Tips For Avoiding Acute Exacerbation Of COPD or Chronic Obstructive Pulmonary Disease

In this blog, we will review a few simple things that the patient and the patient’s family with chronic obstructive pulmonary disease (COPD), emphysema, and chronic asthma may use to prevent COPD exacerbations.

Many patients with COPD may have underlying chronic asthma and many are active or
former smoker.  Many may have associated emphysema in conjunction with intermittent symptoms of asthmatic bronchitis. Preventing a flare-up of COPD and/or underlying asthma may further help improve quality of life and may decrease use of acute care/hospitalization.

(1) Understanding severity of disease. One needs to understand underlying severity of COPD if underlying bronchial asthma or emphysema is present or not. There are no specific COPD cures, but controlling the symptoms helps improvement of respiratory symptoms and sense of wellbeing. One may consider pulmonary function test if not done to assess underlying severity.

(2) Understanding of acute or chronic COPD symptoms. Keeping a log of regular COPD symptoms and any changes may help to seek early medical treatment for control of COPD exacerbation in the early phase rather than later. The patient may get low-grade fever, increase in cough, quantity, change in the color, and/or increase shortness of breath.

(3) Home oxygen use. A few patients with COPD may need use of oxygen either at night or on exertion or continuously. This needs to be evaluated by their physician.

(4) Emergency plan. It would be good to have an emergency plan if there is worsening of the symptoms. If someone with severe asthma and/or COPD, it may be good to have a course of antibiotic and a tapering course of prednisone handy and start it with exacerbation of symptoms in conjunction with their primary care and/or pulmonologist. If there is worsening of COPD then it would be good to call 9-1-1 and go to the Emergency Room.

(5) Anxiety symptoms. Anxiety, COPD, asthma, emphysema symptoms go hand-in-hand.  With the change in respiratory symptoms and an increase in air hunger there may be fluctuation in anxiety and depression symptoms. Relaxation is the key. Slow deep breathing exercise may help.

(6) Exercise. Regular walking, breathing exercises and moderate strenuous exercise, depending on heart condition may be considered based on physician advice. This has been shown to decrease exacerbation of COPD, and clearing of respiratory secretions in the morning.

(7) Avoiding certain foods. Usually cold water, cold drinks, dairy products, ice cream, and chocolate may trigger underlying COPD/asthma. Bananas increase mucus formation.  This may be good to void. Many patients notice a change once they cut down the use or discontinue it.

(8) Medications. Use of inhalers, nebulizers, oxygen, its duration frequency and maximum dose, needs to be understood. The common mistake many COPD patients make is overuse of long-acting bronchodilators in place of short-acting inhalers or nebulizer treatment. This needs to be avoided. Correct inhaler technique is the key.

I hope this may help in understanding underlying symptoms of COPD and exacerbation factors and cut down any major flare-up.

Chronic Asthma Symptoms , Postnasal Drip , Sinus Congestion And its association of Asthma flare up

In this blog, we will see the relation of postnasal drip and associated chronic symptoms of asthma and how asthma may improve with improvement in postnasal drip.

Chronic cough is one of the important symptoms in the patient with chronic asthma in association with wheezing and shortness of breath.  More than one-third of patients with chronic asthma have associated postnasal drip and/or sinus congestion, which is present most of the days in a week.  There may be a variation in seasonal pattern where it may exacerbate more in the spring and the fall, and may be less in the summer.  Any associated infection, exposure to chemicals, dust, or perfumes may exacerbate the nasal symptoms and may further increase the need of rescue inhaler for a patient with chronic asthma.

The treatment of postnasal drip may vary from use of inhaled steroids to simple measures like Neti Pot, sinus rinse, or saline spray.  Many patients have allergies to cats, rugs, birds, pollen, etc., and avoiding the allergens may further help decrease the sinus symptoms.

Many patients have associated constipation or irregular bowel movement or may have GERD-like symptoms.  With improvement in regular bowel movement, the gastrocolic reflex decreases and thereby many chronic asthmatic patients may experience some improvement in the sinus symptoms.

The association of postnasal drip and GERD has a relation with control of asthma symptoms.  In the previous blog, the relationship of GERD symptoms and asthma has been discussed.  If one is experiencing either of these symptoms or its combination, the control of one of these symptoms may further help to control asthma. There is a significant relation between persistent postnasal drip and difficulty controlling asthma symptoms with increase need of a rescue inhaler.

Some simple breathing techniques like alternated nostril breathing, slow deep breathing exercises, and healing breath exercises may help to improve nasal symptoms and thereby improve the airflow through both nostrils, which improves the sense of well being in many asthmatic patients because of improvement of breathing.  This will further help in decreasing the chest symptoms, nighttime wheezing and cough.

In a patient with chronic asthma, if they get a sinus infection, this
needs to be treated on an urgent basis and many may require 2 to 3 weeks of
antibiotics.  Regular use of Neti Pot or sinus rinse in many patients with chronic sinus congestion may help keep the nasal passages open and thereby decrease asthma flareup.  Many factors exacerbate asthma, and nasal sinus congestion or postnasal drip is among them so by improving the symptoms it may help in controlling asthma.

Bronchial Asthma Assessment And Methacholine Challenge Test

In this blog, we will look into methacholine challenge test and its importance and assessment of bronchial asthma.

Bronchial asthma is a reversible airway disease where there is an increase in FEV1 of 12% and  increase of 200ml post  bronchodilator in a pulmonary function test.  The same may be true for FVC (force vital capacity).

In many situations there is a question if someone currently has asthma or not.  Methacholine challenge test may help in assessing if somebody does not have asthma, especially if the methacholine challenge test negative.  It has a negative predicted value; meaning, if the test is negative then the chances of having underlying bronchial asthma would be less likely.  If the test is positive, it does not mean that the person has asthma and it may be other conditions like postnasal drip, gastroesophageal reflux disease, sinus congestion, etc., that may give a falsely positive methacholine challenge test.

Methacholine challenge test is performed in increasing concentrations of challenge with methacholine and if the highest concentration of 16 mg/ml does not show any bronchospasm then the underlying likelihood of bronchial asthma would be less likely.

Chronic asthma symptoms may be evaluated with methacholine and if the methacholine test is negative then it would make underlying bronchial asthma less likely although the person may be experiencing asthma-like symptoms and it could be related to other symptoms like postnasal drip or gastroesophageal reflux disease. A complete pulmonary function test needs to be performed or at least a spirometry with and without bronchodilator needs to be performed prior to the assessment of methacholine challenge test.

In summary, methacholine challenge test is an important test assessment of bronchial asthma and if there is a question of presence of an asthma or not, a negative methacholine challenge test may help in ruling out underlying bronchial asthma.  The positive methacholine challenge test needs to be clinically assessed for the likelihood of underlying bronchial asthma.

Chronic Asthma Management and Use of Peak Flow Meter

In this blog we will look into the peak flow meter, and its use and management of bronchial asthma.

A peak flow meter is a very good simple device that a patient with bronchial asthma may use for management of bronchial asthma to check the variability of airway responsiveness.

There is a predicted peak flow based on age, height, sex, and race which one may need to know. Obtain the predicted peak flow calculation through your healthcare provider or you can search on line for the formula.  It is a general number for a guideline and may have some variations but it will be a good gauge to understand a person’s peak flow.

Generally, the variation is less than 20%.  In patients with mild, intermittent asthma the peak flow is generally more than 80% of the predicted and the variation should be less than 20%.

The patient with asthma symptoms or experiencing acute on chronic asthmatic bronchitis may experience an increase in peak flow variation during the acute phase and should stabilize to the baseline.  Generally, with mild intermittent asthma, the peak flow variation is less than 20%.

With mild persistent asthma, patients will have an increase in severity of asthma where they tend to have symptoms more than two times at night in a month and about twice a week.  Although the predicted peak flow is greater than 80%, they may experience a peak flow variability of 20-30%.

For example, if a 35-year-old gentleman with a height of 5 feet 6 inches has a peak flow of 512 liters per minute, the 20% variation would be a peak flow range between 400 to 600 liters per minute.  If it goes less than 400 liters per minute, it should be considered increased variability.

Also, there are some peak flows which are color coded with a green zone, a yellow zone and a red zone.  This makes it a little simpler for people to follow.  As long as they stay within the green zone, they should be okay; but once they change to the yellow zone, this may suggest increase bronchospasm, increase mucus formation or start of early infection, etc.  One needs to contact the healthcare provider as it could be an early sign of asthma flare up.

The peak flow can help in asthma exacerbation prevention by monitoring very closely before it becomes worse.  Patients with chronic asthma will find it helpful.

If the patient has bronchial asthma but also has associated chronic pulmonary disease, the variation in the peak flow may not be as much especially if one is a smoker.

In patients with moderate persistent asthma, the peak flow variability may be more than 30%.

This would be someone who has daily symptoms and uses a rescue inhaler at least twice a week or more and has a one-time nighttime symptom in a month.  Also, patients with severe persistent asthma may have daily symptoms and frequent nighttime symptoms.  The peak flow generally varies less than 60% of the predicted, and has increase variability to more than 30% in a day from a baseline.

As asthma improves with treatment, the variability may change and should become less than 20% with decrease in the need of rescue inhaler.  Monitoring acute infections, avoiding drugs that produce bronchospasm,  eliminating foods that increase mucus formation, and avoiding external factors that increase bronchospasm in conjunction with the standard treatment with inhalers and medication may further help chronic bronchial asthma treatment and management with monitoring of one’s own peak flow and keeping a log on a regular basis.  This log may also help provide a chance for the healthcare professional to review the change and make adjustments in medications as needed and the person to better understand their own underlying asthma and its variability.  A simple peak flow meter can give a lot of insight into one’s own bronchospasm and its management.

For more information on peakflow you can visit the following website.

If anyone interested in joining the asthma program please free to contact us  at or call at 717-338-9797
Best wishes!


In this blog we will briefly review the asthma action plan or different techniques one may use to control and manage asthma, better understand one’s own health with goal of prevention of asthma attack thereby helping control of asthma, decreasing need for medications, and decreasing exacerbation of asthma.  This blog gives a general guideline and one may want to talk to their physician to better understand and coordinate the plan.

Also, different asthma action plans can be found on line for further developing your own plan and coordinate with the family member in case of an emergency on how it needs to be tackled.

  1. Understanding ones own asthma. Have a clear picture from a physician whether the asthma is mild, moderate or severe. Understand the use of medications an correct inhaler technique. Know the difference between a maintenance inhaler and rescue inhaler or nebulizer. How frequently it can be used and what is the maximum dose in 24 hours. Are there other associated conditions with asthma that have been triggered such as postnasal drip, heartburn, etc.
  1. Understand which inhalers your physician has recommended, and what is the regular dose. Is it twice a day? Is it once a day? Or, does it need to be used every 4 hours as needed? For example, Advair Diskus, Symbicort inhaler, Dulera inhaler are twice a day inhalers, but Albuterol inhaler as a rescue can be used every 4 to 6 hours if needed. Singular may be a once a day medication. Rinsing the mouth afte  the use of inhalers may help in preventing oral thrush.
  1. Family plan. Have a documented family plan with the family members if the asthma
    gets worse, and how it should be tackled. In mild situations, the primary care can be contacted.  How will moderate to severe asthma  situations be tackled? Through primary care or the Emergency Room?  Have this be clear with the primary care and family members, and what are the steps that can be taken to prevent an  Emergency Room visit.
  1. Prevention of exacerbation of asthma. Find out different triggers that have been exacerbating the symptoms like allergies, increasing the dripping and asthma symptoms, wheezing, smoking, smoke exposure directly or indirectly.  If one is smoking then he/she needs to quit and at the same time prevent second hand smoke exposure, perfumes, cologne, etc., one needs to avoid this contact.  If someone is working with dust or chemicals use a mask to prevent or to avoid symptoms altogether to avoid this kind of work exposure.
  1. Peak flow meter. One may want to have a peak flow meter, which may have a green, yellow and red zone.  Monitoring the peak flow may help to understand the severity of asthma and once there is  change in the color may contact primary care.  Example: A person with a peak flow in the green zone and if changes to
    yellow zone may be a sign to contact a primary care.
  1. Asthma education. Obtain asthma education through the primary care, other sources like the internet, and educational books and material that provide a basic
    education for asthma.  Also, there  are foods that may trigger bronchospasm like yogurt, dairy products, cold water,  cold drinks, cola, chocholate  etc., which may be avoided. Fruits like bananas may trigger asthma or nasal congestion symptoms  in many that may want to be avoided. Speak to your doctor about a change in diet before making any  dietary changes.
  1. Log of symptoms, inhalers. Keep a regular log of symptoms like wheezing, coughing, postnasal drip, gastroesophageal reflux disease, sleep symptoms one has and how frequent they are. Also, get input from the family members as many times the one coughing is not aware about the coughing, but the family member is aware. Also, keep a regular log of use of rescue inhaler and review with the primary care or  your lung doctor if you have one.
  1. Sleep symptoms. Are asthma symptoms waking you up at night? How frequent is
    it? Is there nighttime use of inhalers? Are you coughing and wheezing? As asthma improves, the symptoms should  resolve and one should be able to sleep regularly.
  1. Exercise. Regular exercise further helps to control asthma. If someone has exercise-induced asthma, may use a rescue inhaler prior to that. Before you start an  exercise program, check with your primary care.
  1. Pranayama / yoga. Many breathing exercises such as slow deep breathing, alternated nostril breathing if done correctly over a period or time may further
    decrease bronchospasm. If one is interested, he/she may learn many of the simple yoga exercises and by doing it may further help control asthma symptoms along with good sleep, regular exercise, avoiding the triggers of asthma, and remaining vigilant  about the symptoms and its prevention.

11.    Acute infection: In the event of an acute respiratory tract infection, see your primary           care on an urgent basis or if there is an increase in severe symptoms call 9-1-1 or go          to the nearest Emergency Room.

This is a general action plan or something similar one may develop. There are many different states which provide an asthma action plan or one may visit the Center of Disease Control Intervention website for different asthma plan and do ones own research.  This is a general guideline that we have seen that has helped our patients and have found
useful. Please contact your primary care or your pulmonologist and review the asthma plan with your healthcare provider and make appropriate changes as they recommend.
I hope some of these simple measures as stated above help your asthma or someone you may share this information.

Best wishes!

Bronchial Asthma and Night time Symptoms

In this blog we will look into the nighttime symptoms of asthma and its relation with the disease and associated conditions.

Bronchial asthma is a reversible airway disease. There is a good response to bronchodilators.  A person with asthma feels symptomatic improvement when they use a bronchodilator like Albuterol, Combivent, or a nebulizer treatment.  The common medications used for asthma are Advair Diskus or HFA, Symbicort inhaler, Dulera inhaler, etc.  There are many other inhalers and medications used for the treatment of asthma and its control.

Coughing is the most common symptom of asthma. Although in general, people think wheezing is the common symptom, a cough is the early manifestation of asthma especially at nighttime.  Based on the severity of underlying asthma, they have different symptoms and severity. The other symptoms like nighttime awakening, chest tightness, postnasal drip, heartburn are seen in many patients. Many have symptoms of asthmatic bronchitis intermittently when they get sick. Bronchial asthma prevention is key by avoiding the things that one is allergic to like cat, aspirin, specific food if are allergic to like peanut etc. If the asthma symptoms persist then goes into chronic asthma state. Long term uncontrolled asthma can turn into chronic obstructive pulmonary disease after many years or decades of the asthma disease secondary to low grade uncontrolled inflammation into the airways.

The patient with mild, intermittent asthma generally has symptoms of coughing, wheezing, chest tightness for less than twice a week and nighttime symptoms less than twice a month.  If they do their peak flow on a regular basis, the variation in the peak flow is less than 20%.  Meaning, if their average peak flow is 500 liters a minute it may not drop down less than 400 liters per minute, as they have intermittent symptoms, so a short-acting bronchodilator like albuterol inhaler is generally used in most cases. 

In mild, persistent asthma cases where the symptoms are more than twice a week but less than once a day, they do get nighttime symptoms more than twice a month. They have more symptoms than the early group of mild, intermittent asthma. Given the severity, their peak flow also will vary more than 20% and generally around 20-30% variation is present. In the airway situation of average peak flow of 500 liters it may vary by going down between 300 liters to 400 liters. Because there is a grade variation, generally inhaled steroids are used and/or other leukotrene inhibitor medications are used to further control the asthma. Many times, the patient may have associated GERD (gastroesophageal reflux disease) and/or postnasal drip and the nighttime symptoms further get worse.

As the disease progresses, they may have moderate, persistent asthma so they start getting daily symptoms and the need for rescue inhaler or nebulizer is more than twice a week, and once at night in a month. The peak flow variation is also about 30%, so with moderate, persistent asthma there is further increase in severity of the disease. In situations like this, a long-acting bronchodilator needs to be added in conjunction with inhaled steroids and other medications like leukotrene inhibitors are generally added.  A short-acting bronchodilator needs to be used during an acute attack or symptoms.

As the disease further progresses it goes into severe, persistent asthma. Most of the patients we see in the office have fairly daily symptoms with limited activity and they also have frequent nighttime symptoms. The peak flow varies by more than 30%. Again, the treatment is inhaled steroids with long-acting bronchodilator and in some cases a steroid needs to be added.

As the asthma progresses, there is associated nasal congestion, sinus congestion, increase in environmental allergies, poor digestion, and a build up of toxins is generally seen. The nighttime coughing is an important symptom of persistent asthma in most cases. Some may be related to postnasal drip at night and/or heartburn symptoms.

When the asthma slowly gets worse, the nighttime symptoms also get worse and when the asthma slowly improves, the nighttime symptoms slowly improve and with that there is improvement in sleep. Watching the nighttime symptom will give an important clue about the progression of the disease, especially the spouse or family member can help to recognize the symptoms and a keep a log of the events which can further help when one sees their physician or healthcare provider. In a future blog, we will discuss how one can alleviate the symptoms by integrative medical treatment. The goal of asthma treatment is to control the symptoms, the postnasal drip, the GERD, and associated triggering factors as much as possible. This may further help in overall improvement of asthma and improve the quality of life.

If anyone is interested in learning more about asthma program please feel free to call at 717-338-9797 or