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.

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!

Pulmonary Function Test -Understanding Its Basics

In this blog we will briefly see what the pulmonary function test is, how it can help patients with asthma and other underlying lung conditions without going into very technical details and numbers.

 The pulmonary function test is a very unique test to assess the functionality of the lung.  If the chest x-ray of the person is the anatomy of the lung then the pulmonary function test is the physiology function of the lung.  It is like an electrocardiogram (ECG) of the lung to some extent, but not fully.

 The pulmonary function test is a test where one can assess the mechanics of the lung, the lung volumes, the diffusion capacity and airway resistance.  Whether the test is normal or abnormal needs to be looked into upon comparison with the person’s age, sex, race and height.  Weight generally does not have any relation in this calculation.  The numbers that come out in the test are compared with the reference numbers based on the protocol that is used.

 The pulmonary function test has components like spirometry, which is a common part of the test, generally done in a doctor’s office to quickly assess underlying obstructive or restrictive lung disease.  Obstruction lung disease is where there is obstruction of the lung either from asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis or a combination of the disease, etc.  The restrictive lung disease is where there is restriction of the lung, meaning it has become shorter or smaller in size.  Many times it may truly not be decreased but could be from body habitus and weight gain in most patients, but in conditions like pulmonary fibrosis, the lungs may shrink and may give restrictive lung disease.  The lung volumes are generally used for assessment.  Diffusion capacity is also one of the components to see how much of the diffusion of carbon monoxide occurs.

 Generally, in the spirometry component there is forced expiratory volume in first second (FEV1), forced vital capacity (FVC) and the ratio of FEV1/FVC are the common numbers that are used.  Generally, numbers ranging between 80 and 120 predicted for FEV1 and FVC is considered normal.  This gives an idea about if someone has underlying obstruction or restriction and based on the ratio of FEV1 upon FVC. If the FEV1 and FVC are decreased and the ratio of FEV1 and FVC is normal then it has restrictive changes. It will be obstructive changes if the ratio of the FEV1 and FVC is decreased.  In lung volumes, the TLC or total lung capacity is used and generally it is also between 80 and 120% of the predicted.  When numbers are falling out of this range, generally the pulmonary function test will be read as abnormal.

 The pulmonary function test helps to assess the severity of asthma or COPD or any other underlying condition like pulmonary function test, interstitial lung disease, etc.  A smoker should consider having a pulmonary function test if not done to assess and obtain a baseline of his or her lung capacity.  When a good bronchodilator response is seen on the pulmonary function test, it generally has a relation with underlying bronchial asthma.  A pleuritic assessment of lung disease can be performed either with complete pulmonary function test or with just a spirometry component of the pulmonary function test to monitor underlying lung disease.  The person with bronchial asthma or COPD, emphysema, and is on inhalers or nebulizer if they do not have a pulmonary function test performed then they may consider having the test to assess and obtain a baseline and periodically may be performed as clinically indicated to assess the progression or stability of the disease.

 The technique of the pulmonary function test is very important and a good cooperation with a respiratory therapist is key, otherwise the pulmonary function test may be a suboptimal test as it is an effort dependent test.

For patients with asthmatic bronchitis or bronchial asthma symptoms, who are on bronchial asthma treatment and been clinically  monitored, Pulmonary function test may help the monitoring of bronchial  asthma . In patient with chronic asthma as their asthma improves  its asthma  treatment  can be monitored  periodically with the pulmonary function test. Similarly patient with Emphysema on treatment can be monitored.

 To summarize this article, a pulmonary function test is a key lung test for patients with asthma, COPD and other lung disorders to help establish a baseline and assess the progression and/or stability of the disease if done periodically.  It is an effort dependent test so it needs to be done with correct technique otherwise may give rise to false results.  A good bronchodilator response seen on the pulmonary function test may be associated with patients with bronchial asthma.  Smokers may consider having a baseline pulmonary function test if not done.

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

Bronchial Asthma And Its Diurnal and Seasonal Variability from Ayurveda Perspective

In this blog will look into the seasonal change and variability of the diurnal changes and  its  symptoms and exacerbation of the bronchial asthma. It is a  reversible  airway obstructive disease . Will discuss integrative pulmonary medical perspective with use of Ayurveda to understand the disease at new angle.

Bronchial asthma is the bronchoconstrive disease lung disorder  with generally  good a bronchodilator response. It is one the common disorder with about 5% of population been affected at varying degree. An improvement of 12% and more than 200ml in Force vital capacity and or First Expiratory volume in first second on Pulmonary function test suggest underlying bronchial asthma. Also if the mechacholine challenge test is done and is positive at a lower concentration in a clinically adequate picture suggest underlying bronchial asthma. This are the general diagnostic criteria for diagnosis or asthma or exclusion of the bronchial asthma.

Bronchial asthma patient have a varying degree of the symptoms based on the degree of the severity of the disorder one has, specially if they have  more than 3-5 years of the symptoms. Bronchial asthma could be related to the intrinsic asthma factors or the extrinsic  cause or combination of both with allergic symptoms affecting the  nasal and sinus passages. The common asthma symptoms are cough, wheezing, post nasal drip and the reflux symptoms.

Patient with moderate to severe persistent bronchial  asthma symptoms may see a diurnal variation in their daily symptoms and also see the variability of   the symptoms as the weather changes. With the change in the  fall to winter, winter to spring or spring to summer they have different variability of the symptoms and it s exacerbation.

Now lets look into the asthma at different angle. Looking at the angle of Ayurveda and its relation with the daily symptoms. It helps to understand the reason for the change as diurnal variable or seasonal variability.

Ayurveda or traditional  Indian medicine has documented the day divided into 3 sets of 4 hours and similarly for the night also. This change happens with the movement of the sun and so is the change in the barometric pressure in the daytime and the  night time . This will has some effect on the airway in patients with bronchial asthma and change in the wheezing, cough, shortness of breath symptoms.

Ayurveda has describe the day in the Kapha, Pitta, and Vata periods. Kapha is earth and water. Pitta is fire and water. Vata is air and space combinations.  Ayurveda describes five basic elements of the universe from which the body and mind is formed. They are the five great elements namely Space, earth, water, fire, and earth. Body is formed with this permutation and combination of this elements based on one’s on genetics. So this five elements when combined in 3 different combination sets will give rise to 3 basic change or called the Dosha in Ayurveda. So there are Kapha dosha, Pitta dosha and the Vatta dosha. This individual  dosha  again will  give rise to the 3 phases of time during the day and similarly during the night. Day time divided equally with the night time so 12 hours of day and night. As there are 3 dosha will  again divide the day and night in 3 sets again

The Kapha period ( earth + water component which increased at that time in the body  ) is 6am-10am or 6am-10pm where there is increase in flame formation and the mucus secretion. Patients generally have some respiratory symptoms at that time. The Pitta period  ( Fire+ water component increased at this time in the body) is 10am-2pm or 10pm -2am and generally  have the  increase in the acid secretion, GERD symptoms. Genrally there is  decrease in the bronchospasm at that time. Respiratory symptoms do get better generally around lunch time or around midnight  but may get worse latter.  The Vata  period ( air+ space increased at this time in the body) is 2pm-6pm or 2am-6am when the gas is more formed and passed, bronchospasm or cough may come back, person with heart problem may get chest tightness symptoms. Also the night time symptoms of use of inhalers in the middle of the night comes back.

As there is weather pattern in the nature  and it give rise to the   climate.  As discussed  above period  of Kapha, Pitta and Vatta  will give rise to the Kapha period of weather in winter time, Vata period in the spring and the fall time and Pitta period in the summer time. So the patient depending on the genetics  or the Prakruti of the person will have some phase more worse then the other. Some may have worse time in the spring but summer may not be as bad or symptoms may almost goes away. In some it comes in the fall  but winter may be ok. And in some the winter and fall is bad but spring and summer may not be as bad.

By understanding  one owns asthma symptoms if one keeps a log of the symptoms and keep a small diary and the peakflow  one can understand the pattern of the asthma. This may help as a useful guide to prevent future attacks or at least understand the sequence of events happening and more preventive measure may be taken accordingly. If one shows its pattern to their doctor may further guide accordingly.