Expert: Marc Rubin, RPh Asthma Educator - 10/6/2008

Question
QUESTION: For well over twenty years, I have been plagued with frequent bouts of a virus sometimes followed by bronchiospasms.  This happens four to five times a year, mainly between October and May. Symptoms may last anywhere from 4 days to two weeks and can range from very mild to keeping me in bed for a few days.  I have had numerous spirometry tests over the years.  About 70-80% of the time, reduced lung function is evident. The progression of my symptoms are; virus,tightness in chest, congestion (feels like it is in my throat or upper chest), sporadic pressure in chest, cough, wheezing, shortness of breath as activity increases, feeling as if I can not take in a really good deep breath but am not air deprived. Pulse ox ranges from 99 to a low of 92 when I go to the doctors office for a flare up.  I am not sure if I feel better following the use of rescue inhalers, although most of the time, the doctor sees improved numbers for the spiromety test that follows a breathing treatment.  My normal peak flow is 450-500 but goes down to 300-350 when in a flare up.

I am so frustrated as I am once again in the middle of a flare up.  Three days ago, I woke about 5am with a lot of congestion and a 5 minute coughing fit.  After the coughing subsided, you could hear audible wheezing with each breath.  My husband panicked when he heard me breathing (never panics)and convinced me to go to the emergency room. When I first got there, pulse ox was 92 so they put an oxygen mask on me for about 20 minutes to bring up the levels. They listened to my chest and said that there appeared to be good air movement but there was wheezing at the end of a breath.  Chest x-ray and ekg were normal.  I was given 3 breathing treatments over a period of 5 hours and started a 5 day burst of prednisone.  The wheezing improved and I was sent home with rx for rescue inhaler, rx cough meds and prednisone.  I followed up with my doctor the following day. He added advair and wants to see me in two weeks unless I take a turn for the worse. My peak flow has been between 300-325 since I got home on Thursday afternoon.

I have seen several different doctors (allergists, pulmonologists, internists) over the years and have been told that I have frequent acute bronchitis, reactive airway, asthma.  How do I get a correct diagnosis??

ANSWER: Hi Amy,

I just answered your previous post, and now see that you have been to specialists.

Please, if you would, indicate where you live (city,state,country). Also, any pets in the house? Do you live in the city or a rural setting? Occupation? Age of home, and does it have a basement?

I'm glad to see that your physician did what the ER doc should have: put you on a controller. Have any of the docs done allergy testing, and if yes, what results?

Once I get a better feel of the overall picture, I'll be better able to help you.

Look forward to hearing back from you.

Sincerely,

Marc

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

QUESTION: Bridgewater, NJ

I have two dogs.....both husband and myself had dogs since were were kids.  The home is 12 years old.  Our basement is dry and not moldy.  We have a central humidifier that does NOT have a drip pan, the water exits the house through the same hose that the condensation from the central air does. We live in the suburbs about 2 hours from NYC. I work in the new wing of a school that was built five years ago and always keep my window open an inch.  I am a speech lang specialist and work a lot with pre school handicapped, primary autistic and an assortment of other kids K thru 5. Yes, they are walking Petri dishes.  I had allergy testing twice.  I was negative for dog and cat allergies.  The first test was when I was a kid.  I had MILD allergies to maple trees and some seasonal plants but real mild.  The second scratch test was done when I was an adult. The only reaction was to the control allergen.  

Come to think of it, about 20, years ago despite using nasonex regularly, I was on antibiotics for sinus infections and bronchitis at least six times a year for two to three years.  My doctor referred my to an ENT who discovered that a deviated septum and scar tissue caused the one side to completely shut any time the tissues became irritated.  I had surgery to correct the septum and remove turbinates. The results were good. I had about 9 years of only one or two cases of bronchio spasms a year.  Then again, I was home with the kids doing the mommy thing and not exposed to the level of germs that I currently am at work.

Do you know of Dr John Oppenheimer allergist Cedar Knowles NJ?  Are there any other doctors you know of in the area?

Thank you for your help.  I just want to get a correct dx

ANSWER: Hi Amy,

Dr. Oppenheimer has excellent credentials, and is still actively involved in research as well as clinical review committees. You really cannot do any better professionally.

Being married to a teacher myself (kindergarten), and knowing that parents are frequently inconsiderate regarding sending their children to school in spite of infection, this is probably your primary source of trigger. I'm sure the physician has reviewed with you your need to have your influenza and pneumonia vaccines kept up to date, but in addition, while most bacteria do not trigger an asthmatic response, Chlamydia pneumonia and Mycoplasma pneumonia are two bacteria that do trigger reactions. Needless to say, personal hygiene is imperative, but not perfect. I'm certain that you take all your precautions, but getting your special needs kids on board I'm sure is difficult. Just be cautious in the cleaning products you use. There are a number of products lower in volatile fumes that tend to irritate the airways.

The correlation of your flareups coincides with the school year, which then leads me in the obvious direction of you using controller medications (like Pulmicort and Nasonex) on a daily basis. I'd also do a few things to evaluate progress:
1)Have a baseline spirometry test done now,
2)Update your "personal best" target with your peak flow meter, once you are symptom free, then monitor intermittently when feeling well, as well as downturns. Remember to sit down with Dr. Oppenheimer to create your personalized "Asthma Action Plan"
3)Next summer, get a baseline peak flow 2 weeks after the end of school, then go drug-free for the summer, Before school restarts, re-test both your spirometry and peak-flow to see if you have maintained full function without meds. You may find that your underlying lung function may have deteriorated during the summer, warranting year-round treatment. If this is the case, your summer time therapy would probably be at a lower dose of medication. On the other hand, it is quite possible to be drug-free every summer, just getting your meds back on board when school resumes.

One final issue to note before I close..if you are doing any decorating at home,(painting, new carpets, refinishing wood floors) be careful to use products that are low in VOC's (volatile organic compounds). These products out gas, and can continue to irritate airways for a long period of time after being applied or installed. The supplier can help you with these.

I wish you the best of health. You are in excellent hands, and just need to make some adaptations to be well again. Please let me know how this all works out.

Sincerely,

Marc

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

QUESTION: Somehow, I made it through the day at work, but not feel crummy with increased coughing and I have pretty much lost my voice (not convenient for a speech pathologist).  I have an appointment with Dr. Oppenheimer in two weeks and am on the cancellation list for an earlier appointment.

Thank you for taking the time to answer my questions.  I do have one other question.


Are humidifiers good or bad?  Are cool mist or warm mist best?  Today, I spoke with one of the nurses in my doctor's office and she recommended a cool mist humidifier.  I though that they were not recommended.  Any feedback would be appreciated.  

Answer
Hi Amy,

When the relative indoor humidity is low (lets' say below 25%), mucous secretions become thicker, making it more difficult for the airways to move the fluid out. Therefore, in winter time, increased humidity is important.

Whole house humidifiers can get the level up to ~30%, (which, by the way, will make your home feel warmer with a lower temp setting). The biggest problem with the whole house units is the potential for mold development in the system, especially the evaporation unit. May have either a rotating wheel or absorbent pad that the air circulates through to pick up the moisture. These need to be replaced yearly, and the unit thoroughly cleaned.

For room units, I prefer the steam units, since the mist coming out is sterile. I find the cool mist ones with a spinning blade are also more prone to mold (besides being loud), and the ultrasonics leave a coating of dust on everything. New York region has soft water (if I remember correctly) which would result in less dust from the ultrasonics. Regardless of type, maintenance cannot be ignored.

Hope this helps!

Sincerely,

Marc