Asthma: Diagnosis and Management ____________________________________________________________
As noted, the NAEPP updated guidelines include recommenda- tions for the assessment of environmental factors during any stage of asthma management, to provide applicable patient education and manage comorbidities. For example, [9; 10]: • In individuals with sensitization (or symptoms) related to exposure to pests: Conditionally recommend integrated pest management as a single or multicomponent allergen-specific mitigation intervention • In individuals with sensitization (or symptoms) related to exposure to identified indoor allergens: Conditionally recommend a multi-component allergen-specific mitigation strategy • In individuals with sensitization (or symptoms) related to exposure to dust mites: Conditionally recommend impermeable pillow/mattress covers only as part of a multicomponent allergen-specific mitigation intervention, but not as a single component intervention Mold Except in very dry climates, mold spores are the predominant particulate in the air. In the United Kingdom, a relatively damp country where molds flourish, the record count is more than 160,000 spores/m 3 , compared to a record pollen count of only 2,800 grains/m 3 . The size of most mold spores is between 2 and 10 microns, but a few species have spores that are smaller than 2 microns [8; 47; 64]. Molds and fungi reproduce through the release of spores. Often, healthcare providers will refer to mold allergies sin- gularly, because molds are the most common offenders, but layer fungi, including mushrooms and toadstools, also produce allergenic spores. There are different species of mold in differ- ent environments, and these species can grow in a very wide range of situations, including indoors. A sensitive individual may have cross-reactions between some molds, meaning that a sensitive individual will react to a variety of mold species [8; 47; 64]. One mold allergy in particular has a risk of severe reaction. During the spore-producing season, healthcare professionals should consider increasing the dose of preventive inhaler medications for individuals with asthma who also have allergy to the mold Alternaria . Research shows that severe, near-fatal asthma attacks often occur during the Alternaria spore season among those allergic to this mold. These individuals may also be referred to a local pollen/spore monitoring service. Alternaria spore release usually occurs in the summer or fall, although timing varies from one part of the world to another. Alternaria may colonize outdoors, in soil, seeds, or plants, or indoors, in window frames, carpets, or textiles [8; 47; 64].
Mold-sensitive individuals with asthma should be advised to avoid the following places as much as possible; if avoidance is not possible, the use of HEPA facemasks is recommended when patients are in these environments [8; 47; 64]: • Fields of cereal crops in late summer, due to molds that may be present on the leaves. Symptoms are most exacerbated at harvest time, when the harvesting process results in the dispersal of spores. • Forests and old orchards • Gardens with compost piles or piles of dead leaves • Greenhouses • Springs, waterfalls, or any damp, shady places Healthcare professionals should note that mold-sensitive individuals, just as those with pollen allergy or sensitivity, often experience more frequent or intense asthma symptoms during certain times of the year. Increased symptoms during late summer and autumn, when molds flourish outdoors, or following the first frost, which prompts spore release by fungi living in the soil, may indicate a mold allergy. Patients with asthma should be advised to avoid disturbing compost piles, damp straw or hay, piles of grass clippings, or heaps of fallen leaves, all of which are likely to be full of molds. These same patients should not collect fallen leaves or fruit, remove dead leaves or flowers from plants, or water gardens because mold spores are released when water hits dry soil [8; 47; 64]. Indoor molds and the indoor conditions that promote mold growth can be difficult to endure for mold-sensitive patients. Sensitive patients should be advised to avoid the following places, wear a mask while in these areas, or correct the problem areas at their source [8; 47; 64]: • Buildings that are damp or display mold infestation • Houses with central evaporative cooling systems (i.e., “swamp coolers”) • Buildings built in damp environments, near lakes, rivers, or the ocean • Rooms with humidifiers • Bathrooms and shower rooms, unless the rooms are well ventilated • Buildings with dry rot, although not all mold- sensitive individuals react to the spores of these timber-rotting fungi • Buildings where central heating has recently been installed • Buildings with many indoor plants • Cellars and basements
• Sun rooms, unless well-maintained • Antique shops and vacation homes • Farms or mills • Portable school classrooms
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