What Is Urinary Tract Infection (UTI)

Overview

An infection of any part of the genitourinary system can be classified as an Urinary Tract Infection (UTI). Often, the lower urinary tract is involved ie Bladder and urethra, and women are at greater risk of developing UTIs compared to Men. If left untreated, UTIs can ascend and infect the kidneys and spread systemically via the bloodstream and affect the entire body. UTIs are usually treated with antibiotics and preventative measures can be taken.

Symptoms

• Burning sensation or pain while urinating
• Increased frequency of urination with small amounts voided each time. 
• Persistent and strong urges to urinate. 
• Cloudy urine, or urine stained brownish or light pink in colour. 
• Foul smelling urine
• If the UTI affects the kidneys, patients might experience pain over the loin regions where the kidneys are located. 

Classification

The terms used by your doctor to describe UTIs might be confusing. Listed below are explanations of some common terms used by doctors.

Acute Pyelonephritis:

• This refers to an acute situation where the kidneys have become infected. 
• “Pyelo-” refers to “fever”, “-nephritis” refers to inflammation of the kidneys. Hence Pyelonephritis literally means fever due to a kidney infection. 

Cystitis:

• This refers to infection of the Bladder
• “Cyst-” refers to the bladder while “-itis” refers to inflammation. Hence Cystitis means inflammation of the bladder due to an infection, likely an ascending UTI. 

Urethritis:

• This refers to an infection of the urethra. Ie the UTI only involves the lower urinary tract. 

Causes

Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract.

The most common UTIs occur mainly in women and affect the bladder and urethra.

• Infection of the bladder (cystitis). This type of UTI is usually caused by Escherichia coli (E. coli), a type of bacteria commonly found in the gastrointestinal (GI) tract. However, sometimes other bacteria are responsible. Sexual intercourse may lead to cystitis, but you don't have to be sexually active to develop it. All women are at risk of cystitis because of their anatomy — specifically, the short distance from the urethra to the anus and the urethral opening to the bladder.
• Infection of the urethra (urethritis). This type of UTI can occur when GI bacteria spread from the anus to the urethra. Also, because the female urethra is close to the vagina, sexually transmitted infections, such as herpes, gonorrhea, chlamydia and mycoplasma, can cause urethritis.

Risk Factors

• Females: Females are more likely than men to develop severe UTIs because the female urethra is much shorter than men. Ie the distance from the external environment to the bladder is much shorter. 
• Increased Sexual activity. While sexually active women tend to have more UTIs than do women who aren't sexually active, promiscuity, new sexual partners, or even having a sexual partner who is promiscuous increases the risks of UTIs. 
• Menopause. Women past menopause have reduced mucus production in their genital tissues due to the decline in circulating oestrogen. As a result, the genital regions are less lubricated and that in turn increases the chances of atypical bacterial colonisation and UTIs. 
• Structural abnormalities. Patients born with genetic defects affecting the urinary system with obstruction to urinary flow or patients afflicted with renal calculi (kidney stones) are more prone to developing UTIs due to the retention of urine. Patients who have recently undergone surgical procedures and trauma are also prone to developing UTIs, 
• Immunocompromised Patients. Immunocompromised patients are at an increased risk of develop all sorts of infections, UTIs being one of them. 
• Catheter use. The presence of a foreign body within the urinary tract, even that of an indwelling urinary catheter to assist urinary flow, increases the risk of UTIs. 

Complications

• Systemic spread of UTIs can be life threatening. If untreated and left unchecked, UTIs that overcome the body’s defences can ascend and infect the kidneys and become blood borne, thereby infecting all other organs and cause multi-organ failure. 
• Permanent organ damage, usually renal, are known sequelae of untreated UTIs. 
• Recurrent UTIs 

Diagnosis

• Urinalysis. Analysis of a urine sample is the most common way of diagnosing UTIs. A sample of urine is collected and can be tested with a dipstick on site, or sent off to an approved laboratory for further analysis.
• When collecting the urine sample, be sure to clean the genital area and collect midstream urine. Ie Pass urine normally but do not collect the initial sample. 
• Dipstick testing of urine reveals macro-abnormalities and is a convenient and quick way for clinicians to perform bedside testing. 
• Urine samples can also be sent off to a lab where the sample is incubated at optimal temperatures for bacterial growth. If bacteria is successfully cultured, they are then tested against a range of antibiotics to identify further options with regards to antibiotic therapy. 
• Imaging - Direct and Indirect
• Your doctor might recommend imaging for you if you experience recurrent UTIs. 
• Indirect Imaging involves either computerized tomography (CT) or magnetic resonance imaging (MRI). Your doctor will decide the modality to use. In most situations, contrast media is usually injected during the imaging process so if you are allergic to contrast media, definitely highlight your allergy. 
• Direct imaging involves a surgical procedure where your urologist will insert a scope up and through your urethra to view the bladder directly. This is a surgical procedure and is normally done under anaesthesia.

Treatment

Antibiotics remain the mainstay of treatment for UTIs. Choice of antibiotics to be used depend on the local epidemiology and will be made at your physician’s discretion.

Oral antibiotics are usually given as first line therapy though intravenous antibiotics are usually used for more serious infections, especially if the UTI has spread systemically.

For symptom control, your physician may also prescribe some analgesics to help control the pain and discomfort from the UTI.

Prevention

• Increase water intake. Increasing water intake increases urine output, resulting in more flushing of the urinary tract. 
• Personal Hygiene. Keep the genital area clean. When cleaning the perineum, wipe from front to back. 
• Avoid beverages that change the pH of urine. Beverages like citrus juices can cause changes in the acidity of urine, resulting in more bacterial growth. 
• Void after sexual intercourse. Voiding the bladder and passing urine post sexual intercourse flushes the urinary tract and prevents bacteria from manifesting. 
• Avoid contraceptives if viable. Contraceptives like diaphragms, intra-uterine devices, and spermicides all alter the bacterial flora within the genital region and can contribute to higher rates of UTIs. 

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Tinnitus - The Ring In Your Ears

Tinnitus - An overview

Often referred to as “ringing in the ears” by patients, tinnitus is a common presenting complaint by patients and can affect to as many as 20% of the population.

Tinnitus is not a disease. It is not a pathological entity. It is a symptom of underlying conditions such as age-related hearing loss, ear injuries or other systemic diseases like hypertension.


Tinnitus - Symptoms

Symptoms include:

• Ringing in the ear
• Buzzing in the ear

These symptoms can vary in pitch and may be heard in one or both ears. In some instances, it can be so loud so as to cause patients to become distracted in entirety. The symptoms last for a varying period of time, may be cyclical or persistent.

Broadly speaking, tinnitus can be divided into:

• Tinnitus that is only heard by the patient. Ie Subjective tinnitus. Commonly, this kind of tinnitus is caused by problems with either the auditory nerves or nervous pathways involved with hearing.
• Tinnitus that is audible to the physical examiner. Ie the doctor. This type of tinnitus is extremely rare and can be caused by issues with the blood supply, middle ear issues or abnormal musculature.

Tinnitus - Time to see the Doctor?

Bottom line - if it bothers you, please seek a medical consult. Especially if:

• Tinnitus develops and is persistent after a recent upper respiratory infection such as the flu and does not resolve after a week or so.
• Tinnitus occurs out of the blue with no obvious reasons or cause that you can identify
• You experience hearing loss or dizziness and giddiness when experiencing tinnitus 

Tinnitus - Causes

While many conditions can cause tinnitus, sometimes the cause can remain elusive.

From first principles - Tinnitus is caused by abnormal nerve impulses being transmitted from the inner ear, an organ that is lined with microscopic and highly sensitive hairs that move in relation to sound waves. Abnormal nervous transmissions from these hairs causes the brain to interpret these signals as “sound”, thereby resulting in a “ringing” sensation.

Hence, any condition involving the ear or inbuilt physiology of hearing can and will cause tinnitus.


Tinnitus - Common causes

• Age-related hearing loss - Medically termed as “presbycusis”, tinnitus as a result of age-related hearing loss is common and often begins around age 60 or so. 

• Noise Pollution - Noise pollution secondary to industrial and or recreational activities can cause tinnitus. The banging of heavy equipment in factories, the whine of the chainsaw, the boom of the rifle, the roar of rock music played directly into the ear via headphones etc all cause loud noises that impact heavily on the eardrum. This in turn causes tinnitus. Short term exposure to noise pollution usually goes away after some time but chronic exposure can lead to permanent ear damage and hearing loss. 

• Ear Wax - Excessive amounts of ear wax can result in hearing loss and or irritation to the eardrum simply because of physical contact when accumulated in sufficient quantities. This in turn can cause tinnitus. 

•  Otosclerosis - Hardening of bones in the middle ear can affect hearing and cause tinnitus. There is a genetic link for patients suffering from this condition. 

Tinnitus - Less common causes

• Meniere's disease - This is an inner ear disorder caused by abnormal inner ear fluid pressure. It is harmless but can cause severe vertiginous giddiness in associated with tinnitus and can be psychologically traumatizing to patients experiencing their first attack. 

• Disorders with the Temporo-Mandibular Joint (TMJ) - Patients with abnormal TMJ joints can experience tinnitus as a side effect of their problem with the jaw. 

• Head and neck Trauma - Trauma involving this portion of the body can and will affect the inner ear, auditory nerves and brain function. Depending on the site of injury, tinnitus experienced by these patients is usually one sided in relation to their injury. 

• Acoustic Neuromas - This is a benign tumour of one of the cranial nerves that controls balance and hearing. Again, it generally causes tinnitus in only one ear. 

Tinnitus - Rare causes

These are usually related to the blood supply.

• Atherosclerosis. Loss of elasticity in the major blood vessels supplying the middle and inner ear with age due to the buildup of cholesterol causes blood flow within the vessels to be more forceful, causing each “flow” to be heard within the ears. 

• Cancers involving the Head and Neck Region. Any tumour causing compression on blood supply can cause tinnitus as one of the presenting symptoms. 

• Hypertension (“High Blood Pressure”) - Hypertension and any factors that trigger a sudden rise in blood pressure can cause tinnitus simply because of the increased pressure in blood flow to the ears. 

• Turbulent Blood Flow. Any physical cause of narrowing or kinking in the arteries supplying the neck can cause tinnitus due to disruption of blood supply. This is usually seen with either damage or compression to the carotids.

• Congenital Arteriovenous Malformations (AVMs) -  AVMs are congenital and basically refer to direct but abnormal connections between arteries and veins without intervening capillaries. These malformations all for diversion of blood flow and pressure and can cause tinnitus. If present, tinnitus caused by this condition is often one sided.

Medications that can potentially cause tinnitus

• Antibiotics - eg Polymyxin B, erythromycin, vancomycin and neomycin
• Chemotherapy agents - eg mechlorethamine and vincristine
• Diuretics - eg frusemide
• Drugs used for Prophylaxis - eg Quinines 
• Antidepressants 
• Aspirin at high doses

Tinnitus - Risk Factors

• Noise Pollution, especially to loud noises - Extended periods of exposure to high amplitude sound waves damage the microscopic hair cells within the ear, thereby triggering tinnitus in turn. Patients working in noisy environments like industrial complexes, the army or even musicians are more prone to this effect. 
• Advance Age. Tinnitus can develop with advancement of age as the bony structures within the ear harden. 
• Gender - Men are more prone to developing tinnitus compared to women. 
• Smoking -  Likely the secondary effect of cigarette smoke advancing up the eustachian tube irritating the inner ear.
• Cardiovascular problems - As explained above, because changes in blood flow can trigger tinnitus, any condition affecting the cardiovascular system can potentially trigger tinnitus. 

Tinnitus - Complications

While tinnitus is most often simply irritating, in severe cases it can disturb rest and sleep and cause a host of other problems including:

• Memory loss
• Stress
• Fatigue
• Insomnia
• Depression
• Concentration loss
• Anxiety and irritability

Tinnitus - Diagnosis of Underlying Problems

Tinnitus is a symptom rather than a standing diagnosis by itself. To diagnose the underlying problems, the following tests may be used:

• Audiology - Sounds at specific pitch and frequency will be played to the patient in a soundproof room. The patient will be asked to indicate whenever they hear a sound. This test will differentiate between sounds that are played and heard, sounds that are played and not heard, and sounds that are heard but not played (tinnitus) 
• Bedside examination - Doctors might ask the patient to move in certain specified manners to help identify underlying disorders presenting as tinnitus. 
• Imaging - CT and MRI scans of the ear and brain can and will assist with the diagnosis for finding the underlying cause of tinnitus. 

Pitch and tone type of sounds experienced by patients can give a clue to the underlying cause for tinnitus. These include:

• Clicking - Often this is due to spasmic muscle contractions in and around the ear. 
• Rushing or Humming - This may be vascular in origin, especially if variations are noted with change of posture. 
• Rhythmic - Rhythmic pulsations and regular beats of tinnitus can be caused by abnormalities with the blood vessels or cardiovascular system. Eg aneurysms, tumours, or hypertension.
• Low-pitched ringing - eg Minere’s Disease, often associated with vertiginous giddiness and dizziness.
• High-pitched ringing - Often associated with prolonged exposure to noise pollution. Special care needs to be taken if the tinnitus is experienced only on one side. 
• Others - Foreign Bodies, ear wax or loose hair irritating the eardrum can all produce awkward and unpredictable sounds in the ear. 

Note: The underlying cause of tinnitus is often difficult to identify and in many cases, the cause may never be found. However, tinnitus can be managed well in many cases in collaboration with your primary physician.


Tinnitus - Management and Prevention

• Hearing Protectors - Use of hearing protectors reduces damage if exposed to loud sounds over prolonged periods of time. 
• Maintaining Good Cardiovascular Health - Preventing cardiovascular diseases reduces tinnitus. 
• Stop Smoking - Cessation of Smoking will reduce tinnitus. 

Remember - Management of Tinnitus involves treating the underlying cause if identifiable, or managing the symptoms thereof if not.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

High Blood Pressure - The Silent Killer

Overview

Hypertension (High Blood Pressure) is a common chronic condition which are often associated and causes other health issues such as cardiac disease. It’s onset can be insidious and afflicted patients might not be aware of their status until later on in life. However, an asymptomatic individual still has the same risks for developing further health problems, inclusive of heart attacks and stroke.


Symptoms

Hypertension is usually asymptomatic, even at extreme levels.

Patients reporting symptoms usually report headaches, shortness of breath, nose bleeds, and tinnitus (ringing in the ears). However, these symptoms are usually non-specific and patients with poorly controlled hypertension might not manifest any symptoms at all.

Blood pressure is often taken routinely during medical consults. If concerned, ask your doctor to check your blood pressure on your next visit.

If you are aged 40 years or older, or if you have a family history of hypertension, it is advisable to have your blood pressure checked as a routine.

Alternatively, there are automated blood pressure machines available for purchase over the counter for home monitoring.


Types of Hypertension

Primary (Essential) Hypertension

This refers to the group of adults with no identifiable cause for hypertension. It is usually insidious and develops gradually over many years.

Secondary Hypertension

This refers to the group where there are identifiable causes for hypertension. These causes can include:

• Hormonal imbalances eg thyroid issues
• Renal issues
• Occult tumors of the adrenal gland
• Congenital birth defects
• Obstructive sleep apnoea 
• Smoking
• Alcohol abuse
• Medication induced hypertension

Risk Factors

• Age. Risk of hypertension increases around about age 45. It is more common in men than women though the risk profile for women approximates their male counterparts after menopause.
• Race. It has been found that the patients of black origin have a higher tendency to develop hypertension.
• Positive Family History of Hypertension. There is a genetic link for hypertension.
• High Body mass Index (BMI) (Overweight / Obese Categories)  Patients with a high BMI tend to develop hypertension compared to their thin counterparts.
• Generalized Lethargy. Patients who tend to lead inactive lifestyles usually have higher heart rates and have higher BMIs, which in turn increases their risk for hypertension.
• Smoking. Smoking causes a rise in blood pressure and in the long term, causes hardening and narrowing of blood vessels. This effect is also observed in passive second hand smokers.
• Sodium (Table Salt) and Potassium Intake. Table salt, sodium chloride, when consumed in excessive amounts, causes retention of fluid within the body, in turn increasing blood pressure. Potassium, on the other hand, acts in opposition to sodium. Hence an excess of sodium or lack of potassium will both result in Blood Pressure fluctuations.
• Alcohol Intake. Alcohol causes global effects in the body. Excessive consumption of alcohol will cause Blood Pressure fluctuations.
• Associated Chronic Conditions.  Chronic renal failure, diabetes, sleep apnoea etc, and even chronic stress all contribute to hypertension.
• Special Conditions.  Pre-eclampsia, or Hypertension during Pregnancy, congenital defects, are examples of special conditions causing hypertension.

Complications

Cardiac Effects:

• Heart attacks - This is by far the most widely known complication of hypertension.
• Cerebrovascular Accidents - Commonly known as strokes.
• Aneurysms - Prolonged hypertension can cause weakening of arterial walls, causing arteries to bulge, forming aneurysms.
• Cardiac failure - Defined as the inability of the heart to pump blood around the body consummerate to the required needs, cardiac failure is a consequence of prolonged, untreated hypertension. Prolonged hypertension causes thickening of cardiac muscle, resulting in uneven contractions that eventually result in cardiac failure.
• Renal Failure - It is important to note that while renal failure can cause hypertension, hypertension in turn causes weakening of vessels within the kidneys, resulting renal failure.
• Ophthalmological Complications -  Damage to the tiny blood vessels within the eyeball can result in visual disturbances or even vision loss in severe cases.
• Non-specific effects - It has been documented that patients with prolonged and untreated hypertension suffer more frequently from poorer mental function, memory loss, and non-specific groups of symptoms like the Metabolic Syndrome.

Treatment

It is important to speak with your treating physician if you are concerned that you might have hypertension.

When seeing your physician, no special preparations are necessary though it is important that you maintain calm during the examination as anxiety can and will cause blood pressure readings to increase.

Be aware as well that the first consultation can potentially be long as there will be much to discuss prior to commencing medications to treat hypertension if present.

You should inform your physician of the following:

• Any Symptoms you have experienced - eg shortness of breath, chest pain, tinnitus etc.
• Your family history, especially if there is a family history of hypertension.
• Your current medication regime.
• Your current medical history, especially if you also have associated chronic illnesses like diabetes, thyroid abnormalities, and raised cholesterol levels.
• Your current lifestyle in all honesty - This includes diet, exercise, alcohol consumption, smoking.
• Your last Blood Pressure reading if available.

Your physician will measure your Blood Pressure and inform you of your Blood pressure reading.

• Blood Pressure is described with two readings:
• Systolic BP (Higher reading)
• Diastolic BP (Lower reading)

There are many categories of hypertension in relation to the systolic and diastolic blood pressure because the definition of Blood Pressure varies with age and race. Your physician will decide after taking your blood pressure, likely after several readings on different occasions.

In certain situations, your physician might recommend 24hr monitoring of blood pressure to provide a more accurate picture of your blood pressure fluctuations throughout the day. This means you will need to perform own home BP monitoring.

Additional tests your physician might order include:

• Urine tests to check for protein in the urine
• Blood tests to ascertain cholesterol levels
• Electrocardiograms (ECGs)

Upon confirmation of the diagnoses, your physician will likely recommend lifestyle changes as the first line of treatment, followed by pharmaceutical treatment after.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Understanding Gastroesophageal Reflux Disease (GERD)

Overview

“Gastro-” refers to the stomach. “Oesophageal” refers to the oesophagus, or feeding tube, that connects the mouth to the stomach.  “Reflux” refers to backflow. Gastroesophageal Reflux hence refers to backflow of stomach contents into the oesophagus.

GERD is a disorder where patients suffer from sensations of heartburn and acid indigestion and sometimes is confused with chest pain due to cardiac causes. GERD occurs when the lower oesophageal sphincter does not close properly after food has entered the stomach, resulting in a backflow of stomach contents up the oesophagus.


Physiology

Food normally swallowed passes into the stomach via the oesophagus. Upon entering the stomach, the lower oesophageal sphincter (ring of muscle) closes, thereby preventing stomach contents from backflowing back into the oesophagus while the stomach digests and churns the food.

GERD happens when the lower oesophageal sphincter fails to close properly and reflux of stomach contents occurs. This results in a sensation of burning in the chest as stomach contents are normally acidic in nature.

The degree of severity of GERD hence depends on the magnitude of dysfunction of the lower oesophageal sphincter, stomach contents, and back pressure exerted by the stomach.


Causes

From first principles, anything that increases the back pressure exerted by the stomach can potentially cause GERD. These include:

• Diet and Lifestyle: Binge eating, excessive consumption of alcohol, smoking, obesity and certain foods and beverages like coffee have all been implicated with GERD
• Pregnancy.
• Structural abnormalities like a hiatus hernias (outpouching of stomach above the diaphragm).

Symptoms

Patients often complain of “indigestion” or “heartburn”, described as a burning sensation behind the breast bone ascending up towards the throat and neck. Often associated with an acidic or bitter taste, the sensation of heartburn can last for as long as 2 hours and is made worse by lying flat.

Heartburn is often confused with chest pain due to cardiac causes. It is important to differentiate the two because heartburn is treatable while cardiac causes for chest pain carries a significant risk of morbidity.

If in doubt, always consult your physician.


Treatment

Lifestyle and Dietary changes are the mainstay of treatment for GERD.

It is recommended to reduce consumption of acidic foods like citrus fruits and juices, tomatoes, foods that compromise the lower oesophageal sphincter like chocolate, fatty foods, alcohol, and any foods known to cause irritation in specific patients.

Control of serving portions and reduction thereof will also help control symptoms of GERD. Eating meals at least 2 hours prior to sleep will reduce incidence of reflux. Reduction of weight and overcoming obesity will relieve GERD.

Cessation of smoking and reduction of alcohol consumption will both help GERD.

Simple changes of posture during sleep like sleeping on an incline can help GERD.

Beyond lifestyle and dietary changes, medications like antacids help combat symptoms caused by stomach acids and can provide partial relief. Use of antacids for the long term, however, risk aberrations in blood calcium and magnesium levels, which in turn can cause serious problems for patients with kidney disease.

Other medications available include prescription medications like histamine antagonists (eg commonly sold Famotidine in Singapore) and proton pump inhibitors (eg. Omeprazole).

Patients with persistent GERD despite the above treatments might require more invasive investigations like having endoscopy of the stomach performed to exclude other problems like peptic ulcers, and in some instances, oesophageal manometry (measure of pressure along the oesophagus) can help identify if there are abnormalities in the peristaltic movement of the oesophagus, resulting in GERD.

In situations where, for example, a patient has severe GERD due to a hiatus hernia, surgery might be necessary to correct the situation. However, surgery will usually be offered as a last resort by your physician because GERD is not life threatening.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Asthma Part 4: Treatment and Control

There is no cure for asthma. Aim of management is to achieve control of the disease. This includes the following:

• Prevent chronic and recurrent symptoms like nocturnal coughing
• Reduce the use of medications
• Maintenance of lung function
• Maintenance of regular activities
• Preventing severe asthmatic attacks requiring hospital stays or visits to the Emergency Room

Practical tips to control asthma:

• Control other conditions that can aggravate asthma
• Avoid known allergens
• Maintain an active lifestyle
• Have an action plan in the event of asthma attacks

The asthma action plan should include the medications regime, avoidance of triggers, tracking of asthma attacks, and actions to be taken if asthmatic symptoms become more severe despite treatment. Eg When to proceed to the Hospital Emergency Department for treatment


Medications for Asthma

Asthmatic medications can be broadly divided into medications that exert long term control and medications that provide rapid relief from asthmatic symptoms.

Both types of medications aim at reducing airway inflammation to control asthma.

Initial treatment depends on how severe your asthma is. Follow up treatment depends on how well the patient follows the asthma action plan and how effective the action plan is.

Note though that the asthma action plan will vary with changes in your lifestyle and social environment because different social exposures result in exposure to different allergens in your environment.

Adjustment of medication dosage should be at the discretion of your primary physician. If you have adjusted the dose of medication on your own, you should let your primary physician know immediately to facilitate proper titration of medication dosing with each visit to the doctor.

The doctor will always aim to use the least amount of medicine necessary to achieve control of your asthma so it is imperative that the doctor be made aware of how much medications you have been using.

Certain groups of patients require more intensive titration regimes - these include pregnant women, young children, or patients with special needs.


Asthma Action Plan

Every Asthma Action plan should be crafted to the individual patient. The plan should include the medication regime, avoidance of triggers, tracking of asthma attacks and actions to be taken should symptoms of asthma become progressively severe.

It is best to work with your primary physician to draft your asthma action plan. The plan should describe all the above in detail.

In the case of children, parents and caregivers should know the child’s asthma action plan. This should include babysitters, workers at day care centers, parents, schools and organizers of outdoor children activities.


Avoidance of Triggers

An entire multitude of allergens have been documented to be linked to asthma. To the individual patient, the most important thing is to know what triggers asthma in you. Following that, know what steps to take when asthma is triggered.

Simple common sense is essential. For example, if you have a known allergy or sensitivity to pollen, please limit your exposure to pollen and stay indoors if needed. If you are sensitive to pets, or pet fur, please do not keep pets at home or allow pets to enter your bedroom.

Of note, physical activity can also trigger asthmatic attacks. However, it is recommended that asthmatics exercise on a regular basis because in the long run, exercise will help with control of asthma. Speak with your primary physician if you experience asthmatic attacks when engaging in physical activities. There are medications available to control asthma during exercise.

In the event your asthma correlates strongly to allergens that cannot be avoided (eg dust), your primary physician might advise on use of medications against allergies.


Medications for Asthma

Please consult with your primary physician for medications suitable for control of your asthma. Your primary physician will adjust the dose of medications as needed. If you have self adjusted the dose, you must inform your primary physician on your next visit.

Generally speaking, medications for asthma can either be in the form of a pill, an injectable, or as a nebulized drug consumed via use of an inhaler. Nebulized drugs are inhaled directly into the lungs where it exerts its effects.

Please note that use of inhalers will require a certain technique and should be taught by a doctor or a trained health care provider.


Medications targeting Long Term Control

Chronic asthmatics will need medications to achieve long term control of their asthma. These medications work slowly and reduces airway inflammation.


Inhaled Corticosteroids

Inhaled corticosteroids are most commonly used for long term control of asthma. They act by reducing inflammation in the airways of the lungs. Use of inhaled corticosteroids daily will greatly reduce the severity and frequency of symptoms.

The most common side effect of inhaled corticosteroids is oral thrush. Use of a spacer when using the inhaled corticosteroid can reduce the incidence of oral thrush. Check with your primary physician if you are unsure of how to use a spacer. Simple rinsing of the mouth after cosuming inhaled corticosteroids can also reduce the incidence of oral thrush.

Patients who have severe asthma might need to consume oral corticosteroids instead of inhaled corticosteroids to achieve sufficient control of their asthma. Unlike inhaled corticosteroids, which can be taken for years, oral corticosteroids will have significant side effects if used for prolonged periods.

Long term use of oral corticosteroids increases the risk of diabetes, osteoporosis, cataracts, and abnormal metabolic activity.

Consult with your primary physician to measure the risks and benefits before consuming oral corticosteroids.


Other long term medications: 

These include:

• Cromolyn - This drug prevents airway inflammation and is used as a nebulized drug delivered via an inhaler. 
• Omalizumab - This drug is a form of immunotherapy and acts against Immunoglobulin E (anti-IgE) which triggers narrowing of airways. This medication is usually given as an injection once or twice a month and prevents the immune system from reacting to triggers of asthma. It is, however, not a first line treatment for asthma and might not be offered upfront by your primary physician. 
• Inhaled long-acting beta2-agonists - These medications are usually taken together with inhaled corticosteroids to achieve a synergistic effect on expanding the lumen of the lung airways. 
• Leukotriene modifiers - These are oral medications that reduce airway inflammation. 
• Theophylline - Theophylline can be consumed orally or via an injection and acts to open the lung airways. 

Please note that there is a likelihood of symptoms rebounding if long term medications are suddenly ceased. Also, all long term medications will have side effects. Please discuss with your primary physician before commencing long term treatment regimes.


Rapid Acting Medications

Short acting Beta 2 - Agonists are usually the first line medications in this group. They are often delivered in the nebulized form through an inhaler. They act by relaxing the muscles in the airways, thereby allowing more air passage through.

Rapid acting medications should be consumed as soon as symptoms appear.

Should the medication be required for more than 2 days a week, you should inform your doctor to formulate more strategies for your asthma action plan.

Asthmatics are advised to carry their quick relief inhaler with them at all times.

Of note, these medications do not reduce inflammation of the airways and hence cannot replace long acting medications.


Documentation of Asthma Progression

Regular use of the peak flow and regular visits to your primary physician will be the primary means of documenting progression of Asthma.

As a rule of thumb, asthma is well controlled if:

• Symptoms occur no more than 2 days a week
• Symptoms do not disturb sleep more than twice a month.
• There are no limitations to your daily activities.
• Quick-relief medicines are required less than 2 days a week.
• Less than one severe asthma attack a year requiring oral steroids
• Peak Flow Meter readings remain at 80% of baseline level

Peak Flow Meter

Your primary care physician will instruct on the use of the peak flow meter.

When used, the peak flow meter measures the maximum rate of flow of air out of the lungs during exhalation. Regular measurements will allow documentation of asthma progression and it is recommended that patient record their peak flow every morning.

During the initial phase after diagnosis, it is important to ascertain baseline peak flow. This is often touted as the patient’s “Personal Best” peak flow reading. Future control of asthma relies on this baseline. Good asthma control being maintenance of peak flow to at least 80% of baseline.

Regular peak flow readings also help predict impending asthmatic attacks. Progressively deteriorating peak flow readings often indicate an impending attack and should be incorporated into the Asthma Action Plan.


Medical Reviews

Frequent medical reviews with your primary physician every fortnightly is the norm during the initial phase of treatment. Once asthma is controlled, your primary physician might elect to see you across a longer stretch of time.

During the medical reviews, important information required by your primary physician include:

• Frequency of Asthma Attack
• Changes in Symptoms
• Changes in Peak Flow Readings
• Changes in daily activities like exercise tolerance
• Difficulties with adherence to the Asthma Action Plan
• Problems with current medications

Emergency Situations

Seek Medical advice if:

• Regular medications fail to treat an asthma attack.
• Peak flow readings falls to less than 50% of baseline

Proceed immediately to the nearest Hospital Emergency Room if:

• You experience severe shortness of breath to the stage where walking becomes difficult
• Your lips and tongue turn bluish

Asthma - A Lifelong Issue

There is no cure for asthma. Successful management of asthma requires the patient to take an active role in the control of asthma by conforming to an asthma action plan.

Your primary physician is your best partner to develop your asthma action plan. The action plan will keep you reminded of your medication regime, triggers, and protocols to follow when asthmatic symptoms develop or worsen. Even children should be involved in the creation of their action plan because it is the individual effort that counts in the long term care of asthma.

Asthma will not be going away. But it can be controlled.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Asthma Part 3: Special Patient Populations

Children Below 5 Years of Age

Asthma is difficult to diagnose in children below 5 years of age. As the airways of children are naturally small, wheezing, when audible, can be confused between asthma and simple upper respiratory tract infections.

To add to the confusion, fast acting medications like Beta2 Agonists will relieve wheezing in children irrespective of whether they have asthma or not.

Your primary physician might elect to treat your child with long term medications like inhaled corticosteroids after weighing the risks vs the benefits of the drug. They will do so especially if the asthma proceeds beyond 6 years of age.

Inhaled corticosteroids are the preferred drug of choice for young children, Montelukast and Cromolyn being the other options available. Treatment is usually prescribed over a trial period between 4-6 weeks and stopped if no benefits are seen during that period of time.

Side effects of inhaled corticosteroids in very young children include slow growth across all ages. However, poorly controlled asthma also reduces a child’s growth rate. Hence, your primary physician will discuss the risks and benefits of commencing inhaled corticosteroids with you before commencing the medication.


Elderly Patients

Polypharmacy in elderly patients makes treatment in this group challenging. Commonly used drugs like Beta Blockers (for hypertension), aspirin and other NSAIDs (for analgesia) are all contraindicated in the treatment of asthma.

All elderly patients are advised to inform the doctor of all the medications currently consumed.

Side effects from asthma treatment like long time consumption of corticosteroids at high doses include development of osteoporosis and diabetes. Discuss management strategies with your primary physician before commencing these medications.


Pregnant Women

Pregnancy is complicated by asthma because the foetus requires an adequate oxygen supply above and beyond that required by the mother. Asthma also increases the risk of other complications of pregnancy, pre-eclampsia, pre-mature birth and low birth weights notwithstanding.

It is more beneficial to take asthma medicines while pregnant than to risk having an asthma attack. Discuss your Asthma Action Plan with your attending physician if you’re pregnant or planning a pregnancy. Whatever your asthma control may be, continued monitoring and control of your asthma throughout your pregnancy is essential.


Athletes and Growing Children

Physical activities can trigger asthma.

There is a range of medications that may help prevent asthma during exercise. These include:

• Short-acting Beta2-agonists - These are inhaled often before physical activity and have a duration of action up to 2-3 hours.
• Long-acting Beta2-agonists - These are inhaled and have a duration of action up to 12 hours. However, tolerance to these medications can develop and with prolonged use, the duration of action of the drug will be reduced.
• Leukotrienes -.These are often consumed orally hours before physical activity and can relieve symptoms of asthma.

It is important to slowly ease into exercise and not to over exert unnecessarily. A simple warm up prior to exercise, proper clothing and warm down post exercise will all aid in controlling asthma.

With proper control, asthmatics can participate in any physical activity or sport they wish.


Surgical Patients

Asthma is a significant risk factor for general anaesthesia. Tracheal intubation, for example, can trigger an asthmatic attack.

Patients are advised to inform the surgeon and anaesthesia team prior to surgery to pre-empt problems.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Asthma Part 2: The Medical Consult

Asthma is diagnosed in the primary care setting by a comprehensive medical history, family history, a physical examination and lung function tests.

Your primary care physician will determine the severity of your asthma which in turn will affect the treatment you require.

Referral to a Respiratory Specialist in the following situations:

• Subspecialized tests are needed to confirm the diagnosis of asthma
• There is a history of a life threatening asthma attack
• Treatment for specific allergies 
• Polypharmacy (Multiple medications) is needed to control your asthma

Important Points To Mention During Your Medical Consult

Important points to bring up during your medical consult include:

• A Family history of asthma and allergies
• Frequency of asthmatic attacks.
• Timing of asthmatic attacks, especially if it occurs only during certain times of the year, day, or in certain places.
• Triggers of asthma specific to you
• Related conditions when experiencing an asthmatic attack, like a concurrent upper respiratory tract infection, reflux disease, stress, sleep apnoea etc

Physical Examination

Physical examination would include:

• Auscultation by your primary physician to listen for wheezing in the lungs
• Examination of the upper airways, sinuses and upper nasal passages for existing upper airway diseases
• Examination for other signs of allergic conditions eg eczema

Diagnostic Tests For Asthma

Lung Function Tests

Lung Spirometry is a type of Lung Function Test that measures the amount of air you inhale and exhale and the speed thereof.

Some respiratory specialists will use medications to “treat” existing asthma and repeat the lung function tests again to see if there is any improvement. This is usually done if chronic asthma is suspected. It is also done when the diagnosis of asthma is unclear.


Associated Tests For Asthma

Other tests performed by respiratory specialists may include:

• Allergy testing
• Perform Bronchoprovocation tests to “trigger” a controlled asthmatic attack.
• Chest X-Rays
• Electrocardiograms (ECGs) .

Asthma In Young Children

Many children develop asthmatic symptoms before 5 years of age and it is difficult to diagnose asthma in young children because the symptoms often present together with many other childhood diseases.

Reason is because children have small airways to begin with. Any respiratory condition with mucus production, for example, will further narrow their airways causing wheezing to be audible, thereby mimicking asthma. As the child grows older, the airways enlarge, and wheezing no longer becomes audible.

However, asthma should be suspected if:

• One or both parents have asthma
• Other allergic conditions eg eczema is present
• A history of pollen allergy or hay fever is present
• Wheezing is audible even when the child is healthy

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.