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					It is though by some people that up to 20% -- 1 out of 5 -- people in the United States
suffer from some sort of respiratory allergy. (I heard this estimate from an allergist, mind
you... but the number of patients I see with respiratory allergies is pretty high, so he may
very well be right.) Although the most common -- and most infamous -- respiratory
allergen is ragweed pollen, which is responsible for hay fever, there are thousands of
other allergens floating around in the air we breathe, and many people are susceptible to
more than one. (I myself am allergic to 42 different airborne allergens -- and that's out of
only 46 to which I was tested for reactions.)

There are things we can do about allergic rhinitis, though. Although you may not think so
if you have had it long enough, there are many different treatments available for hay
fever and other respiratory allergies, and if you have been suffering for a long time, you
might want to ask your doctor about some of the newer therapies available.

What is Allergic Rhinitis?

Allergic rhinitis, unlike viral rhinitis (the common cold), is caused by allergic reactions of
the mucous membranes in your nose and airway to substances in the air.

The mucous membranes in your nose and throat -- and throughout your respiratory tract,
all the way down to your lungs -- contain cells that produce mucus (which helps trap
small particles of foreign matter so that it can be swept out of the body), as well as cells
with cilia (small hairs that do the actual sweeping). These cells can be made to work
harder by certain antibodies, known collectively as immunoglobulin E or IgE, and by
chemicals such as histamine which are released by immune-system cells when they are
stimulated by allergens. Exposure to allergens eventually results in increased mucus
production, edema (swelling) of the mucous membranes, itching, and sneezing; some of
this reaction is almost immediate, while other parts of the reaction occur as late as 2-8
hours after you run into the allergen.

Note that you actually have to be allergic to something before these reactions happen.
Allergy to a substance is a kind of immune reaction, and, as with viral and bacterial
immunity, you need to be exposed to the allergen before you start having immune
reactions. It's quite unusual for very small children (less than 1 year old) to have
respiratory allergies, simply because they haven't been exposed to the allergens long
enough to become immune/allergic to them. If you are prone to allergies, you tend to be
allergic to more things as you grow older because you have been exposed to more things
for more time. (Like me: I had no allergy problems until I was almost 20. And then the
faucet opened... ) However, many children with respiratory allergies grow out of then as
they grow older.

The allergens that can cause allergic rhinitis are many and varied. The notorious ones are
from plants whose pollens are airborne: these include many weeds, including ragweed
(which is the specific trigger for classic "hay fever"), many trees, and many grasses.
Molds are also capable of triggering allergic rhinitis: a moldy basement or bathroom can
make you miserable, but so can outdoor molds. Animal dander (usually cats and dogs,
but also many other animals) can trigger runny noses and sneezing as well, and dust mites
(microscopic insects which live in bedding and carpet and feed on the microscopic skin
cells we normally shed) are a major allergic trigger for many people.

The specific offenders vary by season: weeds are usually a problem from late summer to
the first hard frost, grasses usually pollinate in the late spring and early summer, while
trees pollinate in the spring and outdoor molds are largely a late winter/early spring
problem. This is, of course, weather-dependent: in near-tropical areas (such as the
southern United States) pollens may present an allergy problem year-round, and this past
winter -- which wasn't much of a winter, as far as cold weather was concerned -- molds
were a constant source of irritation to many of us.

Symptoms of Respiratory Allergies

The classic symptoms of hay fever are sneezing, runny nose (usually the nasal discharge
is clear and thin or watery -- this is as much from fluid discharge from the edematous
mucous membranes as from the mucus itself), nasal stuffiness, and nasal itching. You
may also breathe noisily (often through your mouth because of all the congestion in your
nose), cough or clear your throat (to help remove all the mucus and fluid, either from
your nose or "swept up" by the cilia in your lower airways), snore, or lose your sense of
smell. Your eyes may be red and itchy, and you may have dark circles under your eyes
("allergic shiners" -- these look like "black eyes", but are caused by blocked blood flow
in the tissue below the eye which in turn is caused by all the congestion and swelling).
Small children may make the "allergic salute", in which they rub their nose upward with
their palm. They do this partly because of the itching, but pushing the nose up also briefly
relieves the nasal congestion. Nose picking is also quite common in allergies (sometimes
the mucus in the nose is so thick and hard once it starts to dry that you have to pull some
of it out to breathe more easily), and so are nosebleeds (often from the nose picking, but
it may also be connected to the congestion).

Treatment of Respiratory Allergies

In the last 10-15 years we have started using many new treatments for hay fever and other
forms of allergic rhinitis, and for those of us who have it life during the "season" has
become much more tolerable. (Believe me -- I have tried all of the treatments I describe
here on myself, and last summer, for the first time in over 20 years, I didn't notice when
hay fever season opened. You may not get such results yourself, but if you have hay fever
or other seasonal allergies, you should talk to your doctor about different treatment
options. Most people do not have to suffer during the season.)

Antihistamines

Antihistamines are medicines that block the effect of histamine. Since histamine is the
major chemical agent in allergic reactions, this often provides relief.
Antihistamines have been around for a long time. Unfortunately, the older antihistamines
also affect one's brain, making you very sleepy. In fact, diphenhydramine (Benadryl®), a
very potent antihistamine, is so sedating that it is also sold as an over-the-counter
sleeping pill. Because of this sedative effect, you should NEVER take the older
antihistamines when driving or using machinery, and you should never take the older
antihistamines with any other medicine -- or anything else (including alcohol!) -- that
may also cause sedation, unless your doctor specifically tells you to do so. (A General
Rule: never mix drugs for any reason, unless your doctor tells you that you need to mix
them and can mix them safely.)

There are newer antihistamines available that do not sedate you nearly as well as the
older agents. In fact, they rarely sedate people at all -- although you should still be careful
about driving and machinery until you and your doctor know that the particular medicine
you're taking will not sedate you. The first of these medicines on the market had some
hazardous interactions with other drugs (notably certain antibiotics), but the two most
commonly used non-sedating antihistamines, loratidine and cetirizine, have not yet been
reported to be a problem in combination with any other medicine (although, as Another
General Rule, you should always tell your doctor about every medicine you are taking,
even the over-the-counter medicines, so that you and your doctor can be sure that there
won't be any hazardous interactions.)

Steroids

Steroids, which are hormones normally produced by your body, help regulate many
bodily functions including inflammation. Giving extra steroids for a short period of time
may help reduce inflammation; in particular, steroids can help open an asthmatic patient's
airways by reducing the inflammation in the airway walls. Other steroid hormones help
regulate such things as reproduction, blood pressure, and mineral balances (like sodium
and potassium, which are crucial to many important functions) as well as body
development and growth.

Steroids have their drawbacks. Your body must make steroids all the time for many
processes to work right. If you take steroids for too long, your steroid-making system will
think it's not needed any more and shut down, and if you then face a situation where you
need the steroids (any kind of stress, including surgery) all sorts of things can go wrong --
like your blood pressure, to take one example.

We can use oral steroids to relieve allergic rhinitis. However, we try not to do so unless
someone is really miserable. Unlike, for example, asthma (which can be life-threatening),
allergic rhinitis will make you miserable but does not endanger you. However, we can
give steroids as nasal sprays; when sprayed into the nose these steroids work on and in
the nose and upper airway without being absorbed by the rest of the body. (Usually the
nasal steroids are ones that are broken down immediately by your digestive system, so
they can't be absorbed by the body.) We haven't yet seen firm evidence of side effects if
you use nasal steroids for a long time (but that doesn't mean that there are none). I use
nasal steroids on myself mainly before and during the ragweed-pollen season, when my
allergies are at their worst.

Mast Cell Stabilizers

The mast cells are part of the lining of the air passages; they are part of your immune
system, reacting immediately to allergens and other obnoxious stimuli. The mast cells
release many different substances when they are stimulated, including histamine.

Cromolyn is a drug that "stabilizes" airway mast cells, making them less prone to
releasing histamine and other substances in response to allergens. Because of this,
cromolyn sprayed into the nose regularly helps to prevent the nasal inflammation and
runny nose of allergic rhinitis. It does not relieve the congestion and drainage
immediately. It only helps prevent them -- and it works best if and only if you use it
regularly, and if you start using it well before (like 2-4 weeks before) the beginning of the
season for your particular allergens.

Immunotherapy (Allergy Shots)

For some patients it is possible to reduce the allergic response to some allergens by
repeatedly injecting low doses of those allergens. This seems to block the allergic
response, although we are not yet quite certain exactly how the shots work. Allergy shots
work best for patients who are sensitive to airborne allergens (they help people with
allergic rhinitis, and can be helpful to some people with asthma), and can also help
reduce sensitivity to certain stinging insects. The drawback to shots is the time
investment and cost involved (you may need one or two shots per week at the beginning,
although once you have been on them for a while you can come down to one shot per
month), and the risk (small, but not negligible) of a life-threatening anaphylactic reaction
to the extract. When they work, though, they work quite well.

Prevention of Allergic Rhinitis

You can reduce your allergy symptoms best just by avoiding exposure to the allergens
you are sensitive to. Sometimes, though, this is easier said than done.

Allergens in your house are the easiest to avoid, since you have some control over your
own environment. Dust mites, for example, live in dust (hence their name) as well as in
bedding. If you are allergic to dust mites, consider these measures:

      If your house (and especially your bedroom) is cluttered, cut down on the clutter.
       The more dust, the more dust mites.
      If parts of your house are damp, look into a dehumidifier. Not only will lower
       humidity reduce molds, but it will also reduce dust mites (which can't survive in a
       dry environment).
      Wash your bedding (bedspread, comforter, blankets, sheets, and mattress pad)
       once every 1-2 weeks -- in HOT water. This will kill any dust mites living in the
       bedding. (Warm water won't kill them.) If you can wash your pillows, do so as
       well (again, in hot water). Cover your mattress and boxspring with covers which
       will trap the dust mites and their "byproducts" (which are the actual allergens),
       and cover your pillows as well if they are not washable. (Plastic covers will trap
       the mites, but are very uncomfortable to sleep on. There are several companies
       that make covers for mattresses and pillows that let air pass but trap mites; your
       doctor may be able to give you the names of sources for these covers.)
      Keep pets out of the bedroom -- or out of the house if need be.
      If you and your family have severe respiratory allergies, you may want to invest
       in a HEPA (high-efficiency particulate) filter, or an electrostatic air cleaner, for
       your forced-air furnace or air conditioner. These devices will remove even
       microscopic allergens from the air circulating in your house.
      Do not allow smoking anywhere in your house. Tobacco smoke is a potent --
       and completely avoidable -- irritant, and makes allergic reactions much worse.

Outdoor allergens are harder to control, of course. You can cut down on some of them in
your vicinity, though, especially outdoor molds, by avoiding dead organic material (such
as wood chips) in your garden -- but this may not help much if there are large
accumulations of organic material (such as a forest) nearby.

				
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