Expert: Marc Rubin, RPh Asthma Educator - 2/1/2008

Question
QUESTION: Hello,
I had pneumonia last fall and since then my x-rays have come back completely clear of the pneumonia.  However, I was still having trouble with shortness of breath and wheezing even after the pneumonia had cleared, so my doctor sent me to see a Pulmonologist who immediately said that I have asthma and put me on Advair and Albuterol.  I'm 24 years old and I've never had any symptoms of asthma before; I have allergies, but they have never been so bad that I was prescribed medicine long-term by my doctor.  Since I've started the new medications, I've been having trouble taking in full breaths - my doctor says that's a normal sign of an asthma attack and put me on prednisone.  I'm curious if it's possible that my problem is not asthma related at all?  Thanks!

ANSWER: Before I can go forward, I need some more information.
1)What tests did the pulmonologist run prior to making the diagnosis, e.g.: spirometry with an albuterol challenge, or with methacholine?, Blood work up: CBC with differential?
2)Have you been given a peak flow meter, taught how to use it, so to monitor your breathing?
3)Which doctor put you on the steroids, and was this done after doing a peak flow or spirometry test?

After I receive your responses, we'll go from there.

Thanks!

Marc

---------- FOLLOW-UP ----------

QUESTION: 1 - The pulmonologist did a spriometry test the day I was in the office and I did have blood work done following my visit (CBC diff).  But he prescribed me with the advair and albuterol the same day anyways.
2 - No, I was not given a peak flow meter.
3 - The pulmonologist put me on the steriods but without having me do any add'l tests; this is about a week and a half after my original appt. and tests.  

Thanks in advance for you help!!


Answer
Although you may not previously been diagnosed with asthma, patients with mild cases, not knowing that their diminished capacity was out of the ordinary, you probably have had it for years. But that is a mute point, since we look at what your situation is at the present, while reflecting upon your past medical history: your allergies.

The fact that the pulmonologist put you on Advair is an indication of the level of inflammation present in our lungs. A major trigger that can produce a significant decrease in lung function in an asthmatic is a virus, especially the flu virus. This could be what brought everything to light.

The reason for the CBC with differential was to determine if your respiratory difficulties were due to an allergic, bacterial, or viral source...in your case, it did show that yours is of an allergic nature, and it may have also indicated a viral infection present. There are only a couple of bacterial infections that can actually increase inflammation, but typically only in children. Mycoplasma is one of them.

Inhaled steroids are the gold standard for persistent asthma, but can take a few weeks to begin having a noticeable effect to improve the status, and actually take up to a full 6 months to reach maximum benefit. So in a more moderate case, a combo drug like Advair is use that will open the airways, just like the albuterol, but for a longer duration, and lower side effects, and actually allows the use of a lower dose of steroid due to the cross-benefit.But, due to the slow onset of the steroid, if you are more severe, a short burst of oral steroid is necessary to gain the upper hand. This is usually done for 3 to 10 days, with a maximum of 14 days. Longer than that, continuous use of oral steroids begin to have a higher level of side effects, and cannot just be stopped, but must be tapered. This is utilized only in very severe cases.

Now on a final note, the fact that after starting Advair you experienced increased difficulty concerns me on two levels. First, what training did you receive in the proper administration of the Advair and Albuterol units. A large number of patients do not use them correctly, leading to unwanted side effects. If you were not trained and observed for correct technique, check to see if your pulmonologist has a staff member who is an asthma educator to review this with you. You may also want to go to http://www.chestnet.org, or http://www.aaaai.org, two major professional web sites that provide patient education guides to show you technique. Also, if you Google Advair, the manufacturer has a training piece at their site. For the albuterol, Google Proventil HFA, Ventolin HFA or ProAir, all of these being albuterol products, and you should find a training piece at them. Now the second issue, I don't know your race, but genetically, in up to 30 of the Afro-American population, and ~ 10 of the Caucasian have a genetic variation which can have a different response to the albuterol and the bronchodilator in Advair. If your breathing gets worse after using the albuterol, it may be an indication that you are one of this population, and require the drug Ipratropine for rescue rather than the beta-agonists (albuterol