting Beta-Agonists Prove Safe After All”), and it should be used for the shortest time possible. LABAs include salmeterol (Serevent), formoterol (Foradil), aformeterol (Brovana) and extended release albuterol tablets (VoSpireER). The Food and Drug Administration (FDA) issued the following statement on the use of long-acting beta-agonists to treat asthma. These drugs should:

• Only be used in combination with an asthma controller medication, such as an inhaled corticosteroid.
• Be used for the shortest time possible to bring asthma symptoms under control, and then discontinued.
• Only be used long-term in patients for whom asthma control cannot be achieved with other drugs.
• Be used by children and adolescents only in the form of combination drugs that contain both a long-acting beta-agonist and a corticosteroid.

In making its decision, the FDA cited studies showing an increased risk of severe worsening of asthma symptoms, leading to hospitalization and even death in some children and adults. Some studies have indicated that using an inhaled corticosteroid in combination with a LABA abolishes the risk, but this has not been proven and continues to be studied. The warning does not apply to people with COPD.

The two most commonly used LABAs are salmeterol and formoterol. Four drugs that combine a LABA with an inhaled corticosteroid are available and include salmeterol plus fluticasone (Advair, AirDuo), formoterol plus budesonide (Symbicort), formoterol plus mometasone (Dulera), and vilanterol plus fluticasone (Breo Ellipta).Alternatively, for moderate persistent asthma, a leukotriene modifier or theophylline may be given with a low dose of an inhaled corticosteroid. In any case, a short-acting beta-agonist will continue to be used for immediate symptom relief.

Severe Persistent Asthma

Severe persistent asthma is treated with medium-to-high doses of an inhaled corticosteroid combined with a long-acting inhaled beta-agonist. Just as with moderate persistent asthma, use of a long-acting beta-agonist without an inhaled corticosteroid is not recommended.

For some patients with severe persistent asthma, a biologic also may be considered. All the biologics are used only in combination with other asthma medications.

People with severe asthma that cannot be controlled with any of these therapies may be given oral corticosteroids. This practice is generally recommended only for short periods of time, due to the potential side effects of taking corticosteroids in pill form rather
than inhaled.

Recommendations for All Asthma Patients

Once a treatment plan has been established, patients with asthma should visit their health-care professional every one to six months (depending on the severity of their asthma) to ensure that treatment is working and that the treatment goals are being met.

This cannot necessarily be assumed. One study found that 49 percent of asthma patients were not using needed controller medication. Of the 51 percent of asthma sufferers who were using controller medications, only 14 percent had adequate control of their asthma. People with poor asthma control are at higher risk for emergency department visits and hospitalizations. Another study found that children with poorly controlled asthma had lower-quality schoolwork and more sleep problems than children with well-controlled asthma.

Improving the control of asthma symptoms has clear benefits for both children and adults. The challenge is how to accomplish this. People with moderate-to-severe asthma must set aside time from busy lives to take controller medication every day. It is easy to forget, but receiving reminders can help, and a variety of smartphone and tablet apps are available to aid with this.

It also is wise to make sure your vitamin D levels are normal, as high levels of vitamin D have been associated with better lung function, and a better response to drug therapy with inhaled corticosteroids.

Gastroesophageal reflux disease (GERD), which causes acid to back up from the stomach into the esophagus, causing heartburn and other symptoms, also can interfere with asthma control.

Everyone with asthma should take an active role in managing and monitoring their condition by using medications as prescribed, keeping track of the frequency and intensity of symptoms, identifying triggers, and recognizing early signs that asthma may be worsening. You may be instructed in how to use a peak flow meter to keep track of your lung function at home. At visits to the physician’s office, spirometry often will be used to test your lung function.

Immunotherapy

If your asthma symptoms are clearly triggered by identifiable allergens, attempts can be made to reduce your body’s reaction to the stimulus. This can be done with the biologic medication omalizumab, or with immunotherapy (“allergy shots”). Immunotherapy involves repeated injections of small amounts of the allergen (the substance triggering the reaction) in an attempt to desensitize the body to the substance. Immunotherapy is most effective in people who have a reaction to a single allergen, particularly dust mites, animal dander, or pollen. Allergy shots can be given to children over age five and adults of all ages, even older adults. A recent study that tested allergy shots in adults ages 65 to 75 found them to be both safe and effective.

Traditional allergy immunotherapy is called subcutaneous immunotherapy (SCIT). Before immunotherapy is begun, skin tests are performed to clearly identify the allergen. First, allergy shots are given under the skin once or twice a week for about four to six months. For the next four to six months, the shots are given every two to four weeks. This therapy generally continues for several years. Eventually the body becomes less sensitive to the allergen, reducing the chance of asthma attacks.

In rare cases, a severe and potentially life-threatening reaction called anaphylaxis can occur as a result of the shots. For this reason, it is important that the shots be administered in a physician’s office that is equipped with the facilities and trained personnel to treat this type of reaction (patients are generally asked to wait in the lobby for about 10 minutes after the shots to ensure they do not have a reaction).

For people with grass or ragweed allergies who don’t like shots, there is another option: With sublingual immunotherapy (SLIT), small tablets are placed under the tongue, where they dissolve and are absorbed into the body. The pills are taken once a day. It must be started three to four months before exposure to the allergic substance. For a person with a pollen allergy, this means starting to use the sublingual tablets in mid- to late winter, depending on the climate where you live.

Three sublingual treatments are available: Grastek (for grass pollen allergies), Oralair (for grass pollen allergies), and Ragwitek (for ragweed allergies). Like with the allergy shots, a severe allergic reaction (anaphylaxis) can occur. Therefore, the first dose of the sublingual tablets must be taken in the doctor’s office, and, as mentioned above, the patient usually remains in the office for at least 10 minutes after the shots to ensure that there is no reaction.

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A: PPIs work by reducing the amount of acid produced by glands in the stomach lining. They are commonly prescribed to people with gastroesophageal reflux disease (GERD), of which heartburn is a major symptom. In recent years, some research has suggested that the medications may be associated with cognitive decline. Researchers theorized that part of the drugs may cross the blood-brain barrier (which becomes porous with age) and interfere with healthy brain function. Another theory is that the drugs may lead to lower levels of vitamin B12, which can also affect brain function. However, a large population study published earlier this year found that there was no association between long-term PPI use and a decline in thinking skills.

A study published in early 2018, though, did find that the use of certain PPIs (pantoprazole, lansoprazole, and rabeprazole) was associated with a greater risk of depression. This finding is new, and more studies are needed to learn more about any possible depression risks posed by PPIs. This year’s study was an observational study, however, and did not prove any type of cause-and-effect relationship between PPIs and depression.

If you have concerns about the side effects of these drugs, talk with your doctor about alternative treatments for your condition.

Q: Why is it that my mind seems to race at bedtime? I have a million thoughts in my head, and it makes it difficult to fall asleep.

A: You are certainly not alone, as an estimated one in three people have at least mild insomnia. There are, of course, many causes of insomnia, and a busy mind at bedtime is a common one. There are also several possible explanations for your racing thoughts at bedtime. The brain is always “remaking” itself as it processes new information and stores new memories. Studies have shown that this type of activity is elevated in some people with insomnia, making it more difficult to relax and fall asleep. Racing thoughts may also be a sign of anxiety. If you tend to worry about future events, dwell on past events, or feel overwhelmed by your responsibilities, then you may have anxiety.

A therapist may be able to help you deal with your anxiety and manage your thoughts and feelings to help you relax. If you just need to quiet your mind enough to fall asleep at bedtime, try occupying your brain with innocuous, but pleasant activity: Make a list of your 10 favorite books or movies; mentally rearrange the furniture in the lobby of a luxury hotel; imagine all the steps involved in taking a trip, from packing a suitcase, boarding a plane, and arriving at your destination.

Q: I’ve started using calendars, lists, and other reminders more than ever. I find them very helpful, but I wonder if I’m “cheating” by not challenging my brain to keep track of things. Should I change what I’m doing?

A: You can challenge your brain in many ways besides tasking it to keep track of doctor appointments, passwords, errands and other responsibilities. What you are doing is a smart way to stay organized, avoid missing out or losing information, and preserve your independence. If you want to give your brain a workout, you have countless options. Try learning a new language or computer skills, or start a new hobby. Read books and articles which interest you, but contain new and challenging material. Travel, meet new people, or volunteer. You’re only “cheating” yourself if you don’t keep your mind busy with something and stay engaged with other people.

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Safe in the Short Term, but Often Overused. Studies have found, however, that nearly half of all patients taking PPIs don’t actually need them. Many patients simply take them for much longer than necessary, researchers have reported. While short-term use is safe, the U.S. Food and Drug Administration reports that long-term use is associated with an elevated risk of fractures, hypomagnesemia, Clostridium difficile–associated diarrhea, and vitamin B12 deficiency. Now, a study published in the April issue of the Journal of the American Geriatrics Society has added community-acquired pneumonia to the list.

Mining for Data. The researchers scoured a database of electronic medical records to find patients who were age 60 or older; had been taking PPIs such as esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole sodium for at least a year; and who had at least one year’s worth of records available from before they took the PPIs. All told, they found 75,000 records, which they matched against controls with no history of PPI use. They found that patients who had been taking PPIs had a statistically significantly higher risk of developing community-acquired pneumonia in the second year of PPI use.

One possible explanation is that the gastric acid that is bothersome to people with conditions like GERD is actually an important part of the body’s response to bacterial infections. When medications suppress the acid, the body loses a line of defense.

What This Means for You. If you show symptoms that suggest pneumonia, such as a fever and shortness of breath, take them seriously and be sure to tell your health-care provider that you are taking a PPI. Take a PPI only as long as it is necessary. If you take over-the-counter PPIs, be sure to tell your physician and talk to him or her about how long you’ve been using the drug. He or she can work with you to balance the risks of PPI use with the benefits of controlling your GERD or related condition.

You may be able to try different medications or lifestyle modifications to reduce your need for PPIs, but it’s important to taper off your drugs instead of stopping all at once.

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A: “A medium baked potato (with skin) is a good source of potassium, vitamins C and B₆, and fiber. But potatoes don’t contain other nutrients, such as the carotenoids and phytochemicals found in more brightly-colored vegetables,” says Helen Rasmussen, PhD, RD, a senior research dietitian at Tufts’ Human Nutrition Research Center on Aging. “Peeling to remove the skin to make fries and chips results in the loss of a large portion of the fiber, further diminishing the potato’s nutritional value. In addition, French fries are typically salted. Most of us consume more than the recommended amount of sodium, and eating highly salted foods like fries makes that situation worse.”

“Deep frying potatoes to turn them into French fries does not change them that much, but it does increase the number of calories per serving, so we get less nutrients per calorie when we eat them. We each need a particular number of calories to fuel our bodies, and we also need a sufficient intake of many different nutrients. If we choose to consume something like French fries frequently and in a large quantity, we will surpass our calorie needs before we meet all of our nutrient needs, which can impact health.”

“Enjoy potatoes sometimes as part of a balanced, healthy dietary pattern. Think of them as a substitute for grains rather than vegetables when you fill up your plate. Leave the skin on, prepare them in a variety of ways, and avoid adding a lot of butter, cream, and salt. Round out your plate with plenty of colorful vegetables and other plant foods.”

Q: I’ve heard that drinking lemon water can help with my acid reflux. Is this true?

A: Judith C. Thalheimer, RD, LDN, managing editor of TuftsHealth & Nutrition Letter, answers. “There is no research to back up the idea that lemon water helps with acid reflux, but there are some steps you can take if you suffer from this condition.”

“Acid reflux occurs when the muscle between the stomach and the esophagus weakens, allowing stomach acid to flow back into the esophagus. Symptoms include heartburn, belching, and nausea. Many people get occasional acid reflux, but frequent occurrences may indicate a chronic disorder called gastroesophageal reflux disease (GERD), a serious condition that can lead to esophageal cancer if not treated.”

“In addition to acid-reducing medications that your doctor can recommend, avoiding certain foods or drinks may help reduce acid reflux. These include alcohol, caffeine, chocolate, deep fried/greasy or spicy foods, mint, carbonated beverages, tomato products, garlic and onions, and citrus fruits and juices, like lemons. The following tips are also recommended:

• Don’t lie down for at least 45 to 60 minutes after meals; and stop eating at least three hours before going to bed
• Avoid overeating, and try smaller, more frequent, meals
• Avoid tight waistbands
• Don’t smoke
• Lose weight if necessary”

“Lemon juice is quite acidic, so too much could actually make reflux worse. If you enjoy lemon water, make sure to add only a small amount of lemon juice. Also, be aware that lemon juice can damage the enamel on your teeth, so if you do drink lemon water, use a straw.”

Q: I heard that the heat from cooking makes oil dangerous. Is oil safe to cook with?

A: “Oil is safe to cook with under usual conditions,” says Alice H. Lichtenstein, DSc, senior scientist at Tufts’ HNRCA and executive editor of Tufts Health & Nutrition Letter. “The primary concern I suspect your source was referring to is oxidation, a natural process that occurs when one molecule gives up an electron to another as part of a chemical reaction. The process creates free radicals, which can cause damage that could increase risk for problems such as heart attack, stroke, and cancer. Oils and oily foods (like nuts and whole grains) can oxidize over time, even without cooking. Exposure to light, heat, and air speed up this process. Keep oils in a cool, dark place, and store nuts, whole-grain flours, and fish-, nut-, and seed oils in the refrigerator to keep them fresh longer. Repeatedly-heated cooking oil has been found to have more signs of oxidation, so it’s best not to reuse cooking oil.”

“To counteract free radicals, whether they are formed by normal metabolism in the body or in oils, eat plenty of plant foods. Fruits, vegetables, and other plants have antioxidants that can counteract free radicals in the body.”

—Jerold R. Mande, MPH

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Dysphagia

Difficult or painful swallowing is called dysphagia. Dysphagia can be caused by a problem with the muscles or nerves involved in the swallowing process, or by a physical abnormality that impedes the movement of food and/or liquid. It’s important to differen-tiate between structural and neurological causes of dysphagia because different treatments are needed for each.

Esophageal Dysphagia

Esophageal dysphagia manifests as the sensation that something is stuck in your throat, usually because the esophagus is nar-rowed or inflamed. Esophageal dysphagia is typically caused by a structural problem rather than a nerve or muscle disorder (alt-hough these disorders can be the culprit in some cases). Possible causes include:

• Gastroesophageal reflux disease (GERD). This is a condition in which contents from the stomach flow backwards into the esophagus, irritating the lining of the esophagus. Over time, this irritation can cause scarring that narrows the diameter of the esophagus near the stomach.
• Eosinophilic esophagitis. An inflammatory condition in which a type of white blood cell builds up in the lining of the esophagus. It can cause the esophagus to swell and become so narrow that food gets stuck.
• Narrowing of the esophagus (stricture), which can cause particles of food to get stuck. The esophagus can become narrowed by a number of conditions, including chronic reflux and scarring, ulcers, inflammation, infection, tumors, and irritation from certain medications.
  Esophageal spasm. A rare disorder in which the normal contractions of the esophagus (peristalsis) that propel food downward be-come poorly coordinated. These muscle spasms generally cause pain and difficulty swallowing.
• Achalasia. A disorder in which the valve-like muscle complex between the esophagus and stomach (the lower esophageal sphinc-ter) fails to relax and open wide enough to allow food to enter the stomach. In addition, the muscles of the esophagus wall do not contract properly and do not move food downward.
• Scleroderma. A connective tissue disease that causes changes in the skin, blood vessels, muscles, and internal organs. Excess de-posits of collagen cause scar-like tissue to form in internal organs, including the esophagus. It also can weaken the lower esophageal sphincter, causing GERD symptoms. Difficulty swallowing is just one of several symptoms of this disease.
  Oropharyngeal Dysphagia
  Oropharyngeal dysphagia makes it difficult to maneuver food towards the back of your throat so that you can swallow it. Intoler-ance of solids may progress to intolerance of liquids and the condition frequently causes food and liquids to come out through the nose (nasal regurgitation), and an inability to tolerate both liquids and solids.
  Oropharyngeal dysphagia usually has a neurological cause, but it also can result from cancer, or a condition called Zenker’s di-verticulum.
• Neurological causes such as Parkinson’s disease, Huntington’s disease, multiple sclerosis, amyotrophic lateral sclerosis (Lou Geh-rig’s disease), muscular dystrophy, and myasthenia gravis can weaken or damage the throat muscles used for swallowing, mak-ing it difficult to move food from the mouth to the esophagus. Sudden damage to nerves due to a stroke or head injury also can impair the swallowing muscles.
• Cancer. More rarely, head and neck cancers, oral cancer, and thyroid cancer can impair swallowing or block the esophagus.
• Zenker’s diverticulum. These are pouches that develop in the upper throat. They can cause difficulty swallowing, and result in the regurgitation or aspiration of food.

Dysphagia Symptoms

Common symptoms include painful swallowing, the sensation that something is stuck in the throat, and regurgitation of food. Some people with dysphagia may be unable to swallow solid food or liquids, and some may become incapable of swallowing altogether or—in the worst cases—be unable to swallow saliva.

Diagnosing Dysphagia

There are several tests (see Chapter 2) that can diagnose dysphagia.

• A barium swallow can reveal any changes in the shape of the esophagus. In a variation called cine esophagography, the passage of barium is viewed in real time as it travels from the mouth to the stomach
• Endoscopy allows a physician to see the inside of the esophagus
• A pH test can measure acid reflux in the esophagus
• Esophageal manometry can determine how well the valve between the esophagus and stomach is working and if the esophagus is moving food and liquid down towards the stomach
• Multichannel intraluminal impedance can check for both acid and alkaline reflux.

Treating Dysphagia

The treatment of dysphagia depends on the cause. Some conditions, like GERD, can be treated with medications, while others, like achalasia, may be treated with endoscopic intervention, dilation, or surgery.

For neurological causes of dysphagia, a speech or swallowing specialist may be consulted. Treatment may include exercises to strengthen the swallowing muscles and improve coordination, and it may be necessary to position the body or head in certain ways to assist with swallowing.

Symptomatic Zenker’s diverticulum is often treated with open surgery or rigid endoscopy. Both procedures carry a high rate of complications, largely due to the advanced age of patients and the need for general anesthesia. Flexible endoscopy is the pre-ferred procedure, as it can be performed in an outpatient setting without general anesthesia and with a low rate of complications. In treating Zenker’s diverticulum with endoscopy, the gastroenterologist must open the wall between the pouch and esophagus, in essence preventing the pouch from retaining swallowed food. The procedure cannot be performed on small diverticula or patients who cannot extend their neck. Only a limited number of practitioners have experience treating these outpouches with flexible endoscopy.

If dysphagia is severe enough to completely prevent the consumption of foods or liquids, a feeding tube may need to be in-serted directly into the stomach to bypass the swallowing mechanism.

Gastroesophageal Reflux Disease (GERD)

What most people commonly know as “heartburn” is a symptom of GERD. Heartburn—a sharp, burning feeling in the chest—can be an occasional problem that doesn’t require anything more than symptom relief with an over-the-counter (OTC) antacid. But if heartburn becomes a persistent problem, it could be a symptom of a more serious issue requiring medical attention. This is especially true if it is accompanied by difficulty swallowing or by weight loss.

GERD occurs when the acidic contents of the stomach flow backwards (reflux) into the esophagus. This happens when the low-er esophageal sphincter separating the lower end of the esophagus from the stomach becomes weak or doesn’t close properly. The lining of the esophagus is not meant to withstand stomach acid, which leads to inflammation and pain.

There are several possible causes that can underpin reflux:

• An overly full stomach, which may push some of the acidic contents back up into the esophagus
• A hiatal hernia
• Pregnancy, as the growing uterus presses on the stomach and pregnancy hormones cause digestion to slow down
• Drugs that may cause the valve to remain relaxed—these include beta-agonists (used for treating asthma), calcium channel blockers (for treating high blood pressure), some antihistamines (such as Benadryl), and sedatives
• Being obese or overweight.

GERD should be taken seriously, especially if you experience symptoms often, since it can lead to other conditions. Too much acid in the esophagus can cause esophagitis (inflammation of the lining of the esophagus), a condition that may lead to esophageal bleeding or ulcers. Also, acid can scar the esophagus, causing it to narrow and making swallowing difficult.

A small percentage of people with long-term exposure to GERD develop a condition called Barrett’s esophagus, which can lead to esophageal cancer.

GERD Symptoms

Persistent recurring heartburn is the main symptom of GERD—if heartburn occurs more than twice a week, GERD is the most likely reason. However, older adults may not experience as many symptomatic episodes.

Other symptoms of GERD include chest pain, trouble swallowing, and difficulty keeping food down after meals. Some people taste the stomach acid in the back of their mouth: It has a metallic taste, and may cause bad breath. GERD also can cause a sore throat, dry cough, hoarseness, or a repeated need to clear the throat. Some experts believe that GERD may be a cause of sinusitis (inflamed or infected sinuses) and dental erosions.

Because GERD can cause chest pain that may be similar to the chest pain caused by heart problems, it’s important for anyone at risk for heart disease to be checked to rule out a heart-related cause for the discomfort before attributing it to GERD. Risks for heart disease include a personal or family history of heart disease, high total cholesterol, high LDL (“bad” cholesterol), low HDL (“good” cholesterol”), high blood pressure, being overweight or obese, diabetes, smoking, physical inactivity, and being age 65 or older.

Diagnosing GERD

GERD is frequently diagnosed on the basis of symptoms alone, but a pH test also may be used (see Chapter 2).

Treating GERD

Lifestyle measures may help you avoid GERD, and a range of medications is also available to prevent and treat the symptoms. Sur-gical interventions are considered a last resort.

Lifestyle Measures for GERD

Certain foods can weaken the lower esophageal sphincter, triggering GERD symptoms. These include chocolate, peppermint, fatty foods, caffeine, and alcohol. If you experience GERD after eating these foods, eliminating them from your diet should relieve the symptoms.

In addition to modifying your diet, there are other strategies you can try to alleviate your symptoms. For example, eat small meals frequently, rather than large ones less often. Don’t eat or drink anything after 7 p.m., and don’t lie down for at least an hour after eating any meal. Also, stop smoking, and lose weight, if you are overweight. Do not wear tight-fitting clothing or belts, and avoid strenuous exercises that increase abdominal pressure, such as sit-ups. To help alleviate heartburn during the night, elevate the head of your bed on six- to eight-inch blocks, or put a foam-rubber wedge below the mattress under your shoulders and upper back. This may help the acid remain in your stomach.

Medications for GERD

There are numerous OTC and prescription medications available to treat GERD. These medications fall into three categories: ant-acids, H2 blockers, and proton pump inhibitors (PPIs).

• Antacids: Antacids contain calcium carbonate, aluminum hydroxide, and magnesium hydroxide, all of which neutralize acid. These are generally the first drugs recommended to relieve heartburn. Examples include Maalox, Mylanta, Tums, Pepto-Bismol, and Rolaids. They start working rapidly, but last only two hours or less. You can take them after a meal, while you are having symp-toms.Long-term use of antacids can cause side effects. Magnesium salts can lead to diarrhea, and aluminum salts and calcium car-bonate can cause constipation. If you need antacids more than twice weekly for more than one month, and/or you have trou-ble swallowing or notice you are losing weight, see your doctor.
• H2 blockers. These drugs decrease the production of stomach acid, preventing heartburn for up to eight hours. Examples of H2 blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75). These are available OTC, and in stronger versions by prescription. H2 blockers require 30 minutes to two hours to take effect, so you should ingest them before symptoms appear. They are effective in about half of people with GERD symptoms.
• PPIs. These are more potent acid suppressors than H2 blockers, and work by blocking an enzyme necessary for acid secretion. PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), esomeprazole (Nexium), omeprazole/sodium bicarbonate (Zegerid), and dexlansoprazole (Dexilant). Several of these are available OTC.

PPIs are effective for most people who have GERD, particularly when the drug is taken 30 to 60 minutes before the first meal of the day. One study found that by reducing nighttime symptoms of GERD, PPIs improved sleep quality and daytime productiv-ity.

GERD Medication Cautions

Nonprescription PPIs contain lower doses of the medication than prescription-strength PPIs, and are intended for a 14-day course of treatment up to three times per year. Long-term use of PPIs in high doses may decrease the absorption of calcium, lower bone density, and increase the risk of fractures, particularly in postmenopausal women. However, increased fracture risk with short-term low-dose PPI use is unlikely.

Rarely, PPIs also may lower magnesium levels, which can impact numerous vital functions in the body. Low magnesium levels (hypomagnesemia) can result in muscle spasms, an irregular heartbeat, and convulsions—or no symptoms at all. Hypomagnesemia is treated with magnesium supplements. There also is a small increased risk of contracting pneumonia with PPI use, especially among older adults.

The potential for a drug-drug interaction has prompted the Food and Drug Administration to caution against the simultaneous use of the PPI omeprazole and clopidogrel (Plavix, an anti-platelet drug used to prevent stroke and heart attack), since the PPI decreases the effectiveness of clopidogrel. However, while some studies have shown an increased cardiovascular risk with con-current use of PPIs and clopidogrel, others have not, leaving the association questionable. As a precaution, ask your doctor how to time the medications—for example, it may be a good idea to take them 12 hours apart to minimize the risk of interaction. Al-ternatively, your doctor may recommend you use an H2 blocker instead of a PPI.

In other studies, PPI users in general were found to be 12 to 16 percent more likely to have a heart attack than non-PPI users—however, the relationship was seen as an association, not cause and effect, and the fact that PPIs cause an increased risk of heart attack has not been confirmed. Nevertheless, the association suggests that anyone at increased risk for heart attack discuss the risks and benefits of using PPIs with their doctor before buying an OTC product.

For some people who cannot tolerate PPIs, or want to reduce their dependency on these drugs, making dietary changes also may help (see “Mediterranean Diet May Help Eliminate Need For Reflux Medications”).

Interventional Treatments for GERD

If the symptoms of GERD do not abate with medications, dietary restrictions, and/or weight reduction, a surgical or endoscopic procedure is the last resort; however, only a small number of patients require one of these procedures.

There are several surgical treatment approaches for GERD, all aimed at restoring normal function of the lower esophagus. In laparoscopic Nissen fundoplication, the upper part of the stomach is wrapped around the lower part of the esophagus (like a hot dog in a bun) to create a tight sphincter that prevents reflux. The procedure is safe, effective, and requires only small incisions in the abdomen, through which surgical instruments are inserted.

Another approach employs the Stretta device. In this procedure, an endoscope is placed in the patient’s mouth and passed down the throat and into the esophagus. A thin tube is guided through the endoscope to the lower end of the esophagus, just above the stomach. A balloon at the end of the tube is inflated and high‑frequency radio waves are delivered to the lower esophageal sphincter muscle. This tightens the lower esophageal sphincter to prevent stomach acid from entering the esophagus.

Transoral incisionless fundoplication (TIF) is the most recent interventional option. In this procedure, a specially designed de-vice is passed into the mouth and down the esophagus to the stomach. The lower esophageal sphincter is reconstructed through the device. Because there are no incisions, recovery time is much quicker than with the traditional fundoplication procedure.

Perhaps more unusual is the Linx Reflux Management System, which uses a ring of magnetic beads to encircle the esophageal sphincter. The beads hold the sphincter closed, yet readily open for food or as needed for burping or vomiting.

Barrett’s Esophagus

In Barrett’s esophagus, long-term exposure to acid coming from the stomach alters the lining of the lower esophagus. In most people, the change causes no symptoms or problems—however, in a small percentage of people the changes can lead to cancer of the lower esophagus (esophageal adenocarcinoma). The condition also has been associated with increased risk of colorectal cancer and benign adenomatous tumors of the colon.

The lining of the esophagus is different from the lining of the stomach. At the juncture where the two organs meet, a border separates the two types of tissue. In Barrett’s esophagus, the cells that line the stomach and small intestine grow above the bor-der into the lower esophagus—a change called intestinal (or gastric) metaplasia. Over time, these cells can become abnormal (dysplasia) and may turn cancerous. Fortunately, this happens in only a small percentage of people with Barrett’s esophagus, but it means that people with the condition must be closely monitored with endoscopy.

Barrett’s esophagus occurs about three to five times more often in people with GERD, but it also can develop in people without GERD symptoms. Men (particularly white men) are about twice as likely as women to be affected, and the condition usually occurs after age 60. Being overweight or obese also is a risk factor for Barrett’s esophagus.

Barrett’s Esophagus Symptoms

Barrett’s esophagus does not cause symptoms itself—rather, the GERD that typically underlies the condition causes symptoms.

Diagnosing Barrett’s Esophagus

Presently the only way to confirm Barrett’s esophagus is with an endoscopy (see Chapter 2), which allows the physician to see the inside of the esophagus, but new tests are being developed (see “Balloon Test Can Detect Barrett’s Esophagus”).

Because the lining of the stomach has a distinctly different appearance than the lining of the esophagus, it’s relatively easy to see whether the stomach lining has grown into the esophagus. During the procedure, the gastroenterologist will take biopsies from the esophageal lining for examination under a microscope. A pathologist can confirm the presence of cellular changes that indicate metaplasia, dysplasia, or cancer.

Because there are no symptoms specific to Barrett’s esophagus, it can be difficult to know who needs an endoscopy to look for it. There is no consensus about who should be screened. If screening is performed, and Barrett’s esophagus is not found, the screening does not need to be repeated. That being said, endoscopy is recommended for GERD patients aged 40 and old-er—particularly men—with severe or long-standing heartburn.

Treating Barrett’s Esophagus

The choice of a treatment approach for patients with high-grade dysplasia (which carries an increased risk of becoming cancer-ous) must be individualized, and partly depends on available resources, the gastroenterologist’s expertise and experience, and the patient’s preferences. If a biopsy shows cancer, surgery will be needed. No matter which treatment path is taken, action is key for long-term survival (see “Treatment Improves Overall Survival for Older People With Early-Stage Esophageal Cancer”).

Endoscopic Ablation

If a biopsy shows high-grade dysplasia, endoscopic ablation will likely be considered. In this treatment, the abnormal cells in the esophagus are destroyed by heating or freezing.

Surgery

If a biopsy shows cancer, surgery will be needed. The operation involves removing a portion of the esophagus, pulling the stom-ach up, and attaching it to what remains of the esophagus. This surgery is sometimes performed if the biopsy shows high-grade dysplasia, but the American College of Gastroenterology (ACG) recommends frequent and intensive biopsies or endoscopic abla-tion therapy instead.

Eosinophilic Esophagitis

In eosinophilic esophagitis, white blood cells called eosinophils build up in the lining of the esophagus. The exact cause for this accumulation is unknown, but it may be an allergic reaction, since increased production of eosinophils is found in allergic conditions such as asthma, allergic rhinitis, and atopic dermatitis.

Eosinophilic Esophagitis Symptoms

Symptoms associated with eosinophilic esophagitis include dysphagia, heartburn, and chest pain.

Diagnosing Eosinophilic Esophagitis

Eosinophilic esophagitis is diagnosed with an upper endoscopy and biopsy of tissue taken from the lining of the esophagus. This tissue is inspected for the presence of eosinophils.

Treating Eosinophilic Esophagitis

Treatment for eosinophilic esophagitis may include dietary changes. If the inflammation is caused by a food allergy, the food that triggered the response must be avoided. Skin tests may be performed to determine which food might be causing the reac-tion—alternatively, an elimination diet may be recommended to pinpoint the offending food. In an elimination diet, certain foods that commonly trigger allergic reactions are systematically removed from the diet. One study found that a six-food elimination diet that included cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy effectively induced remission of eosinophilic esophagitis for up to three years with individually tailored diets that excluded particular foods.

Eosinophilic esophagitis also may be treated with medications, such as the steroid drug fluticasone (Cultivate), or PPIs.

Achalasia

In achalasia, the esophagus does not function the way it should. One problem involves the lower esophageal sphincter. Normally, this valve stays closed until it senses the presence of food in the esophagus—then it relaxes, opens, and allows the food to pass through. In people with achalasia, the sphincter does not relax enough to open properly, making it difficult for food to pass into the stomach.

A second impairment concerns the peristaltic movements of the esophagus. In achalasia, these wave-like, rhythmic contrac-tions that mechanically propel food down toward the stomach are lost.

The cause of achalasia is unknown, but it may be related to a malfunction of the nerves of the esophagus. It is a rare disorder that generally occurs in adults aged 25 to 60.

Achalasia Symptoms

The most common symptoms are difficulty swallowing liquids or solids, and regurgitating food. Other symptoms include chest pain due to distention of the esophagus, weight loss, heartburn, and coughing.

Diagnosing Achalasia

Achalasia is diagnosed with a barium swallow (see Chapter 2). The x-rays will show the absence of peristalsis, widening of the esophagus due to food build-up in the area, and a narrowing at the lower esophageal sphincter. The diagnosis is confirmed using esophageal manometry.

Treating Achalasia

Achalasia can’t be cured, but it can be treated. Treatment is aimed at getting the sphincter to open wide enough to allow food to easily pass. This can be accomplished with surgical and nonsurgical techniques.

In 2013, the ACG published new guidelines for the treatment of achalasia. They recommend treating the condition with pneu-matic dilation or laparoscopic surgery.

In pneumatic dilation, the diameter of the sphincter is widened with an inflated balloon. The surgical procedure is called laparoscopic myotomy, and involves cutting the muscles of the esophageal sphincter to allow it to open so that food can pass through it. The surgery has a high success rate. To lower the risk of developing GERD, the ACG recommends that fundoplication be performed at the same time.

When patients are not suitable candidates for myotomy or pneumatic dilation, botulinum toxin is a nonsurgical alternative. In-jecting the substance directly into the sphincter relaxes the muscle and relieves the symptoms of achalasia. However, because symptom relief is not permanent, the procedure must be repeated as often as every six to 12 months.

Esophageal Cancer

Two types of cancer can develop in the esophagus. Squamous cell carcinoma can develop in cells that line the inside of the esophagus. It usually occurs in the upper and middle part of the esophagus. Adenocarcinoma can develop in glandular tissue toward the lower end of the esophagus.

The exact cause of some esophageal cancers is unknown. However, it is more common in adults aged 60 and older, and in men. Major risk factors include tobacco and alcohol use, obesity, and infection with the human papilloma virus (HPV) during oral sex. A diet high in fruits and vegetables is linked with lower risk. Barrett’s esophagus increases the risk for adenocarcinoma. Any type of irritation to the lining of the esophagus also can potentially increase the risk of esophageal cancer.

Esophageal Cancer Symptoms

Esophageal cancer begins with a small tumor that may not cause any symptoms. As the tumor grows, however, it can start to block the passageway, causing difficulty swallowing. At first, larger food particles will get stuck, but eventually, eating and drinking any-thing becomes difficult. Other symptoms may include:

• Severe weight loss
• Pain in the throat or back, behind the breastbone, or between the shoulder blades
• Hoarseness or chronic cough
• Vomiting
• Vomiting blood.

Diagnosing Esophageal Cancer

Because esophageal cancer symptoms may have other causes, the doctor will order diagnostic tests that include an upper GI series and an endoscopy with biopsy (see Chapter 2) to look for the presence of any cancer cells.

Treating Esophageal Cancer

Treatment for esophageal cancer depends on several factors. The first step is to determine the stage of the cancer.

• Stage I. The cancer is confined to the top layer of cells.
• Stage II. The cancer has gone into the deeper layers of the esophageal lining, but it has gone no further.
• Stage III. The cancer has spread even further into the wall of the esophagus, or to nearby tissue or lymph nodes.
• Stage IV. The cancer has spread to other parts of the body, such as the liver, lungs, brain, or bones. Esophageal cancer can spread to any part of the body.

Once the extent of the cancer is known, treatment may involve surgery, radiation, and/or chemotherapy. Surgical removal of the tumor, along with all or part of the esophagus, is usually performed. The stomach is then pulled up into the chest cavity and attached to the remaining portion of the esophagus. In some cases, the surgery may be done using a less-invasive technique called transhiatal esophagectomy, in which the esophagus is removed through incisions in the abdomen and neck without opening the chest. Radiation and chemotherapy also may be required.

If the cancer cannot be removed surgically, a laser may be used to destroy the cancer cells, or a stent (a small wire tube) may be placed in the esophagus. Both procedures can help relieve the blockage and make swallowing easier.

Hiatal Hernia

In hiatal hernia, a portion of the upper stomach protrudes up through the diaphragm. The diaphragm is a dome-shaped muscle wall that separates the chest cavity from the abdomen. The esophagus extends through the chest cavity and meets the stomach just below the diaphragm. A hiatal hernia forms at the opening (hiatus) in the diaphragm where the esophagus meets the stomach. If the muscles around this opening become weak, a portion of the upper stomach can push up through the diaphragm into the chest cavity.

Normally, the lower esophageal sphincter is level with the diaphragm. The diaphragm helps keep the sphincter closed when there is no food in the esophagus. If a hiatal hernia pushes the sphincter above the diaphragm, this can impede its function, allowing it to open at the wrong times and letting stomach acid reflux into the esophagus. Also, stomach acid may collect in the herniated part of the stomach, and this acid can then flow into the esophagus and remain there for a period of time. For these reasons, hiatal hernias may be a cause of or a contributing factor to GERD.

Hiatal Hernia Symptoms

A hiatal hernia may cause no symptoms or only mild symptoms, particularly if the hernia is small. Such hernias do not require treatment—however, larger hiatal hernias may interfere with the proper working of the lower esophageal sphincter, allowing stomach acid to back up into the esophagus and cause heartburn (this is the most common symptom of a hiatal hernia).

Diagnosing a Hiatal Hernia

A hiatal hernia is typically discovered during evaluation for another gastrointestinal condition, such as GERD. A hernia may be de-tected on a barium x-ray or endoscopy.

Treating a Hiatal Hernia

Symptomatic hiatal hernia is treated with the same medications used for GERD: antacids, H2 blockers, and PPIs. When symptoms associated with a large hernia are not relieved with medications, surgical repair is possible. During the surgery, the portion of the stomach that protrudes through the diaphragm is pulled back down, and the opening in the diaphragm is reduced.

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