Subject: alt.support.asthma FAQ: Asthma -- General Information
From: [email-masked]
Cc: [email-masked]
Date: 31 Oct 2000 22:47:17 GMT
Newsgroups: alt.support.asthma,alt.med.allergy,sci.med,alt.answers,sci.answers,news.answers

Archive-name: medicine/asthma/general-info
URL: http://www.radix.net/~mwg/asthma-gen.html
Posting-Frequency: monthly
Last-modified: 17 September 2000
Original-author: Patricia Wrean <[email-masked]>
Version: 5.3

       alt.support.asthma FAQ:  Asthma -- General Information
       ======================================================

Introduction:
------------

Welcome to alt.support.asthma!  This newsgroup provides a forum for
the discussion of asthma, its symptoms, causes, and forms of treatment.
Please note that postings to alt.support.asthma are intended to be
for discussion purposes only and are in no way to be construed as
medical advice.  Asthma is a serious medical condition requiring
direct supervision by a physician.

This FAQ attempts to answer the most frequently asked questions about
asthma on the newsgroup alt.support.asthma.  It was compiled by Patricia 
Wrean <[email-masked]> and is currently maintained by Marie
Goldenberg <[email-masked]>.  The Asthma Medications FAQ is also posted
monthly as a companion to this one.  For information about allergies,
please see the alt.support.asthma FAQ:  Allergies -- General Information
(still under construction), and its companion posting, the Allergy
Medications FAQ. 

Please be aware that the information in this FAQ is intended for
educational purposes only and should not be used as a substitute
for consulting with a doctor.  Most of the contributors are not
health care professionals; this FAQ is a collection of personal
experiences, suggestions, and practical information.  Please remember
when reading this that every asthmatic responds differently; what is
true for some asthmatics may or may not be true for you.  Although
every effort is made to keep this information accurate, this FAQ
should not be used as an authoritative reference.

Comments, additions, and corrections are requested; if you do not wish
your name to be included in the contributors list, please state that
explicitly when contributing.  I will accept additions upon my own
judgement -- I'll warn you right now that I'm a confirmed skeptic and am
not a great believer in alternative medicine.  All unattributed portions
are my own contributions or those of the original maintainer, Patricia
Wrean <[email-masked]>. 

+ = added since last version
& = updated/corrected since last version

======================================================================

Table of Contents:
-----------------

General Information:
     0.0  Changes since the last version
     1.0  What is asthma?
          1.0.1  What is chronic asthmatic bronchitis?
          1.0.2  What is status asthmaticus?
          1.0.3  What is anaphylactic shock?
          1.0.4  What is COPD?
          1.0.5  What is emphysema?
          1.0.6  What is bronchitis?
          1.0.7  What is pneumonia?
          1.0.8  What is cystic fibrosis?
     1.1  What is an asthma attack?
         1.1.1  What is wheezing?
         1.1.2  Do all asthmatics wheeze?
         1.1.3  What is "coughing asthma"?
         1.1.4  Is asthma hereditary?
     1.2  How is asthma diagnosed?
          1.2.1  What is a spirometer?
          1.2.2  What is a peak flow meter?
     1.3  How is asthma normally treated?
          1.3.1  How is an acute asthma attack treated?
     1.4  What are the most common triggers of asthma?
          1.4.1  What is intrinsic/extrinsic asthma?
          1.4.2  Can gastric reflux trigger asthma?
          1.4.3  What is occupational asthma?
     1.5  Asthma and Pregnancy

Medications:
     2.0  What are the major classes of asthma medications?
     2.1  What are the names of the various asthma medications?
          2.1.1  Are salbutamol and albuterol the same drug?
          2.1.2  Can albuterol be taken while taking salmeterol?
     2.2  Are some asthma drugs banned in athletic competitions?
     2.3  What kinds of inhalers are there?
          2.3.1  Do inhaler propellants bother some asthmatics?
          2.3.2  What is a spacer?  What is a holding chamber?
          2.3.3  What is "thrush mouth" and how can I avoid it?
          2.3.4  Is Fisons still making the Intal Spinhaler?
          2.3.5  What's the difference between Spinhalers and Rotahalers?
          2.3.6  Why are so many asthma drugs taken via inhaler?
          2.3.7  How can I tell when my MDI is empty?
          2.3.8  Are my aerosol inhalers going to disappear?
     2.4  What kinds of tablets are there?
          2.4.1  Why do I need a blood test when taking theophylline?
          2.4.2  Why are combination pills not commonly prescribed?
     2.5  What is a nebulizer?
     2.6  What medications should asthmatics be careful about taking?
          2.6.1  What about corticosteroids and chicken pox?

Miscellaneous:
     3.0  What resources are there for asthmatics?
     3.1  Where can I get the latest copy of the FAQs?
     3.2  What is an FAQ, anyway?  What is a Usenet newsgroup?
+    3.3  How about some other WWW links?

List of Contributors
References
Disclaimer

======================================================================

0.0  Changes since the last version
-----------------------------------
     September 17, 2000
     ------------------
     Asthma Gen: Added 3.3 WWW links section
     Asthma Gen: Added reference to Living Well With Asthma book
     Asthma Gen: Added reference to The Doser (inhaler counter) in section 2.3.7
     Asthma Med: Added reference to Advair (salmeterol / fluticasone)
     Asthma Med: Added reference to Bambec (bambuterol)
     Asthma Med: Added reference to Combivent (ipratropium / salbutamol)
     Asthma Med: Noted that Bronkaid and Isuprel appear to have been 
                 discontinued in Canada
     Asthma Med: Added reference to Xopenex (levalbuterol)
     Asthma Med: Added reference to Oxeze (formoterol) turbuhaler
     Asthma Med: Added reference to Pulmicort neb soln available in US

     September 17, 1998
     ------------------
     Asthma Med: Added note that Foradil (formoterol) now available in Canada

     February 17, 1998
     -----------------
     Asthma Med: Added Serevent Diskus, Flovent Rotahaler, Pulmicort, 
          Airomir, Tilade nebulizer solution, and Singulair
          (newly approved medications)
     Asthma Med: Added note that Medihaler-Epi has been discontinued
     Allergy Med: Added note that Seldane has been discontinued
     Allergy Med: Added Nasonex (newly approved medication)
     Asthma General: Added section 1.4.3, Occupational asthma

     December 6, 1997
     ----------------
     Asthma General: Split web version of FAQ document into multiple-page 
		format.

     August 17, 1997
     ---------------
     Asthma General: Added section 1.5, "Pregnancy and Asthma"

     Asthma General: Added reference to new version of NHLBI report

     Asthma General: Added reference to Adams book

     Asthma General: Correct reference to Gershwin to reflect 2nd edition

     June 17, 1997
     -------------
     Asthma General: Correct publication information on "Children With 
     Asthma" by Dr. Plaut

     Asthma General: Added links to archived version of Allergy 
     Medication FAQ

     May 17, 1997
     ------------
     Asthma Med: Added note that Nasalcrom now Over-The-Counter (OTC) in US.

     Asthma Med: Added Zyflo to Leukotriene Receptor Inhibitor section

     Asthma Med: Added Proventil HFA MDI

     Asthma General: Added discussion of phaseout of CFC 
     (chlorofluorocarbon) MDIs

     Asthma General: removed comment that "both spinhaler and rotahaler are
     available in the US" (the spinhaler is not available in the US)

1.0  What is asthma?
--------------------

     Asthma is best described by its technical name:  Reversible
     Obstructive Airway Disease (ROAD).  In other words, asthma
     is a condition in which the airways of the lungs become
     either narrowed or completely blocked, impeding normal
     breathing.  However, in asthma, this obstruction of the lungs
     is reversible, either spontaneously or with medication.

     Quickly reviewing the structure of the lung:  air reaches the
     lung by passing through the windpipe (trachea), which divides
     into two large tubes (bronchi), one for each lung.  Each
     bronchi further divides into many little tubes (bronchioles),
     which eventually lead to tiny air sacs (alveoli), in which
     oxygen from the air is transferred to the bloodstream, and
     carbon dioxide from the bloodstream is transferred to the air.
     Asthma involves only the airways (bronchi and bronchioles),
     and not the air sacs.  The airways are cleaned by trapping
     stray particles in a thin layer of mucus which covers the surface
     of the airways.  This mucus is produced by glands inside the
     lung, and is constantly being renewed.  The mucus is then
     either coughed up or swept up to the windpipe (trachea) by
     cilia, tiny hairs on the lining of the airways.  Once the
     mucus reaches the throat, it can again be coughed up or,
     alternatively, swallowed.

     Although everyone's airways have the potential for constricting
     in response to allergens or irritants, the asthmatic's airways
     are oversensitive, or hyperreactive.  In response to stimuli,
     the airways may become obstructed by one of the following:
         - constriction of the muscles surrounding the airway;
         - inflammation and swelling of the airway; or
         - increased mucus production which clogs the airway.
     Once the airways have become obstructed, it takes more effort
     to force air through them, so that breathing becomes laboured.
     This forcing of air through constricted airways can make a
     whistling or rattling sound, called wheezing.  Irritation of
     the airways by excessive mucus may also provoke coughing.

     Because exhaling through the obstructed airways is difficult,
     too much stale air remains in the lungs after each breath.
     This decreases the amount of fresh air which can be taken in
     with each new breath, so not only is there less oxygen
     available for the whole body, but more importantly, the high
     concentration of carbon dioxide in the lungs causes the blood
     supply to become acidic.  This acidity in the blood may rise
     to toxic levels if the asthma remains untreated.

1.0.1  What is chronic asthmatic bronchitis?
--------------------------------------------

     Chronic asthmatic bronchitis is the condition in which the
     airways in the lungs are obstructed due to both persistent
     asthma and chronic bronchitis (see sections 1.0 and 1.0.6).
     People with this disease generally also have a persistent
     cough which brings up mucus.  Chronic asthmatic bronchitis
     which also involves emphysema is usually classified under
     the more general category of COPD.

1.0.2  What is status asthmaticus?
----------------------------------

     Status asthmaticus is defined as a severe asthma attack that
     fails to respond to routine treatment, such as inhaled
     bronchodilators, injected epinephrine (adrenalin), or
     intravenous theophylline.

1.0.3  What is anaphylactic shock?
----------------------------------

     Anaphylactic shock is defined as a severe and potentially
     life-threatening allergic reaction throughout the entire
     body.  It occurs when an allergen, instead of provoking a
     localized reaction, enters the bloodstream and circulates
     through the entire body, causing a systemic reaction.
     (There may also be an intrinsic trigger, as some cases of
     exercise-induced anaphylaxis have been reported.)

     The symptoms of anaphylactic shock begin with a rapid
     heartrate, flushing, swelling of the throat, nausea, coughing,
     and chest tightness.  Severe wheezing (asthma), cramping, and
     a rapid drop in blood pressure follow, which may lead to cardiac
     arrest.  Hives and vomiting are also common features.  The
     treatment for anaphylaxis is intravenous epinephrine (adrenalin),
     with antihistamines and steroids also being used in selected
     cases.  Aminophylline may also be given for pronounced asthmatic
     reactions that do not respond to epinephrine.

1.0.4  What is COPD?
--------------------

     COPD is chronic obstructive pulmonary disease, also known as
     either COAD, for chronic obstructive airway disease, or COLD,
     for chronic obstructive lung disease.  COPD is a disease in
     which the airways are obstructed due to a combination of
     asthma, emphysema, and chronic bronchitis.  The 1987 Merck
     Manual notes that "the term COPD was introduced because these
     conditions often coexist, and it may be difficult in an
     individual case to decide which is the major one producing
     the obstruction."

     [Maintainer's note:  the entries for COPD, emphysema, bronchitis,
     pneumonia, and cystic fibrosis have been included because of
     common confusion between the various diseases which can affect
     the lungs.]

1.0.5  What is emphysema?
-------------------------

     Emphysema is the disease in which the air sacs themselves, rather
     than the airways, are either damaged or destroyed.  This is an
     irreversible condition, leading to poor exchange of oxygen and
     carbon dioxide between the air in the lungs and the bloodstream.

1.0.6  What is bronchitis?
-------------------------

     Bronchitis is an inflammation of the bronchi, the large airways
     inside the lungs.  (Bronchiolitis is the inflammation of the
     bronchioles, the small airways.)  This inflammation often leads
     to increased mucus production in the airways.

     Bronchitis is generally caused either by a virus or by exposure
     to irritants such as dust, fumes, or cigarette smoke.  If caused
     by a virus, the bronchitis will likely be only temporary.  In
     the case of prolonged exposure to irritants, particularly
     cigarette smoking, if there is permanent damage to the bronchi,
     bronchitis may become chronic.

1.0.7  What is pneumonia?
-------------------------

     Pneumonia is an infection of the lung tissue.  In adults, it is
     generally caused by bacterial infections, though viruses, fungi,
     and protozoa may also be culprits.  The latter microorganisms
     have become very common as causes of pneumonia in immunosuppressed
     persons, such as those with HIV infection.  However, for those
     with chronic illnesses, especially cardiac or respiratory
     diseases, or those at increased risk for pneumonia, there is a
     pneumococcal pneumonia vaccination available as a preventive
     measure for the most common of these bacterial infections,
     streptococcus pneumoniae.  In children, pneumonia is most
     commonly caused by viruses.

1.0.8  What is cystic fibrosis?
-------------------------------

     Cystic fibrosis is a disease in which excessive amounts of
     unusually thick mucus are produced throughout the body.
     Because this mucus production also occurs in the lungs,
     people with cystic fibrosis are extraordinarily prone to
     bacterial infections which result in progressive lung damage.
     Cystic fibrosis can be diagnosed by a "sweat test" as people
     with cystic fibrosis have elevated chloride levels in their
     perspiration.  This condition often resembles asthma in
     children.

1.1  What is an asthma attack?
------------------------------

     An asthma attack, also known as an asthma episode or flare,
     is any shortness of breath which interrupts the asthmatic's
     well-being and requires either medication or some other form of
     intervention for the asthmatic to breathe normally again.

1.1.1  What is wheezing?
------------------------

     Wheezing is the whistling or rattling sound that occurs when
     air flows through obstructed airways.  At the start of an
     asthma attack, wheezing usually only occurs while exhaling, or
     breathing out, but as the attack progresses, wheezing may
     then be heard both while inhaling and exhaling.  If after
     the attack progresses further, the asthmatic then stops wheezing,
     this may indicate that many bronchioles (small airways) have
     become completely blocked, which is a very serious condition.

1.1.2  Do all asthmatics wheeze?
--------------------------------

     No, not all asthmatics wheeze.  Although wheezing is extremely
     common in asthmatics, in _All About Asthma_, Dr. Paul says,
     "It is important to note that not all asthmatic symptoms need be
     present for one to experience an asthma attack.  For instance,
     not all asthmatics wheeze.  And sometimes wheezing is so slight,
     it can only be heard with a stethoscope.  With some asthmatics,
     coughing is the only symptom present."  Similarly, in _Children
     with Asthma_, Dr. Plaut states that children with chronic coughs
     "may have asthma even though no wheezing is present."  He
     diagnoses such children with asthma if their peak flow improves
     when given an inhaled bronchodilator.

1.1.3  What is "coughing asthma"?
---------------------------------

     In _Children with Asthma_, Dr. Plaut defines "coughing asthma"
     as "a form of asthma in which coughing is the only symptom and
     there is no abnormality in any lung function test."  This
     condition is also known as "cough variant asthma."  Coughing
     asthma often improves when standard asthma medications are
     taken.

1.1.4  Is asthma hereditary?
----------------------------

     No, asthma itself is not hereditary, but there does seem to be
     a hereditary component to the tendency to develop asthma.  In
     _All About Asthma_, Dr. Paul states that if neither parent has
     asthma, the chances of each of their children having asthma are
     less than 10%.  When one parent has asthma, the chances rise to
     25%, and when both parents have asthma, the chances climb to 50%.
     (Actually, there is considerable disagreement among my sources
     as to the exact numbers, but all agree that the chances climb
     dramatically if one or both parents have asthma.)

     Similarly, if one or both parents have allergies, the chances
     of each of their children having allergies are 35% and 65%,
     respectively, compared to a less than 10% chance if neither
     parent has allergies.

     However, Dr. Paul cautions that "children don't inherit asthma
     itself, but the tendency to develop it."  Whether or not an
     individual develops asthma is also influenced by their exposure
     to various other factors such as infections, irritants, and
     allergens.

1.2  How is asthma diagnosed?
-----------------------------

     Asthma is diagnosed based on a physical examination, personal
     history, and lung function tests.  The physical examination looks
     for typical asthma symptoms such as wheezing or coughing, and the
     personal history provides additional clues such as allergies or a
     familial tendency towards asthma.  Although lung function tests
     have not always been used for diagnosis in the past, the NHLBI
     Guidelines for the Diagnosis and Management of Asthma state that
     "Pulmonary function studies are essential for diagnosing asthma
     and for assessing the severity of asthma in order to make
     appropriate therapeutic recommendations.  The use of objective
     measures of lung function is particularly important because
     subjective measures, such as patient symptom reports and
     physicians' physical examination findings, often do not correlate
     with the variability and severity of airflow obstruction."
     Lung function tests may be as simple as measuring peak flow with
     a peak flow meter, or using a simple spirometer, or may involve
     a battery of spirometry tests in a pulmonary function lab.

1.2.1  What is a spirometer?
----------------------------

     A spirometer is a machine for testing lung function that you
     breathe in and out of through a hose attached to a mouthpiece.
     You are usually given nose clips so that all the air you breathe
     goes through the machine.  One I've been tested on had a little
     expanding tank surrounded by water into which the air goes, and
     I could see the top rising and falling as I breathed out and in.
     It can measure a fair number of characteristics of your lungs,
     including FVC, FEV1, and PEPR.  FVC, or forced vital capacity,
     is the amount of air that you can exhale forcefully after taking
     a deep breath.  FEV1, or forced expiratory volume in one second,
     is the amount of air that you can be exhale in one second.
     Peak flow, or PEPR, is described in section 1.2.2.
     The sophisticated spirometers I've seen have a PC attached, and
     have neat little curves generated with each breath, which
     apparently have characteristic shapes for different respiratory
     diseases.

     There is a slightly less sophisticated machine that I've blown
     into, and I'm not sure if this is also classed as a spirometer or
     not, but you take a deep breath and blow into it, much like a
     peak flow meter, except that it draws a little graph of how much
     volume you've blown out, and I'd imagine that you can get the
     FVC and FEV1 off this graph.

     For more information, I recommend the book by Drs. Haas,
     _The Essential Asthma Book_, which goes into more detail about
     the various things you can find out from spirometry.

1.2.2  What is a peak flow meter?
---------------------------------

     A peak flow meter is a little plastic device which you blow hard
     into, after having taken a deep breath.  It records the rate at
     which you've blown into it in litres exhaled per minute (L/min)
     -- this is called the peak expiratory flow rate (PEF or PEFR).
     The meter is essentially a cylinder with a mouthpiece at one end,
     a place for the air to escape at the other end, and a calibrated
     meter along the side.  When you blow into it, a marker is pushed
     along the scale and comes to rest at a point which indicates your
     PEF.  Since you want to measure your maximum peak flow, it is
     important to take a deep breath and blow as hard and as fast as
     you can.  Many asthmatics find that their maximum peak flow provides
     a good objective measure of how their asthma is doing, so peak flow
     meters now are used extensively for self-monitoring of asthma, and
     also for monitoring the effectiveness of asthma medications.

1.3  How is asthma normally treated?
------------------------------------

     Treatment of mild asthma usually tries to relieve occasional
     symptoms as they occur by use of short-acting, inhaled
     bronchodilators.  Treatment of moderate or severe asthma,
     however, attempts to alleviate both the constriction and
     inflammation of the airways, through the use of both
     bronchodilators and anti-inflammatories.  Bronchodilators are
     drugs which open up or dilate the constricted airways, while
     drugs aimed at reducing inflammation of the airways are called
     anti-inflammatories.

     Taking anti-inflammatory drugs (usually inhaled corticosteroids)
     daily for moderate to severe asthma is a relatively new approach
     to treating asthma.  The idea behind it is that if the underlying
     inflammation of the airways is reduced, the bronchi may become
     less hyperreactive, making future attacks less likely.  Such
     anti-inflammatory therapy, however, must be taken regularly in
     order to be effective.

     For asthma which is strongly triggered by allergies, allergen
     avoidance can often greatly reduce the amount of medication
     needed to control the asthma.  Taking anti-allergic medications
     or taking shots for allergy desensitization are other
     alternatives.  For more information about allergen avoidance
     and allergies in general, please see the alt.support.asthma FAQ:
     Allergies -- General Information (still under construction).

1.3.1  How is an acute asthma attack treated?
---------------------------------------------

     An acute asthma attack is usually treated with bronchodilators
     to reduce the constriction of the airways.  Intravenous adrenalin
     and theophylline are often given in emergency rooms for this
     purpose, if short-acting bronchodilators given by nebulizer
     haven't sufficiently controlled the attack.

     Once the acute attack is over, anti-inflammatories may be used to
     reduce the inflammation of the airways.  Inhaled steroids are
     usually the first choice, but for a sufficiently severe attack,
     oral steroids such as prednisone may also be given.

1.4  What are the most common triggers of asthma?
--------------------------------------------

     The most common triggers of asthma are:
         - viral respiratory infections, such as influenza (the flu)
           or bronchitis;
         - bacterial infections, including sinus infections;
         - allergic rhinitis;
         - irritants, such as pollution, cigarette smoke, perfumes,
           dust, or chemicals;
         - sudden changes in either temperature or humidity, especially
           exposure to cold air;
         - allergens, for people with allergies;
         - emotional upsets, such as stress; and
         - exercise.

1.4.1  What is intrinsic/extrinsic asthma?
------------------------------------------

     Intrinsic and extrinsic asthma are outdated terms which have now
     been replaced by terms related to the asthma trigger, since the
     inflammatory response of the airways is the same independent of
     the cause of the asthma.  What was known as extrinsic asthma is
     now called allergic asthma, while asthma triggered by non-allergic
     factors, formerly called intrinsic asthma, is separated into such
     categories as exercise-induced asthma and occupational (chemical-
     induced) asthma.

1.4.2  Can gastric reflux trigger asthma?
----------------------------------------

     Yes, gastric reflux can act as an irritant which triggers
     asthma.  Reflux, properly known as gastroesophageal reflux,
     occurs when the liquids in the stomach pass up the esophagus,
     or feeding tube.  Because these liquids are usually highly
     acidic, they can irritate and inflame the esophagus, and
     also the airways of the lung, should any of this liquid be
     aspirated.  This irritation can trigger an asthma attack.

     Asthma flares caused by reflux are more common at night,
     for it is easier for material to pass up the esophagus when
     one is lying down.  Some simple treatments to prevent reflux
     include raising the head of the bed, not eating close to
     bedtime, or using either antacids or medications such as
     ranitidine (Zantac) which reduce the amount of acid produced
     by the stomach.

     Contributed by: Betty Bridges			[email-masked]

1.4.3  What is Occupational Asthma?
-----------------------------------
     Occupational Asthma is asthma that is caused by sensitization from
     exposures in the workplace.  Asthmatics whose asthma is exacerbated by
     exposures in the workplace would not be classified as having 
     occupational asthma.

     There are over 200 substances that have been documented as causing
     occupational asthma, but there are probably more that have not been
     recognized. The substances that are known to cause occupational asthma
     can be divided into two main categories.

     High molecular weight proteins of animal or plant origins are common
     causes.  Things like animal dander, flour proteins, and animal scales
     are frequently causes of occupational asthma.  These same things are 
     also common causes of non-occupational asthma.  These are usually 
     IgE-mediated responses.

     Low molecular weight chemicals that have the ability to bind with
     proteins or act as haptans are causes of occupational asthma.  There 
     may be other mechanisms involved besides the classic IgE-mediated 
     responses as not all those that are sensitized have specific 
     antibody production.  Reactions may have reflex, inflammatory, 
     pharmacological, or immunologic pathways or a combination of several.
     
     Often occupational asthma is difficult to diagnosis.  There are may be
     immediate, late, or biphasic reactions.  In late reactions the symptoms
     may not occur until away from the work place.  Frequently the asthma
     worsens as the workweek progresses and improves over the weekend.

     Treatment for occupational asthma is basically the same as any other
     asthma with a few very important exceptions.  For those that have
     chemically induced asthma from sensitization to that chemical; 
     avoidance of the trigger is essential. While steroids and other 
     medications are helpful in treating the symptoms, they do not 
     prevent the underlying sensitivity from increasing.

     Once sensitized to a substance, some react to minute amounts.  Levels
     below current TLV levels still trigger reactions. For a sensitized 
     individual any exposure can cause symptoms.

     Continued exposure to the triggering chemical can cause permanent lung
     damage, chronic asthmatic conditions, and even death.  Medication 
     should never be used to allow the worker to continue to work in an 
     environment where there is exposure to the triggering substance.  Early 
     recognition and removal from exposure is essential in preventing long 
     term disability from asthma.

     Chemically induced asthma can occur both in the workplace and outside 
     of the workplace.  There are many exposures outside of the workplace 
     that there are exposures to chemicals that can induce asthma.  Most 
     physicians are not familiar with this type of asthma. For anyone that 
     has chemically induced asthma, avoidance of the trigger is essential.

1.5  Asthma and Pregnancy
-------------------------
     Many people have posted to ask about whether it is safe to become 
     pregnant while suffering from asthma, and in particular whether it is 
     safe to use their asthma medications while pregnant.

     The general consensus (from the doctors I have consulted) is that
     asthmatics can safely become pregnant without undue worry about whether
     the mother and the baby will be all right.  Most doctors talk about a
     "rule of 1/3" by which they mean that roughly 1/3 of all asthmatics get
     better while pregnant, 1/3 stay the same, and 1/3 find their asthma is
     aggravated (I improved with one pregnancy, and stayed the same with the
     next). 

     In any event, the bottom line when pregnant is ensuring that the baby
     receives sufficient oxygen - and medications should be used as 
     appropriate to control the asthma and protect mother and child.  
     It is inadvisable to stop or reduce asthma medication solely because 
     of the pregnancy without careful supervision, as this can lead to 
     poorly controlled asthma, unnecessary ER visits, and poor outcome for 
     the baby and/or mother.

     Most commonly-used asthma medications appear to be safe when used in
     pregnancy; notable exceptions include the combination pills (Marax, 
     Tedral etc.) and those containing iodine (e.g. Theo-Organidin).
     Many people are concerned in particular with the use of inhaled, 
     intranasal, and/or oral steroids but it has been my experience that 
     most doctors are quite willing to use these as needed, especially the 
     inhaled and intranasal steroids. It is my understanding that ephedrine 
     (alone or in combination drugs), and phenobarbital (an ingredient in 
     Tedral and other combination drugs) should be avoided. 

     There are choices in most classes of drugs, e.g., the bronchodilators, 
     and many doctors will elect to put their patients on those drugs with 
     the longest history of use in pregnant women - the assumption is that 
     the longer a drug has been in use, the likelier it is that any problems 
     would have become evident.  For this reason, beclomethasone (Beclovent, 
     Vanceril) is the preferred inhaled corticosteroid.  Cromolyn Sodium
     (Nasalcrom, Intal) also appears to be safe for use in pregnancy.

     In addition, if you need to use systemic steroids for a brief flareup,
     old concerns over fetal abnormalities (cleft palate etc.) appear to 
     be less worrisome; I know of one case in which a woman used prednisone 
     for something other than asthma for several months while pregnant and 
     her baby had no problems.

     Antibiotics may be used if needed; there are some such as tetracycline 
     which should be avoided but others (such as penicillin) appear to be
     safe.

     There is some anecdotal evidence from one contributer to the newsgroup
     that Serevent, the longer-acting B2-agonist, might be related to several
     cases of fetal abnormalities; I have not seen any official reports
     supporting or denying this but it may be worth discussing with your
     doctors if you use Serevent and are considering pregnancy. 

     Note: the above is a compilation of my own experiences as a pregnant
     asthmatic, anecdotes from the newsgroup, and excerpts from The Asthma
     Sourcebook and the National Asthma Education and Prevention Program 
     Expert Panel Report.  It should in no way substitute for consultation 
     with qualified medical personnel. 

======================================================================

2.0  What are the major classes of asthma medications?
------------------------------------------------------

     There are seven major classes of asthma medications:
         - steroidal anti-inflammatories,
         - non-steroidal anti-inflammatories,
         - beta-agonists,
         - xanthines,
         - anticholinergics,
         - leukotriene receptor antagonists, and
         - anti-allergics.

     The first two categories of drug treat the underlying
     inflammation of the lung.  All steroidal anti-inflammatories
     are glucocorticosteroids, which are entirely different from the
     anabolic steroids that have become notorious for their abuse
     by athletes.  There are many different corticosteroids available
     for the treatment of asthma, almost all available via inhaler
     to reduce the amount of side effects (see section 2.3.6).  The
     non-steroidal anti-inflammatories currently available are
     nedocromil sodium and cromolyn sodium, though cromolyn sodium
     is perhaps more properly known as a mast cell stabilizer, since
     it blocks both the release of histamine and inflammatory
     mediators, which means that although it blocks the inflammatory
     response, it cannot reverse inflammation once it has taken place.
     For this reason, I have classed it as an anti-allergic since it
     is mostly commonly taken for asthma that has a strong allergy
     component.

     The second two classes of asthma medications, beta-agonists and
     xanthines, are both bronchodilators, meaning that they relax the
     muscles lining the airways, allowing the airways to expand to
     their normal size.  Beta-agonists are chemically related to
     adrenalin, but are specifically tailored to be more effective
     on the muscles of the lung while having little effect on the
     muscles in the heart.  They are usually taken in inhaled form,
     and all but one (salmeterol) are short-acting.  Theophylline,
     the major xanthine, is chemically related to caffeine, since
     caffeine is also a xanthine derivative, and is present in tea.
     Theophylline is taken orally, often in a sustained-action form
     (see section 2.4).  Because its therapeutic range is close to
     its toxic range, asthmatics taking theophylline should have
     their blood levels monitored to ensure that their blood
     concentrations of theophylline lie within the therapeutic
     range (see section 2.4.1).  There are some asthmatics, however,
     who cannot tolerate even very low doses of theophylline.

     Anticholinergics, the fourth class of medication, work by
     blocking the contraction of the underlying smooth muscle of
     the bronchi.  Although used to treat asthma in Canada, the
     anticholinergic ipratropium bromide (Atrovent) has not approved
     by the US Food and Drug Administration for the treatment of
     asthma, but is used for the treatment of COPD.
     (It is interesting to note, however, that in the April 1982
     issue of The FDA Drug Bulletin, the FDA states that "the
     FD&C Act does not, however, limit the manner in which a
     physician may use an approved drug.  Once a product has been
     approved for marketing, a physician may prescribe it for uses
     or in treatment regimens or patient populations that are not
     included in a approved labeling."  The FD&C Act is the Food,
     Drug, and Cosmetic Act.)

     The newest class of asthma medications is leukotriene receptor
     antagonists.  My information as to how they work is sketchy,
     but as I understand it, the leukotriene receptor starts off the
     inflammator response of the immune system when it detects an
     allergen, so presumably an antagonist would block the receptor
     from responding to the presence of an allergen.  Zeneca
     Pharmaceuticals has just now announced that its new leukotriene
     receptor antagonist, zafirlukast (Accolate), has been approved
     by the FDA (the US Food and Drug Administration) and will be
     available in November of 1996.  Abbott Laboratories now produces
     a second drug in this class: zileuton (Zyflo).

     The last class, the anti-allergics, has been included because
     the two anti-allergic drugs, cromolyn sodium and ketotifen, are
     commonly taken for the prevention of allergic asthma.  Cromolyn
     sodium is a mast cell stabilizer -- it blocks the release of
     histamine from mast cells, which acts to prevent asthma flares
     since histamine is a very strong bronchoconstrictor.  However,
     it isn't considered an antihistamine because it cannot prevent
     the effects of histamine once the histamine has been released
     from the cell.  Similarly, it blocks the release of inflammatory
     mediators from the mast cell, and so prevents the inflammatory
     response, although it cannot reverse inflammation once the
     mediators have been released.  Ketotifen fumarate (Zaditen),
     a non-sedating antihistamine used mostly for the treatment of
     pediatric allergic asthma, is not currently available in the
     United States.

2.1  What are the names of the various asthma medications?
----------------------------------------------------------

     For a complete listing of asthma medications, please see the
     alt.support.asthma FAQ:  Asthma Medications.  Allergy medi-
     cations are listed in the alt.support.asthma FAQ: Allergy 
     Medications.  They are posted monthly as companions to this 
     general information FAQ.

2.1.1  Are salbutamol and albuterol the same drug?
--------------------------------------------------

     Ventolin is the brand name of salbutamol, which is the WHO
     (World Health Organization) recommended name for the medication.
     Unfortunately, in the US this same drug is called albuterol,
     leading to endless confusion.  In fact, it's one of the few
     drugs in which the brand name stays the same from country
     to country, while the chemical name changes!  Ventolin is made
     in the U.S. by Allen & Hanburys, and Proventil is the same drug
     manufactured by Schering.  You can also get this drug in
     a sustained-action tablet, called either Repetabs (by Schering,
     again) or Volmax (Muro).

2.1.2  Can albuterol be taken while taking salmeterol?
------------------------------------------------------

     Yes.  Quoting from the Product Information Sheet that comes
     with the Serevent (salmeterol) inhaler, manufactured by
     Allen & Hanburys:

     "Serevent Inhalation Aerosol should not be used more frequently
     than twice daily (morning and evening) at the recommend dose.
     When prescribing Serevent Inhalation Aerosol, patients must be
     provided with a short-acting, inhaled beta2-agonist
     (e.g., albuterol) for treatment of symptoms that occur despite
     regular twice-daily (morning and evening) use of Serevent."

     "When patients begin treatment with Serevent Inhalation Aerosol,
     those who have been taking short-acting, inhaled beta2-agonists
     on a regular daily basis should be advised to discontinue their
     regular daily-dosing regimen and should be clearly instructed to
     use short-acting, inhaled beta2-agonists only for symptomatic
     relief if they develop asthma symptoms while taking Serevent
     Inhalation Aerosol."

     "The safety of concomitant use of more than eight inhalations per
     day of short-acting beta2-agonists with Serevent Inhalation
     Aerosol has not been established."

     So the above quotes seem to imply that it is okay for asthmatics
     taking Serevent regularly to also use Ventolin (albuterol) as
     needed, provided one doesn't need it too often.

2.2  Are some asthma drugs banned in athletic competitions?
-----------------------------------------------------------

     The determination of whether a drug or substance is banned or
     allowed in amateur athletic competitions is not based on whether
     it is medically necessary.  Rather, such a determination is based
     on whether the substance in question can be performance-enhancing
     and offer an unfair competitive advantage.  There are several
     organizations that make this determination and an athlete on an
     asthmatic drug should check with his coaches, physician, and
     appropriate athletic authority.  Different athletic organizations
     may differ on what is banned or allowed.  For example, the
     United States Olympic Committee (USOC) follows International
     Olympic Committee guidelines for testing at Olympic events.  Many
     amateur athletic organizations (termed National Governing Bodies)
     adopt USOC guidelines for drug testing at their events.  In
     contrast, the NCAA has less stringent guidelines for certain
     substances used by asthmatics in during competitions.  Further
     complicating an athlete's understanding of the situation, some
     substances that are banned in tablet form are allowed in inhaled
     form.

     As an example, the USOC allows inhaled forms of the beta-2 agonist
     albuterol with written notification by a treating physician but
     bans tablet forms of albuterol.  Certain other beta-adrenergic
     agonists (e.g. ephedrine, bitolterol, metaproterenol) are banned
     by the USOC.  An athlete who participates in an amateur athletic
     event where drug testing may occur should check with his or her
     coaches and physicians regarding the allowed vs. banned status of
     any substance while competing.  The United States Olympic
     Committee Drug Hotline, (800) 233-0393, or NCAA, (800) 546-0441,
     may provide information to specific questions on drugs, and
     educational materials in this regard.  An asthmatic should also
     not assume that an over-the-counter (OTC) status of any drug
     implies its allowed status in athletic competitions; many OTC
     agents (e.g. combination decongestant-bronchodilators containing
     ephedrine) or herbal preparations bought in food stores
     (e.g. Ma Huang) contain stimulants useful for asthma but banned
     in certain athletic competition settings.

     Contributed by:  Lyn Frumkin, M.D., Ph.D. [email-masked]

2.3  What kinds of inhalers are there?
--------------------------------------

     aerosol inhalers:
     ----------------

     MDI         - metered-dose inhaler, consisting of an aerosol unit
                   and plastic mouthpiece.  This is currently the most
                   common type of inhaler, and is widely available.

     autohaler   - MDI made by 3M which is activated by one's breath,
                   and doesn't need the breath-hand coordination that
                   a regular MDI does.  Available in U.S., UK, and NZ.

     integra     - MDI with compact spacer device.  Available in UK.

     respihaler  - aerosol inhaler for Decadron.  I have no idea how
                   this differs from the usual MDI.  Available in the
                   U.S.

     syncroner   - MDI with elongated mouthpiece, used as training device
                   to see if medication is being inhaled properly.
                   Available in Canada and UK.

     dry powder inhalers:
     -------------------

     accuhaler   - dry powder inhaler for use with Serevent.  It contains
                   a foil strip with 60 blisters, each containing one dose
                   of the drug.  Pressing the lever punctures the blister,
                   allowing the drug to be inhaled through the mouthpiece.
                   Available in the UK.

     diskhaler   - dry powder inhaler.  The drug is kept in a series of
                   little pouches on a disk; the diskhaler punctures
                   the pouch and drug is inhaled through the mouthpiece.
                   Currently available in Canada, South Africa, and UK,
                   not in U.S.

     insufflator - dry powder nasal inhaler used with Rynacrom
                   cartridges.  Each cartridge contains one dose;
                   the inhaler opens the cartridge, allowing the
                   powder to be blown into the nose by squeezing
                   the bulb.  Available in Canada.

     rotahaler   - dry powder inhaler used with Rotacaps capsules.
                   Each capsule contains one dose; the inhaler opens
                   the capsule such that the powder may be inhaled
                   through the mouthpiece.  Available in the U.S.,
                   Canada, and UK for Ventolin.  In Canada, Beclovent
                   Rotacaps are also available, as are Becotide
                   Rotacaps in the UK.

     spinhaler   - dry powder inhaler used with Intal capsules for
                   spinhaler.  Each capsule contains one dose; the
                   inhaler opens the capsule such that the powder
                   may be inhaled through the mouthpiece.  Available
                   in Canada, UK, and the Netherlands.  No longer
                   manufactured in the U.S.

     turbuhaler  - dry powder inhaler.  The drug is in form of a pellet;
                   when body of inhaler is rotated, prescribed amount of
                   drug is ground off this pellet.  The powder is then
                   inhaled through a fluted aperture on top.  Available
                   in Australia, Canada, Denmark, Switzerland, and
                   the UK (spelled 'turbohaler' in the UK).

2.3.1  Do inhaler propellants bother some asthmatics?
-----------------------------------------------------

     Some asthmatics find the dry powder inhalers more effective than
     their MDI (aerosol) counterparts.  It is suspected that the
     aerosol or propellant in the MDI may act as an irritant to some
     asthmatics, as in the following article:

     J.R.W. Wilkinson et al., Paradoxical bronchoconstriction in
     asthmatic patients after salmeterol by metered dose inhaler,
     British Medical Journal 305 (1992) 931.  The first sentence
     in the conclusion is:  "Bronchoconstriction after both
     salmeterol and placebo by metered dose inhaler but not after
     salmeterol by diskhaler suggests that the irritant is not
     the salmeterol itself."  . . . "The similarity in characteristics
     of bronchoconstriction after beclomethasone by metered dose
     inhalers implicates one or both chlorofluorocarbons . . . as
     the irritant.  That salbutamol caused no bronchoconstriction was
     attributed to its faster onset of action opposing any
     bronchoconstrictor effects of the propellants."

     ** However, according to the 1994 Physicians' Desk Reference,
        Intal Spinhaler capsules are "contraindicated in those
        patients who have shown hypersensitivity to . . . lactose."
        So asthmatics who are lactose-intolerant may not have this
        form of cromolyn sodium as an option.

2.3.2  What is a spacer?  What is a holding chamber?
----------------------------------------------------

     Metered dose inhalers (MDIs) for asthma medications typically
     consist of a metal aerosol canister (containing the medication and
     a propellant) in a plastic sleeve with a mouthpiece.  The patient
     inhales one or more metered doses of a medication through the
     mouthpiece.  Most people find it difficult (at least initially) to
     time the spraying of an MDI and the inhalation of the medicine:
     the patient must exhale fully and inhale and release the metered
     dose just at the beginning of the inhalation so as to draw the
     medication as fully and deeply into the lungs as possible.

     All too often the puffs are mis-timed and only make it part of the
     way into the airways, and some of the medication is invariably
     deposited into the mouth and on the back of the throat instead of
     into their lungs.  In addition to being less effective, this can
     lead to other side effects (e.g., for inhaled steroids, an
     increased potential for thrush, an oral fungal infection described
     in section 2.3.3).

     Several devices have become available that address these
     difficulties to varying degrees.  The devices are generally
     referred to as "spacers" since they place additional space between
     the patient and the MDI.  The medication is sprayed into the spacer
     instead of the mouth.  As the patient inhales, the column of
     medication passes through the mouth and throat relatively quickly,
     leaving little opportunity for the medication to be deposited in
     the mouth or throat.  This is a more efficient means of delivering
     the medication to the airways where it's most needed.

     The simplest kind of spacer is basically a tube.  The patient
     sprays the medication in one end of the tube and inhales it out
     the other end.  Azmacort has a simple spacer attached to it.  A
     cardboard tube from the core of a roll of bathroom tissue can be
     used as a spacer (as long as it's clean, lint-free and germ-free).
     While a simple spacer reduces the amount of medication that gets
     deposited in the mouth and throat, it still requires you to
     carefully time your inhalation with the discharge of the
     medication to minimize the amount of the medication that escapes
     from the spacer.

     A "holding chamber" is a more sophisticated device.  It is a sealed
     chamber (once the inhaler is inserted) that traps and holds the
     medication, allowing the patient to spray the medication into the
     chamber and take a few seconds to inhale the medication.  Since
     the medication is temporarily suspended in the holding chamber,
     the timing of the inhalation is not nearly as critical as with
     simple spacers or no spacer.  AeroChamber is a brand of holding
     chamber.  It's a plastic tube with a mouthpiece on one end and a
     place to insert the MDI on the other.  The mouthpiece has a
     one-way valve built in that temporarily contains the sprayed
     medication, and also allows the patient to exhale without
     displacing the medication in the chamber (as without a spacer, the
     patient should exhale as completely as possible before taking in
     any medication, so that the medication can be inhaled as deeply as
     possible).

     In addition to improving the timing of the inhalation, a holding
     chamber makes it possible to take in the medication more slowly
     than is possible without a spacer or with a simple spacer.  This
     is important for the symptomatic patient, since rapid inhalation
     of the medication is more likely to trigger coughing and cause the
     patient to lose the medication before it has had a chance to be
     absorbed.

     Some spacers are clear so that you can see the puff of medicine,
     and so that you can see when the medication is building up on the
     inside, indicating that the spacer needs cleaning.

     Spacers and holding chambers need periodic cleaning; clean
     carefully, following the manufacturer's instructions so as not to
     damage any delicate internal parts or allow molds or other
     contaminants to be introduced.

     There are special holding chambers for younger children.  There's
     a pediatric Aerochamber that has a mask built in; the child
     breathes normally for a few seconds with the mask held over
     his/her mouth and nose.  This is typically used when a nebulizer
     is not available or not required, and for medications that are not
     available in a nebulized form, such as Beclovent or Vanceril.

     There is also a device for children (and for people that have
     trouble holding their breath) called an InspirEase.  It's kind
     of like a plastic bellows or balloon with a plastic mouthpiece.
     The patient inflates it, the medicine is sprayed into it, and the
     patient inhales, holds his/her breath for the count of 5 (or
     whatever the doctor recommends), exhales into the device, and then
     repeats.  Some patients are instructed to breath slowly in and out
     several times instead of holding their breath.  The InspirEase
     really helpful for younger children who yet aware of the
     difference between breathing in and breathing out or don't yet
     know how to hold their breath or breathe evenly and slowly.  It
     gives them immediate physical feedback, and it also  has a whistle
     built in to tell them when they're breathing too fast (although
     they seem to like making it whistle, so it's positive
     reinforcement for something that they shouldn't be doing).  As the
     child grows, the Inspirease becomes less effective, since it has a
     limited capacity, although I've been told that it is available in
     different capacities.

     Knowing the difference between a simple spacer and a holding
     chamber can help you use each in its proper way.  If you use both a
     holding chamber *and* a simple spacer (e.g., a holding chamber for
     your Ventolin and the simple spacer attached to your Azmacort),
     you need to remember which you're using and adjust your style
     accordingly.

     Spacers and holding chambers are sometimes provided by some HMOs
     and covered by some insurers.

     Contributed by:  Mark Feblowitz                [email-masked]

     [Maintainer's note:  Some spacers seem to be prescription only,
          while others are not.  Whether you need a prescription also
          seems to vary from state to state in the US.  When in doubt,
          ask.  As to why you would need a prescription (i.e.  how
          could you abuse this simple plastic tube?), the nurses at
          National Jewish were as puzzled as I was.]

2.3.3  What is "thrush mouth" and how can I avoid it?
-----------------------------------------------------

     Thrush, or thrush mouth, is the popular term for a yeast
     infection (candida albicans) in the back of throat.  The major
     symptom of thrush is a white film located at the back of the
     throat and tonsil area.  It is usually cured by the use of an
     antifungal mouthwash.

     Thrush is a very common side effect of taking inhaled
     corticosteroids, since steroids alter the local bacteria and
     fungal population of the mouth, enhancing fungal growth.  The
     way to avoid this complication is to ensure that the back of
     the throat doesn't remain coated with corticosteroid after use
     of the inhaler, either by using a spacer or by rinsing the mouth
     very thoroughly afterwards.  Unfortunately, some people still
     get it even when they are very thorough about rinsing.

2.3.4  Is Fisons still making the Intal Spinhaler?
--------------------------------------------------

     In the US, Fisons is no longer manufacturing either the
     Intal Spinhaler (a dry powder inhaler for cromolyn sodium)
     or the capsules for it.  However, the Spinhaler and capsules
     are still available in Canada and the United Kingdom.  For
     further information,  Fisons Corporation's number in the US
     for Rx Customer Service is (800) 334-6433.

2.3.5  What's the difference between Spinhalers and Rotahalers?
---------------------------------------------------------------

     [Maintainer's note:  the Rotahaler is a dry powder inhaler
     for Ventolin (albuterol), manufactured by Allen & Hanburys,
     while the Spinhaler is a dry powder inhaler for Intal
     (cromolyn sodium), manufactured by Fisons Corporation. ]

     The Rotahaler and the Spinhaler are very different animals.
     The Rotahaler is a pussycat, the Spinhaler a ferocious lion.

     The Rotahaler is a two-part mouthpiece that you snap apart,
     put a capsule in, twist, and inhale.  When you twist the device,
     the capsule breaks open.  When you inhale, the medicine lands
     in your lungs.

     The Spinhaler is a three-piece device: a mouthpiece, a tiny
     fan, and a cap to cover the fan.  You open it, put the capsule
     in a space on the fan, close it, push down then up on the cap
     (this breaks the capsule) and then tilt your head back, put
     the mouthpiece in your mouth, and inhale.  The fan throws the
     medicine into the back of your throat.  Then you gag.

     I don't like the propellants in MDIs, so I was highly motivated
     to get a Spinhaler.  It took me a month to get my drugstore to
     find it, and now I must admit I'm disappointed.  I tried using
     an Intal capsule in the Ventolin Rotahaler, since that device
     works so well, but the medicine seems to be of the wrong
     consistency, and the capsule is too large for the space it
     should go into.

     Another difference: The Spinhaler comes in a little container
     like a medicine bottle, but the lid doesn't stay on very well in
     a purse.  The Rotahaler comes in a little plastic case sort of
     like a compact and stays shut (i.e. clean) in a purse, backpack,
     or jeans pocket.

     Contributed by:  Paula Ford                    [email-masked]

2.3.6  Why are so many asthma drugs taken via inhaler?
------------------------------------------------------

     Medications taken orally almost always have a much higher
     systemic concentration (concentration in your entire body)
     than inhaled medications.  So if the side effects are due
     to systemic concentrations, then an inhaled drug is less
     likely to have these side effects, or may have them much
     less severely.

     The idea behind an inhaler is that the full dose is delivered to
     the lungs, where it is immediately absorbed by the lung tissue,
     and starts to take effect locally.  Excess drug may be absorbed
     by the bloodstream and delivered to the rest of your body, but
     this amount tends to be minimal.  So your lungs receive an
     immediate, high concentration of the drug, and the rest of your
     body receives very little.

     If you take the drug orally in tablet or capsule form, then you
     need a much higher dose.  The reason is that for the same amount
     of drug to reach the lungs through the bloodstream, you need the
     same concentration of drug in the rest of your body.  For example,
     most people take one or two puffs of albuterol (Ventolin or
     Proventil) every four to six hours, and each puff is 90 micrograms
     of albuterol.  The usual dosage of Ventolin in tablets is 2-4
     milligrams three or four times a day, which is something like 200
     times the amount inhaled.

     However, one advantage that tablets have is that the medication
     may be available in a time-release format.  So for a short-acting
     medication like albuterol, the inhaled version might need to be
     taken every four to six hours, while a extended-release tablet
     such as Volmax would need to be taken only every twelve hours.

2.3.7  How can I tell when my MDI is empty?
-------------------------------------------

     The float test (in which you take the MDI canister out of the
     mouthpiece and place it in a container of water to see if it
     sinks) is no longer the recommended way to determine whether
     your MDI (metered dose inhaler) is empty.  Glaxo, the
     manufacturer of Ventolin and Beclovent, claims that the float
     test is inaccurate, and recommends that doses be counted instead.
     Other manufacturers agree:  the triamcinolone acetonide (Azmacort)
     package insert recommends dose counting also and the cromolyn
     sodium (Intal) inhaler package insert states that the metal
     cylinder should never be immersed in water.  The number of doses
     per canister should be clearly written on the canister label.

     One variation of dose counting, for medications that are taken
     regularly, is to calculate the date on which the medication will
     be used up, and discard the old canister for a new one on that date.

+    There is also a gadget called The Doser. It fits on top of any MDI, 
     and keeps track of how many doses you've dispensed from the inhaler. 
     It provides daily totals for the past 30 days, and is useful if
     (like me) you tend to forget whether you've taken your maintenance
     inhalers already!  See http://www.doser.com for more information. 
     The Doser is over the counter, but the units can be hard to locate - 
     if a drugstore can get them at all, the pharmacist usually has to 
     special order them.

2.3.8  Are my aerosol inhalers going to disappear?
--------------------------------------------------

As you may know, CFC (chlorofluorocarbon) chemicals, which are used as
propellants in aerosol products including asthma inhalers (MDIs), damage
the ozone layer.  As a result, there has been a worldwide ban on the
production of these chemicals for all but essential uses.

Products which relied on CFCs, such as air conditioning units, 
refrigerators, and most aerosol products, have been modified to use 
alternative chemicals which do not damage the ozone layer.  Due to their 
nature, however, metered dose inhalers have been granted an "essential 
use" exemption to the worldwide ban, which grants the manufacturers an 
extra few years to develop alternatives.

Since the inactive ingredients (i.e., everything but the drug itself) 
must be changed, it's not as simple as using a different chemical for the 
propellant - the new device must go through much the same approval 
process as the original inhaler did, to ensure that the same dosage is 
delivered to the patient, that there are no side effects, that patients 
tolerate the new formulation well, etc.

The FDA has already approved one new non-CFC inhaler, Proventil HFA 
(albuterol), which uses hydrofluoralkane instead of CFC propellants.  
Other non-CFC devices are currently in the works.  It is expected that 
future non-CFC inhalers may be reviewed and approved more quickly than 
the earlier ones.

CFC-based MDIs will continue to be available for some time.  Proposed
guidelines for final phaseout include that there be at least 3 multi-use
(see below) non-CFC devices available in a drug class (i.e.,
bronchodilators, corticosteroids), providing at least 2 different drugs,
before all CFC inhalers in that class are banned.  As an example,
CFC-based bronchodilators would be permitted as long as Proventil HFA is
the only alternative; if Ventolin (also albuterol) and Alupent
(metaproterenol) had non-CFC versions, then all CFC formulations might be
banned. 

The term "multi-use" refers both to aerosol inhalers and multi-use 
dry-powder inhalers such as the diskhaler.  It does not include 
single-use dry-powder inhalers such as the rotahaler, which requires 
insertion of a new capsule of medication with each use.

2.4  What kinds of tablets are there?
-------------------------------------

     CR  - controlled release.  This means that the drug has a
           constant rate of release.
     DR  - delayed release.  This generally refers to enteric-
           coated tablets which are designed to release the drug
           in the intestine where the pH is in the alkaline range.
     ER  - extended release.  Dosage forms which are designed to
           release the drug over an extended period of time, such
           as implants which release the drug over a period of
           months or years.
     SA  - sustained action.  Used interchangeably with CR
           (above), except that SA usually refers to the
           pharmacologic action while CR refers to the drug
           release process.
     TD  - time delayed.  This is slightly different from DR in
           that the drug release is designed to occur after a
           certain period of time, such as pellets coated to a
           certain thickness, multi-layered tablets, tablets
           within a capsule, or double-compressed tablets.

     Contributed by:  Susan Graham                  [email-masked]

2.4.1  Why do I need a blood test when taking theophylline?
-----------------------------------------------------------

     Theophylline is commonly used as a third-line agent in the
     management of asthma, after beta-agonists and anti-inflammatories.
     Unfortunately, its therapeutic level is quite close to its toxic
     level.  This means that the dose that the asthmatic needs to get
     the full benefit of the drug is not very much lower than the dose
     which causes side effects which range from unpleasant to
     dangerous.  This would not be such a problem if there weren't
     such large variations in the rate at which people metabolize
     theophylline.  Apparently, if a group of people are given
     the same dose of theophylline, the concentration of the
     drug in their bloodstreams may vary by up to a factor of
     seven.  Therefore, the best way to monitor that the asthmatic
     is receiving the optimal amount of theophylline is to take
     a blood level concentration.

2.4.2  Why are combination pills not commonly prescribed?
---------------------------------------------------------

     The combination drugs such as Tedral and Marax commonly
     contain theophylline, ephedrine, and some form of sedative
     such as phenobarbital.  These combination pills are no longer
     commonly prescribed because the amount of theophylline in
     the pill cannot be varied with respect to the other drugs.
     Since there is great variation in the rate at which an
     individual metabolizes theophylline, it is now considered
     better to take theophylline separately, for better adjustment
     of theophylline levels.  In fact, Tedral is no longer
     manufactured by Parke-Davis in the U.S.

     Also, ephedrine is no longer considered the bronchodilator
     of choice.  From Drs. Haas, _The Essential Asthma Book_,
     "ephedrine initiates the release of catecholamines -- including
     adrenaline -- that are already stored in the body.  This is
     its biggest drawback.  Its effects depend on the availability
     of catecholamine in the body at the time it is given, and
     these concentrations vary."  Since much better bronchodilators
     are now available, ephedrine is no longer commonly prescribed.

2.5  What is a nebulizer?
-------------------------

     A nebulizer is a device that uses pressurized air to turn a
     liquid medication into a fine mist for inhalation.  If you've
     ever received emergency treatment for asthma, they've probably
     used a nebulizer on you.

     The term nebulizer is often used to describe both the pump
     that pressurizes the air, and the part that holds and
     "nebulizes" the medication.  There are hand-held nebulizer
     units and ones with masks that you strap onto your face.

     The pressurized air typically comes from a portable pump unit
     that internally consists of a motor-driven air pump that
     resembles the fancier types of aquarium pumps.  It forces air
     through a plastic tube into the plastic nebulizer unit.  Inside,
     the nebulizer unit acts much like a perfume atomizer, creating
     a fine mist that is directed either through a tube that you
     inhale through or a mask that directs the mist into your nose
     and mouth.

     Since the nebulizer takes a few minutes to deliver the medication,
     you inhale it over a longer period of time than if you were using
     an inhaler.  This can really help, especially if your passages are
     not fully open and you're taking a bronchodilator.  As you breathe
     the medication, your lungs can gradually accept more and more of
     the medication.  In addition to the medication, many people find
     the accompanying mist (typically a sterile saline solution) to be
     soothing.

     For very young children, the nebulizer is the only practical
     means of administering inhaled medications.  Older children and
     adults have the options of using inhalers and a variety of
     spacers to make the timing a bit easier.  The doctor overseeing
     the treatment decides which is the most effective/appropriate
     delivery mechanism.

     At least in Massachusetts, the nebulizer pump unit, the
     hand-held nebulizers, the medications, and the sterile saline
     inhalation solution are all prescription items.  Replacement
     parts for the pumps are not available to the general public
     (if there are sources, I'd like to hear about them).

     The portable nebulizer pump units cost little ($100-$300)
     relative to the cost of an emergency room visit, so some health
     plans / insurers provide them to patients for times when an
     asthma episode is "manageable but not dangerous." This seems to
     be a trend in the management of pediatric asthma.

     Our family has been able to successfully avoid a few trips to
     the ER, and have even been able to head off some more severe
     allergic asthma episodes with early intervention.  After a few
     rather gruesome visits to the Mass. General Hospital's waiting
     room on a Saturday night, we welcome opportunity to treat our
     children at home, when it's safe.  We tend to go in to the doctor
     or ER for the more severe episodes or those that don't respond
     well enough to early intervention.

     Contributed by:  Mark Feblowitz                [email-masked]

2.6  What medications should asthmatics be careful about taking?
----------------------------------------------------------------

     Aspirin can trigger an asthma attack in approximately one in
     five asthmatics.  This is especially common in those asthmatics
     who also have nasal polyps.  As acetominophen (Tylenol), also
     known as paracetamol overseas, doesn't have this effect, it may
     be used as an alternative for anyone who suspects that they might
     have aspirin sensitivity.

     Cough medicines should also be treated with caution.  In general,
     suppressing a productive cough (one which is bringing up mucus)
     is not a good idea, since the mucus can obstruct the airways
     and also irritate them further.  Also, in _Asthma:  Stop
     Suffering, Start Living_, the authors caution that "prescription
     cough suppressants (including those with codeine) are potentially
     dangerous for asthmatics.  They may make you sleepy and reduce
     your breathing effort.  They may also dry out your secretions,
     making mucus harder to raise."

     Antihistamines, however, should not pose a problem for most
     asthmatics, in spite of many warning labels.  In _Children with
     Asthma_, Dr. Plaut states, "Most asthma experts see no problems
     with using antihistamines between or during asthmatics . . .
     Theoretically these drugs might dry up the mucus in the
     windpipes, thus making it harder to cough it up, but this has
     never been proved."

     Asthmatics taking theophylline should be careful when taking any
     of the following medications:  the ulcer medications cimetidine
     (Tagamet) and troleandomycin (TAO), beta-blocker drugs such as
     propranolol, and the antibiotics erythromycin and ciprofloxacin.
     These medications may increase the concentration of theophylline
     in the bloodstream, possibly even to the toxic level (see
     section 2.4.1).  People taking theophylline should be alert for
     signs of possible toxicity such as rapid or irregular heartrate,
     nervousness, or nausea, when taking these medications.  In fact,
     asthmatics taking theophylline should check with their physician
     before taking any OTC medication, as the list of drugs, including
     antihistamines, which affect theophylline levels is almost
     endless.

     Beta-blockers, usually taken for hypertension, can pose problems
     even for those asthmatics not taking theophylline.  Beta-blockers
     work by blocking the hormone adrenalin, but as adrenalin and
     other adrenergic drugs help keep airways dilated, the use of
     beta-blockers may aggravate asthma symptoms.

2.6.1  What about corticosteroids and chicken pox?
--------------------------------------------------

     According to the pamphlet "Advice from your Allergist", published
     by the American College of Allergy & Immunology, children taking
     oral or injected corticosteroids may be at increased risk of
     complications from chicken pox.  Such children should avoid
     exposure to chicken pox -- if the child has been exposed, their
     physician should be notified.  However, the child's medications
     shouldn't be changed without advice from their physician, since
     corticosteroid therapy should not be stopped abruptly.

     Children taking inhaled corticosteroids are not at this increased
     risk, according to the pamphlet, since the system concentrations
     of the medication are so small.

======================================================================

3.0  What resources are there for asthmatics?
---------------------------------------------

     Please see the alt.support.asthma Reading/Resource List.  It
     is maintained by Lynn Short <[email-masked]>, and is
     posted periodically to alt.support.asthma, alt.med.allergy,
     sci.med, and misc.kids.  I highly recommend it!

     I also strongly recommend the following guidelines:  the
     "Global Initiative for Asthma", the "NHLBI Executive Summary:
     Guidelines for the Diagnosis and Management of Asthma", and
     the "Executive Summary:  Management of Asthma during Pregnancy"
     (full citations in References section).  They may be ordered
     in the U.S. by calling (301) 251-1222 and asking for publication
     numbers 95-3659, 94-3042A, and 93-3279A, respectively.  When I
     ordered them, and asked that they be sent to a US address, there
     was no charge.

     Another set of guidelines which has been recommended to me but
     which I haven't seen myself yet is "NAEPP.  Nurses:  Partners
     in Asthma Care", publication number 95-3308, which I assume is
     also available at the number given above.

     The newsgroup misc.kids also has an allergy and asthma FAQ,
     which is available either by following the instructions
     posted on misc.kids.info, or by accessing the World Wide Web,
     <URL: http://www.cs.unc.edu/~kupstas/FAQ.html>.

     In addition, I maintain an Asthma and Allergy WWW Resources Page,
     <URL: http://www.cco.caltech.edu/~wrean/resources.html>, and
     two FAQs on allergies.  For information on how to access these
     allergy FAQs, please see section 3.1.

3.1  Where can I get the latest copy of the FAQs?
-------------------------------------------------

     The two asthma FAQs I maintain,
          alt.support.asthma FAQ:  Asthma -- General Information
          alt.support.asthma FAQ:  Asthma Medications
     are posted once a month, on or about the 17th, to the following
     newsgroups:  alt.support.asthma, alt.med.allergy, sci.med,
     alt.answers, sci.answers, and news.answers.

     If these FAQs have already expired at your site, you can get
     them by sending mail to [email-masked], with a blank
     subject line, and with one or more of the following commands
     in the message:

          send usenet/news.answers/medicine/asthma/general-info
          send usenet/news.answers/medicine/asthma/medications

     Alternatively, if you're really in a hurry, you can get them via
     anonymous ftp from rtfm.mit.edu, with the path names:

          /pub/usenet/news.answers/medicine/asthma/general-info
          /pub/usenet/news.answers/medicine/asthma/medications

     The general information FAQ is also available in html format on
     the World Wide Web, at
     <URL: http://www.radix.net/~mwg/asthma-gen.html>; a plaintext 
     version of the FAQ is at http://www.radix.net/~mwg/asthma-gen.txt.

     Of the two allergy FAQs I maintain,
          alt.support.asthma FAQ:  Allergies -- General Information
          alt.support.asthma FAQ:  Allergy Medications
     the first is still under construction.  The second is posted
     monthly to the following newsgroups: alt.support.asthma, 
     alt.med.allergy, sci.med, alt.answers, sci.answers, and news.answers.

     If the allergy medication FAQ has already expired at your site, you
     can get it by sending mail to [email-masked], with a blank
     subject line, and with the following command in the message:

          send usenet/news.answers/medicine/allergy/medications

     Alternatively, if you're really in a hurry, you can get it via
     anonymous ftp from rtfm.mit.edu, with the path name:

          /pub/usenet/news.answers/medicine/allergy/medications

3.2  What is an FAQ, anyway?  What is a Usenet newsgroup?
---------------------------------------------------------

     The term FAQ is an acronym which stands for Frequently Asked
     Questions.  Often the term is also used for any document, such
     as this one, which attempts to answer questions which are
     frequently posted to a specific Usenet newsgroup.  For example,
     this is one of the three alt.support.asthma FAQs which attempt
     to answer questions frequently posted to the newsgroup
     alt.support.asthma.

     A newsgroup is a world-wide electronic forum of discussion which
     generally takes place over the Internet, each newsgroup having
     its own topic of discussion.  For more information about FAQs and
     newsgroups in general, I recommend any of the periodical postings
     in the newsgroup news.announce.newusers, particularly
     "FAQs about FAQs" and "What is Usenet?"  These last two may also
     be accessed by sending mail to [email-masked], with a
     blank subject line, and with one or both of the following commands
     in the message:

          send usenet/news.answers/faqs/about-faqs
          send usenet/news.answers/usenet/what-is/part1

     Alternatively, if you're really in a hurry, you can get them via
     anonymous ftp from rtfm.mit.edu, with the path names:

          /pub/usenet/news.answers/faqs/about-faqs
          /pub/usenet/news.answers/usenet/what-is/part1

+3.3  How about some other WWW links?
---------------------------------------------------------
     The original Asthma Resources page that Pat maintained is temporarily
     unavailable. In the meantime, I'm compiling a list of a few 
     sites whose URLs I have handy. As with any website, these are
     not intended to substitute for competent medical advice, nor
     do I vouch for the currency or accuracy of information on these
     sites.

          http://asthma.about.com
          http://www.virtualdrugstore.com
          http://www.cs.unc.edu/~kupstas/FAQ.html
          http://nationaljewish.org
          http://www.vh.org/Providers/ClinGuide/AsthmaIM/staging/chronic/classif.html
          http://www.pslgroup.com      
          http://www.srs.org.uk
          http://www.gpiag-asthma.org/asthma/GPIAG/welcome.htm
          http://www.nhlbi.nih.gov/index.htm
          http://www.nhlbisupport.com/asthma/index.html

======================================================================

List of Contributors:
---------------------

  Kevin Ball                                        [email-masked]
  Betty Bridges                                    [email-masked]
  Mark Delany                              [email-masked]
  Mark Feblowitz                                    [email-masked]
  Bill Ellis Fleenor                              [email-masked]
  Paula Ford                                        [email-masked]
  Lyn Frumkin, M.D., Ph.D.                     [email-masked]
  Joe Gems                                              [email-masked]
  Susan Graham                                      [email-masked]
  Gwenith Jones                                     [email-masked]
  Philip D. Mayo, M.D., FCCP                     [email-masked]
  Judith B. Paquet, R.N.                                [email-masked]

======================================================================

References:
----------

The Physicians' Desk Reference is published annually by:
     Medical Economics Data Production Company
     Montvale, NJ 07645-1742
     ISBN 1-56363-061-3
     It is a compendium of official, FDA-approved prescription
     drug labeling.  The FDA is the U.S. Food and Drug Administration.

The Compendium of Pharmaceuticals and Specialties is published
     annually by:
     Canadian Pharmaceutical Association
     Ottawa, Ontario, Canada  K1G 3Y6
     ISBN 0-919115-94-2

Robert Berkow, M.D., editor in chief, _The Merck Manual of Diagnosis
     and Therapy_, 15th ed., (Merck & Co., Inc., USA) 1987.
     ISBN 0911910-06-09
     The Merck Manual provides an overview of the diagnosis and
     therapy of the whole range of medical disorders that can occur
     in infants, children, and adults.  I am told that the 16th
     edition is now available, with ISBN 0911910-16-6, and that
     the 17th edition should be available sometime in 1997.

"Global Initiative for Asthma:  Global strategy for Asthma Management
     and Prevention.  NHLBI/WHO Workshop Report.  March 1993",
     National Institutes of Health/NHLBI, Publication No. 95-3659,
     January 1995.

     These are often called the "GINA Guidelines".

National Asthma Education Program Expert Panel Report, "Executive
     Summary:  Guidelines for the Diagnosis and Management of Asthma",
     U.S. Department of Health and Human Services, Public Health
     Service, National Institutes of Health, Publication No. 94-3042A,
     Reprinted July 1994.

     Often called the "NHLBI Guidelines", this is a summary of the
     current wisdom on asthma treatment and prevention for physicians.
     I found it very readable.

     The above report, written in 1991, has now been superseded by:

  National Asthma Education and Prevention Program Expert Panel Report 2:
     Guidelines for the Diagnosis and Management of Asthma (revised 
     6/18/97)

     This report provides clinicians with recommendations for the
     diagnosis and management of asthma.  These recommendations are
     organized into four components of therapy: measures of assessment
     and monitoring, control of factors contributing to asthma severity,
     pharmacologic therapy, and education for a partnership in asthma care.
     The recommendations are an update of the 1991 Expert Panel Report.
 
     The report can be accessed directly from 
        http://www.ama-assn.org/special/asthma/treatmnt
            /guide/guidelin/guidelin.htm

Report of the Working Group on Asthma and Pregnancy, "Executive
     Summary:  Managment of Asthma during Pregnancy", National
     Institutes of Health/NHLBI, Publication No. 93-3279A, March 1993.

The American College of Allergy & Immunology, (ACAI), publishes a
     pamphlet titled "Advice from your Allergist."  It may be
     ordered from:

     ACAI
     85 West Algonquin Road, Suite 550
     Arlington Heights, IL  60005
     (708) 427-1200

+ Michael R. Freedman, Samuel J. Rosenberg, Cynthia L. Divino
     Living Well With Asthma (Guilford Press, USA) 1998.
     ISBN 1572303182 hardback, 1572300515 paperback
     The authors are former associates of National Jewish
     Medical and Research Center.

M. Eric Gershwin, M.D., and E.L. Klingelhofer, Ph.D., _Asthma:
     Stop Suffering, Start Living_, 2nd ed.,  (Addison-Wesley, USA) 1986.
     ISBN 0-201-60847-2
     The first author is Chief of Allergy and Immunology, University
     of California, Davis, Medical School.  He is board-certified
     in internal medicine, allergy, and clinical immunology.

Drs. Francois Haas and Sheila Sperber Haas, _The Essential Asthma
     Book_, (Ballentine Books, USA) 1987.
     ISBN 0-8041-0287-2
     Dr. Francois Haas is the director of the Pulmonary Function
     Laboratory at the Medical Center of the New York University
     School of Medicine, and is on the faculty of the Department
     of Physiology there.

Paul J. Hannaway, M.D.  _The Asthma Self Help Book:  how to live a
     normal life in spite of your condition_, 2nd ed., (Prima
     Publishing, USA) 1992.
     ISBN 1-55958-166-2, 1-55958-434-3 paperback
     The author is Assistant Clinical Professor of Tufts University
     School of Medicine.  The first edition of this book won an
     American Medical Writers Association Award.

Glennon H. Paul, M.D. and Barbara A. Fafoglia, _All About Asthma
     & How to Live with It:  the complete guide to understanding and
     controlling asthma_, (Sterling Publishing Co., NY, USA) 1988.
     ISBN 0-8069-6808-7, 0-8069-6809-5 paperback
     Dr. Paul is the medical director of respiratory therapy at
     St. John's Hospital in Springfield, Illinois, and specializes
     in allergy and respiratory diseases.

Thomas F. Plaut, _Children with Asthma -- A Manual for Parents_,
     (Pedipress, Inc., Amherst, Massachusetts, USA) 2nd edition 1995.
     ISBN 0-914625-03-9

Richard N. Podell, M.D. and William Proctor, _When Your Doctor Doesn't
     Know Best:  medical mistakes that even the best doctors make --
     and how to protect yourself_, (Simon & Schuster, USA) 1995.
     ISBN 0-671-87112-9

Nancy Sander, _A Parent's Guide to Asthma_, (Doubleday, USA) 1989.
     ISBN 0-385-24478-9
     The author is the founder of Mothers of Asthmatics.

Genell Subak-Sharpe, _Breathing Easy -- A Handbook for Asthmatics_,
     (Doubleday, NY, USA) 1988.
     ISBN 0-385-23440-6
     This book was written in consultation with the National Jewish
     Center for Immunology and Respiratory Medicine.

Allan M. Weinstein, M.D., _Asthma - The Complete Guide to Self-
     Management of Asthma and Allergies for Patients and their
     Families_, (Fawcett Crest, NY, USA) 1987.
     ISBN 0-449-21562-8
     The author is Assistant Clinical Professor of Medicine at
     Georgetown University, and is a board-certified allergist who
     practices in Washington, D.C.

Stuart H. Young, M.D. with Susan A. Shulman and Martin D. Shulman,
     _The Asthma Handbook -- A Complete Guide for Patients and Their
     Families_, (Bantam Books, USA) 1985.
     ISBN 0-553-24797-2
     Dr. Young is the Chief of Allergy Clinics in both the Department
     of Medicine and Department of Pediatrics at the Mount Sinai
     Medical Center.  He is also a clinical assistant professor of
     Medicine and a clinical associate professor of Pediatrics at the
     Mount Sinai Medical School.

  Francis V. Adams, MD, _The Asthma Sourcebook_ (Lowell House, Los Angeles
     CA) 1996
     ISBN 1-56565-471-471-4
     Dr. Adams is an award-winning pulmonary specialist in the field of
     asthma.  He is currently Assistant Professor of Clinical Medicine at 
     New York University and Attending Physician at Bellevue Hospital in 
     New York.

The following citations were used in compiling the 
			Occupational Asthma section:
     O'Neil, CE:  Review: Mechanisms of Occupational Airways Diseases 
     Induced by Exposures to Organic and Inorganic Chemicals. Am j Med Sci 
     1990; 299(4) 265-275

     Bernstein, DI: Respiratory Sensitization to Chemical Allergens.  
     Masters in Allergy Vol 1, (1) 17-21

     Grammer, LC: Occupational Asthma. Immunology and Allergy Clinics 
     of North America Vol 13 (4) Nov 1993 769-783

     Chan-Yeung, M: A Clinician's Approach to Determine the Diagnosis,
     Prognosis, and Therapy of Occupational Asthma. Medical Clinics of 
     North America Vol 74 (3) May 1990 811-822

======================================================================

Disclaimer:  I am not a physician; I am only a reasonably
             well-informed asthmatic.  This information is for
             educational purposes only, and should be used only as
             a supplement to, not a substitute for, professional
             medical advice.

Copyright 1996 by Patricia Wrean, 1997-2000 by Marie Goldenberg.  Permission is
given to freely copy or distribute this FAQ provided that it is
distributed in full without modification, and that such distribution is
not intended for profit.