 Hi, I'm Dr. Devendra Kundra, pulmonologist at Manipal Hospital, Dwaraka. So today I'm going to speak on respiratory allergies and Dr. Puneet Fendham would join me as a moderator. So let's begin with the topic respiratory allergies. So as the weather is in transition phase and the environment pollutants are increasing and after lockdown has removed the industrial work has increased, manufacturing the factories and industries have increased so the pollution is increasing and the people who are prone to have allergies they have started developing symptoms of allergies. So before going to the topic directly I would like to tell you what is allergy. So the basic concept of the allergy is it is actually a hypersensitivity response to something this something is allergic to which the individual has been exposed, maybe the individual has been exposed previously or currently has been exposed and has developed the allergy. So actually it is a hypersensitivity response. The only thing these allergens, what are these allergens, anything which causes allergy is allergic. It is actually an antigen that causes allergic symptoms. The symptoms can present in a various form and usually like whenever somebody is exposed to an allergy present in different forms one is like an anaphylactic reaction which can be a very dangerous situation and with allergic reaction occur without any protection and that is a very severe allergic reaction requiring immediate treatment for the patient and secondly sometimes you know in the form of angioedema it is actually a non-inflammatory edema involving skin or maybe airways mainly the larynx causing edema of the larynx and causing airway obstruction leading to the breathlessness and the third is it can appear as a atopy which is actually a hypersensitivity disease that the subject have to because of the hereditary influences. So atopy itself is you know it is a genetic predisposition to have allergies. So in the family you know in some patients it has been a history of atopy which carry on the nation to generation. And another one form of the allergy is like artychiria which involves the skin actually. It is a vascular reaction of the skin marked by the elevated pale skin patches with severe aging like if someone is exposed to some allergens the skin has come into the contact of that allergen and you know there is a itching all over the skin, redish or pale elevated skin lesions appear so this also one of the form in which allergy appear. So but as allergies can be triggered by something we eat something we touch but I would like to tell you all allergies are not same and so basically my topic is the respiratory allergy which is absolutely you know I would say that to the different form present. It is triggered by something we inhale and respiratory allergies refer mainly refer to the allergic reaction that are triggered by any substance that is inhaled and causes a problem throughout the respiratory tract. The respiratory tracts which start from the nose to the base of the lungs like the nasal cavity, sinuses, throat and earwax in the lungs. So as I said the allergens are the key factor for developing the allergy here also in the respiratory allergy these are the key factors for developing the allergic inflammation in both the upper earwax as well as the lower earwax with different intensity and the clinical spectrum of these allergic respiratory allergies as I said like allergic rhinitis, one of the common respiratory allergies like asthma and some patient you know conjunctivitis can involve the eyes so my talk would be centered around the asthma and allergic rhinitis that we will discuss later on and as there is a concept that one earway and one disease means whichever the allergy involves the upper earway so now later it involves the lower earways also and it present as a one disease. So unified assessment of the earway is necessary because of this one earway one disease concept irrespective of whether symptoms of the asthma are there or the symptoms of line of conjunctivitis are present. So as I said the allergic reaction they are the four types of the allergic reaction type 1, 2, 3, 4 and the 1, 2, 3 they are the comparative you know related kind of respiratory allergies and the type one is it is an antigen antibody radiative allergy which is more like the skin contact because of the legend come into the contact of the skin causing the aortic area and the type 2 where there is an anti membrane antibodies are present so it leads to the hemolysis type 3 we have heard of the serum sickness because this is it is immune complex mediated one and the type 4 which is a cell mediated delayed type of a cell allergy like the contact dermatitis. So as I said the clinical presentation whenever someone is who is prone to have allergy exposed to the allergy so what kind of the presentation that person may have depends on the or the affected if the skin is affected then the skin reaction would have occurred otherwise you know even the cardiovascular reactions if cardiovascular system is involved like the anaphylactic reactions it may lead to the life-threatening situation respiratory system involved and the breathlessness, mucus production and many more problems occur with the respiratory system involvement if eye is involved, dryness of the eye, itching in the eyes, water area is just to understand and track may more which lead to you know the eye area being absorbent vomiting also and sometimes a generalize anaphylaxis. So as I said the skin reactions contact dermatitis then the drug erections and drug erections occur like the aortic area, edema, angioedema and the respiratory if I talk about the respiratory reactions then the rhinitis, leningoedema, bronchospasm, mucous production, breathlessness, whistle sound coming from the chest which is known as a V's and the cardiovascular manifestation in which patient might have palpitation, tachycardia, abnormal rhythm of the heart and the patient may have low BP, high potential, patient may become you know unconscious, need immediate support and because indeed to the anaphylactic shock which is a fatal condition. Now here is the overview but so I have spoken so far like the manifestation of allergy in one of the various organ, you can see like the respiratory tract, skin saying corduobus cooler, system generalized skin eruptions or maybe allergy just in one of the localized part. So as I said my talk will be centered on the asthma and the allergic rhinitis and these are the commonest respiratory allergies problems. So the brief and asthma is just I will tell you asthma is a chronic inflammatory condition in which patient usually present with breathlessness and shortness of breath along with the V's, patient may complain of the chest tightness and curve. Well, these symptoms are variable in the intensity and whenever we check their air flow, it is a air flow limitation which is also variable and those are but the thing is that the asthma is a period where the patient remains symptom free. It is actually intermittent disease, it is not a persistent disease. So whenever patient has allergy and during that time the patient may have all those asthma symptoms and in between whenever the patient is set up and then there will be no symptoms of the asthma. And this rhinitis is also allergic condition as it is inflammation of the lining in the nose and the nasal passage. So how it presents is marked by the sneezing, congestion of the nose, very nose, itchiness and the respiratory allergies can also cause watery eyes along with the itchiness and swelling. And these symptoms can seem similar to the common cold as in the common cold, the itching in the eyes, the nose, congestion in the nose and the nose and the drip is there. So all these the manifestation of the allergic and initis and another thing these manifestation increase the risk of developing the bronchial asthma in the future. So as I told you in the beginning that we take Aspiratory Allergy as a concept of one ear break, one disease. So person who is having allergic rhinitis, those people are always prone to have asthma later in their life. So how do we diagnose Aspiratory Allergy actually? You know, bronchial Aspiratory Allergy is diagnosed based on the clinical history. We always ask for the history, what are the symptoms of the patients, whether the symptoms are intermittent per system, is there any specific time period or specific weather, anything the patient knows that they are on exposure to that particular thing, patient develops symptoms. So the clinical history always helps in making the diagnosis and physical examination with some specific tests also they help in consolidating the diagnosis. So basically we get our lung function test done in the case of wherever we suspect asthma. It is actually, it is a Aspiratory test where we diagnose the asthma and differentiate it from the other respiratory disorder like the other obstructive area of the disease like COPD which is a smoker lung disease and then mainly the difference between the asthma and the COPD is that in asthma it is a intermittent disease and the COPD is a persistent progressive disease. So here the pulmonary function test, Aspiratory is very helpful. And the variability of the airflow obstruction can be measured at the home also. If the pulmonary function test cannot be done then we use the big flow maker which is a simple, handy device can be guided by the patient at home, patient can check the flow of air from the lungs in the day, in the morning or at the night and the variation between the values we come to the diagnosis whether the patient is having variability of the airflow limitation or not. And there are some allergy tests also like the skin prick test, specific IgE test, when a total IgE test help us to check whether the patient is having atopy or not and there are some allergen challenge tests also. These are helpful in making the diagnosis and we use these tests when the patients have no symptoms and the lung function test may fail to detect the air wind So these are allergen tests in an ancillary test to get the diagnosis of respiratory allergies. Let's begin with the asthma. As I said, it is a chronic lung disease affecting the airways of the lungs and it causes what you may need of inflammation of airways, mucous production and because of this mucosal inflammation there is a bronchospasm in the airway leading to the breathlessness and asthma as I said most of the patient have a history of you know topical allergy in the family it has been seen it runs in the families and the risk increase in the family members have allergies or asthma like anyone who has a family member the immediate family member who has a history of the asthma then the person having the asthma increases chances of having asthma increases and the risk also increases with the allergic skin problem if anyone has a problem of eczema and that person may have an increased risk of having respiratory allergies later in their life. Asthma symptoms as I said it's a breathlessness, a wheezing from the chest which is a whistle sound coming from the chest, cough and shortness of the breath. So symptoms may vary in the severity as I said and not all the symptoms are present. Some patients may present only with the cough that is you know known as a cough maybe we call it a cough variant asthma. Some people come with only a chest tightness while during change of weather some people say that they have breathlessness and many of them have reported that they have noticed some whistle sound coming from the chest. So the variability of the symptoms along with the test which we get done for them and the availability of the airflow limitation it helps us in making the diagnosis of the asthma and the person can experience asthma with pores or seasonal allergies. Some patients have only seasonal allergies whenever there is an increase in the pore and in season these patients develop allergies like the allergic rhinitis and these people may develop asthma symptoms also. So even out of the simple viral infection seasonal allergies they can lead to exacerbation of the asthma or may cause the development of asthma symptoms. So there are some triggers of the asthma which lead to initiation or the exacerbation of the asthma these are the inhaled allergens and in which the commonest one is the dust mite, house dust mite, mold and even the pads people are very fond of keeping pads on their hand but I would like to tell them that because of the pads not always all people would have allergies but people who are you know prone to have allergies they might develop asthma symptoms because of the pad their feathers, feathers, skin, saliva, urine here so all these things can lead to allergic reactions. I don't think like the trees, grasses, pollens, weeds, irritants they all lead to the allergic reactions in airway causing asthma symptoms and outdoor pollution like air pollution even indoor pollution also lead to exacerbation of asthma. Some perfumes, strong cleanser, paint, chemicals, smoke in any form this can trigger asthma people who smoke actively or passively and are prone to have allergies they can develop asthma because of smoking so smoking has been seen as one of the factors leading to asthma. And the other things like the patients who have you know repeated viral infection like a common cold they develop asthma symptoms and some people have asthma symptoms during exercise whenever they start exercising they develop asthma symptoms the asthma induces exercise induces asthma so these are all the triggers of asthma so far have been seen. So what actually happens in the asthma airway as the normal airway there is the cross section of the airway remain normal but whenever there is allergic reaction developed in the airways there is irritation and swelling in the airway production of the sticky mucus which is a flamm actually and small muscle tightness occurs there and airway gets constricted actually this is the constriction of the airway due to which a patient you know starts having a wheezing or the breathlessness whenever the is bongo spasm the patient develop wheezing or breathlessness so you can see the normal airway muscle and the linings these are normal the cross section of the airway is normal it's not constricted but whenever there is there is a asthma and the allergic reactions are going this is no philic inflammation going on in the airways then the person develop these are all things like the tightness of muscles running in the airway wall and the mucus production so this factor of the asthma these are the predisposing factor of talking which is a genetic predisposition to have allergies and genetics and if the family member has asthma then the person may have made a lot of asthma later in the life generally it has been seen males are having asthma more than the female and the casual factors are like the indoor allergens or wherever a person is working like the occupational sensitizers are there or the outdoor allergens like the outdoor pollution so the pollens there outside which can lead to asthma symptoms development and contributing factors are like air pollution and some diets even a low birth rate babies it has been seen they are more prone to develop asthma in their life later on and the rest and the people who are having respiratory infection frequently even in their early age they develop asthma later in their life and smoking because it has been seen it's like it has been a very strong contributor of developing asthma symptoms so how do we diagnose asthma again history always as it is a principle to diagnose any of the disease so here also asthma is diagnosed on the basis of the history with the objective measures in the lung function in the form of spirometry and what we see that once a patient performs spirometry we see whether there is an airway obstruction is reversible or not so reversible airway obstruction of the gunko dilator it helps us in making the diagnosis of the asthma another thing is a variable air flow limitation over the time and the airway hyper responsiveness so these are also some tests like the bone provocation test we use to diagnose asthma and assessing the allergic status of the patient like uh say um total IG or the specific IG or to some modes we can get checked to see whether the patient is sensitized to that particular thing or not leading to all these symptoms of asthma and when as I said asthma present with the breathlessness, wheezing, curve, chest tightness so we have to give some other differential diagnosis not mine because always all these symptoms are not because of asthma like so the differential diagnosis to the asthma could be a post infectious curve like a many patients who develop just a LRTI over a spirited tract infection and later on they develop a curve for a longer period of time it might look like it it is an asthma but sometimes it is not it is just a post infectious curve and the people who have a continuous post result they have a chronic curve which will look like asthma but it is not and COPD chronic obstructive pulmonary disease which has been seen in smokers it could be a differential diagnosis to the asthma another thing a heart failure and gyna, lung cancer, hyperventilation if you don't vocal cord these symptoms so these are all the differential diagnosis which we need to exclude before coming to the conclusion that the patient is having asthma and the approach to the management of the patient of the asthma we confirm the diagnosis always first we confirm the diagnosis patient is not having any other disease and then once the diagnosis is confirmed we do the management of the patient like the self making the patient educating regarding the self management of the symptoms like the avoiding of the environmental triggers and taking the inhalers on time teaching the patient proper inhaler technique add on to the treatment and we give the action asthma action treatment plan to the patient the time of the emergency we give the legal therapy we give the control, love therapy we give the regular assessment of the asthma including the spirometry and pulmonary peak respiratory flow with that peak flow meter whenever the patient comes to us but actually the goal of the asthma is to minimize the risk of exacerbation and adequate symptoms control patients should have maximum time of symptom free and these can be achieved with a you know proper assessment adjusting the treatment of the patient and reassessing the patient whether a patient require any change in the treatment the treatment of the asthma requires the actual stepwise management of symptoms with proper assessment followed by treatment adjustment as per the individual patient and review of the patient for further action plan as many patients have uncommitted allergic rhinitis as I say one every one disease so we need to treat the allergic rhinitis also if you want to control symptoms of the asthma we and it is necessary to treat the symptoms of the of rhinitis for achieving well-controlled asthma and treatment modality for the asthma always the main step of the treatment is inhalation of therapy in the form of nebulization or inhalers or a rota cap which include you know steroid or dromco dilators maybe a short acting or a long acting dromco dilators and some patient require with these infections they may require antibiotics also and some patient who have allergic rhinitis they might require nasal spray so moral medication in that in case of the severe asthma we might need to give patient steroid and patient who have a you know chronic persistent severe asthma then they may require immunotherapy now we have good immunotherapies available with us to control the symptoms of asthma which have been uncontrolled so far so the compliance with the treatment and the proper technique of the inhaler are the keys to prevent the exacerbation of the asthma if the patient is taking inhaler but not in a proper way then it's going to be a useless thing so it is always important for the patient as well as for the physician to teach the patient how to take inhaler properly as respiratory energy is induced by the allergens in the airways of prevention requires avoidance of allergens any insect and in any allergy what we need to do we need to avoid allergens if the allergens are avoided obviously allergy will not develop but this is not possible because there are some allergens which are unavoidable and any allergens are unavoidable which a patient can avoid to prevent the allergy but when the patient cannot avoid the allergens and the allergy reaction develop then patient need treatment so the avoidance allergen can be done by creating a clean indoor air by various means like vacuuming floors or cleaning dust and make your home a non-smoking section and using air purifiers and many more things remove the allergens from the environment in the home as well as where you are working so these are some preventive measures I would like to tell you like reducing the exposure to the environmental tobacco smoke like the active and passive smoking all of them have been seen contributing to development of the asthma passive smoking like someone is having an active smoker at home and people in the home dealing with that person passive smoke they also you know become prone to have asthma symptoms in which school-going children are having seen are prone to develop asthma because of this passive smoking so stop smoking and avoid smoke and it's like people who are fond of keeping pets at home if a pet is making your asthma burn the best option by far is to find a new home for your pet if it is not possible then you can do something like the key pet out of the bedroom always wash pet frequently and like you can see remove carpeting is possible you can use a HEPA filter which is available in the market you know vacuuming the furniture regularly with vacuum equipped with a HEPA filter or a central vacuum system with exhaust outside the house so basically we need to remove all the allergens from the house by any means which you can do so that allergens may not develop and the pollens all have been seen leading to development of allergens respiratory tracks actually these pollens are tiny particles that come from trees grass and weeds and if you are allergic to the pollens then as you can do something like these to avoid development of allergy like keep windows and doors closed in home and car during pollen season so avoid exposure to the pollen and after being outside for a long time during pollens shower and change clothes and person with allergy should not move the law so when it is necessary to move along by that person should bear mask now as it is a new normal for us to wear a mask so obviously somehow going to help us in the future to avoid an allergen exposure like similarly the allergens one of the allergen is more uh pollens can be indoor in the damp basement and bathrooms and outdoors in the damp so wherever there is a damp area molds are grown and they lead to the sensitized sensitization of a respiratory tract leading to the you know asthma symptoms development so to avoid this you should uh paint molding areas that keep humidity around 30 to 35 to 45 person can use a knee modifier and get rid of a clutter in the basement and show proper water drainage is there keep bathroom dry don't keep it a wet floor seek professional help if indoor mold doesn't go away by any means and the limit outdoor activities when outdoor mold levels are high and the like of the pollution in the air is increasing so there are so many irritants in the air which are leading to the development of the asthma symptoms so when pollution comes from the many sources like industries from the vehicles exhaust so highest pollution ever time to be during the hot humid days of the summer and we are in the you know as I said in the beginning we are in the transition phase of the weather this is the time when respiratory allergies you know they are on the towards the going towards the peak so to reduce exposure to the air pollution the following may help reduce the outdoor activity when pollution levels are high keep windows and doors close when they are high pollution like in the air conditioning which may be needed when it gets hot reducing exposure to the mold as I said it could help to reduce development of energy and reducing the exposure to the how does my because it has been seen the how does my lead to development of energy in the respiratory tract so use the bedding encasement wash bed linen frequently would help to reduce house dust nights from the home and reduce the humidity level because if you keep the humidity level low how you would you know keep would keep house dust mites away as well as moths away from the home and exercise as it has been seen is a pre-disposital but only for those who are prone to have asthma symptoms during exercise but obesity is also lead to development of the asthma so it doesn't mean that the people should not exercise they should exercise to maintain the weight but people who are prone to have asthma because of the during exercise they can exercise but provided they keep their inhalers with them and before doing exercise they should take their inhalers even after exercise whenever as advised by the physician they should continue with the inhalers so I would again say that exercise is must but exercise induced asthma can be controlled with the inhaler so inhaler is must and lastly the how another part of the widen the frequent you know common cold problem by getting the vaccination done for the influenza and the pneumococcal vaccine which would reduce the you know repeated infection by pneumococcus and another vaccine which is in the pipeline as we all know the corona vaccine in the pipeline soon if it is available obviously and you know as we know that the corona people land up with respiratory problems looks like similar to the common cold so obviously once this vaccine is available so development of you know symptoms of respiratory allergies would reduce now I'll talk on the allergic rhinitis as I said is also one of the respiratory allergies more than the upper airways so rhinitis actually is a two or they are the two or more nasal symptoms like a nasal congestion running nose, rhinorrhea, sneezing or reaching is there in the nose impairment of the smell for more than one hour a day these are the symptoms of the allergic rhinitis so rhinitis occurs most commonly as an allergic rhinitis and it is actually a non-infectious rhinitis which is either allergic or a non-allergic but it has been seen as more usually it is allergic rhinitis and allergic rhinitis is defined as a immunological nasal response primarily mediated by the immunoglobulin IgE so here I have put an Ig level help us in making a you know diagnosis of this allergic rhinitis and the non-allergic rhinitis is defined as a rhinitis symptom in the absence of any identifiable allergens so as such there is no identifiable allergy or a structural novelty or sinus disease so what is the function of the of a nasal system which is a temperature regulation, olfaction, humidification, filtration and protection from the particles which can lead to the allergy so these are the precipitating or predisposing factors of before developing the allergic rhinitis like aerobiological flora, allergic present in the environment these predisposing precipitating factors are almost similar to what I have discussed in the Asthma part and the how does my feathers of you know the pad, tobacco smoke, industrial chemicals, animal tenders and the nasal physiologies that people have you know they would be able to symptom which can lead to the look of the allergic rhinitis, disturbance in the normal nasal cycle and the genetic predisposition again a topic which might lead to the allergic rhinitis, multiple gene interactions and 50% of the allergic rhinitis patient have a positive family history of the allergic rhinitis and as I said in the even in the Asthma there are many people have a family history of Asthma here also people of having a allergic rhinitis have family history of allergic rhinitis and during the puberty even in the pregnant state these allergies may develop in people who are prone to the allergies. Some psychological issues even in the you know frequent infections like a fungal infection may lead to the development of the allergic rhinitis and the degree of the pollution of pollution in the air it may lead to allergy if it is increased and the development of the allergic rhinitis chances of developing allergic rhinitis increases, humidity temperature it is extreme humidity and the temperature differences and the temperature changes and like IGA deficiency and the age and sex it has been seen also a predisposing factor like in early in the age group and in the late age group it has been seen that these people are prone to have a allergic rhinitis and here also may or always in most of the studies I've been seen are prone to develop allergies. So common even common aero allergens can lead to development of allergic rhinitis like the pollens, like the spring trees pollens, grass pollens, wheat pollens, moats and like animal tenders I said insect, cockroaches, house flies, cats, dogs was all these you know cattle or animals these are their first their feeders they are like the birds we keep they made into development of allergic rhinitis even a kind of the food we need can lead to development of this allergic rhinitis like the fish some people are allergic to fish, eggs, males, nuts so it may be prone person to person who's whoever is prone to develop allergic because of this would develop allergic rhinitis because of this classification of the allergic rhinitis is like it's either it's a seasonal means occurring during the change of the weather you know in a particular season or it's a panel means the throughout the year it is present and so in the seasonal allergic rhinitis it is often known as like you know like the misnomer of the hay fever where there is no fever activity like in the summer cold caused by the virus causing the upper respiratory tract infection and you know often satid in India some containment like that colorful or fragrant flower flower plants really cause allergies as they are pollens too heavy to be airborne so it has been seen that you know the legal flowers and those colorful flower flowers people keep in their home and they are less likely to develop allergic but it doesn't mean that these pollens won't cause allergic but it has been seen as compared to other learn of flowers it causes less allergy and the perineal where the allergens present throughout the year so people develop the allergy which remain throughout the year and then the intermittent the symptoms present less than the four days per week and less than four weeks per year so this is an intermittent disease and it is present like a symptoms present more than four days per week and more than four weeks per year then it's a persistent disease sign in the symptoms of the allergic rhinitis like sneezing itching nose itching in the nose ears eyes or in the soft palate vinaurea running nose post nasal breath repeated throat clearing congestion the nose and there is a loss of smell of loss of sense of smell like an osmia headache or earache red eyes swollen eyes drowsiness and the malice so these are all the symptoms of allergic rhinitis and what are the complications of the allergic rhinitis as in the beginning i told you and i mean between also i repeated that line that one way or the other one disease so as allergic rhinitis develop in the upper airways people are prone to develop allergic asthma later in their life so here is the complication first complication of allergic rhinitis is allergic asthma then the chronic hepatitis media maybe a hearing loss patient may develop chronic nasal obstruction and sinus like this so these are all the complications of allergic rhinitis and the treatment in the treatment part we give the space to the patient and some anti-allergic medications if it is required to be surgically corrected and we discussed with the re-entry surgeon and that part to be managed by the re-entry surgeon only and also here even the therapy helps and wherever the patient you know having too much problem with this allergic rhinitis so we can think about the immunotherapy in those patients so basically in my talks i would like to say that allergies can be avoided whether it's a respiratory allergy or any allergy by avoiding the emergence but the treatment is must if because we cannot avoid all the allergens so the patient also ever has been in the allergy in the upper airway though they are prone to have allergy in the lower airways later in their life developing asthma so we treat the patient as a whole targeting the treatment for the allergic rhinitis as well as for the asthma type of symptoms see it depends you know it's a actually a food allergy so even a food allergy can lead to the respiratory symptoms it can lead to you know skin eruptions also so if a person who is you know having an allergy to the egg they may develop the symptoms of gastrointestinal tract like the vomiting the idea of pain in the domain you know blotting in that domain some patient may you know develop the you know skin eruptions and some patient may have you know start sneezing running nose and when a few patients have been seen it may lead to the breathlessness also so you know as it is a food allergy what is actually involved the system says the whole body as such so it depends where this this allergen causes the allergic reaction but basically it causes gastrointestinal tract reactions okay another one is in the covid people one question to me is like the covid people are suffering from the respiratory problem can anti-allergic drugs prevent if we start see we do give anti-allergic medication by the patient person who present to us with the running nose you know sore throat problem post nasal grave so as this is a viral infection and the person has developed the allergic to that and having all these symptoms obviously patient needs to give these anti-allergic medication as in the covid patient like it was it is a infectious disease caused by the virus so obviously avoidance of the allergens is must and if it happens to be a covid disease then the treatment in which anti-allergy is one of the part it doesn't mean that the only anti-allergy would help but anti-allergy would help in managing the symptoms of the patient so definitely it's going to help and we do give so another question is is g rd also symptom of allergy yeah it can you know food allergies can lead to against this gastric reflects gastroesophageal reflux disease like a patient who is like in the previous question somebody asked me about egg allergy or anything like nuts or anything patient have and develop allergy you should might have you know gastrointestinal tract symptoms at that time we should may have you know peeling of vomiting nausea or maybe a gastric reflux but this happens if the patient is allergic to that food so it can happen so I think we are done with that I hope you enjoy the talk and one more question is there can healthy person prevent covid by taking anti-allergy see covid is our infection you can avoid getting covid by taking the precautions which you know very well published all over in the media by getting masked frequent washing your hands avoid contact with the covid infection person and obviously if you avoid all these things you would avoid getting infection with the covid so but taking anti-allergy will not help you know preventing the implementing the you know contacting this disease so anti-allergy just would be a symptomatic management it is not the definitive treatment so you cannot prevent covid by just taking anti-allergy you need to take all the precautionary steps to avoid getting infection with covid19 so I think you're done okay so thank you again for listening to my talk I hope you enjoyed so stay safe