Expert: Marc Rubin, RPh Asthma Educator - 4/8/2008

Question
I have had reactive airway for years.  My only trigger is viral and upper resp. infections. Some colds, viruses do not trigger the airway symptoms, however others put me over the edge.  There appears to be no rhyme or reason as to when the URI will trigger me.  About 4 months ago, I had mild bronchitis after a pesky mild viral infection.  I have been taking both nasonex and singular since the last flare up as a preelectric at least until we get through the viral season. I work in a school with preschool handicapped and autistic children so I am constantly exposed to lots of things.

About 10 days ago, I had real mild viral symptom (low grade fever, feeling just a bit ikcy) but not that bad so I went into work Monday, Tuesday, Wednesday.  By Wednesday afternoon, I felt horrible so I spent a while laying down in the nurses office (I never do that). Thursday I was home sick and went to the doctor. I also felt that I was just starting to feel the tightness,however the doctor didn't hear anything. He said that I had a sinus infection on top of the virus. He gave me antibiotics and added advair to the singular and nasonex to prevent the reactive airway flare up.  By Friday, my temp was up to 101 and Saturday evening 102.  Sunday, the lovely coughing fits and lots of congestion kicked in. I went back to the doctor Monday. There was no evidence of bronchitis or pneumonia, however the doctor said that my airways were in severe spasm.  The doctor pulled me off the advair because she said that some people are experiencing airway spasms as a side effect.  I was given a prednisone shot and rx for liquid breathing treatments (Xopenex).  My fever is way down now to between normal to clammy feeling to 99 at the most. I still have coughing fits, but not as frequent if I take it slow.  I only woke up a few times last night with short (20 second fits).  I was planning on going to work today but when I got up to shower, I had a 5 minute non stop coughing fit. I figure that I will get another breathing treatment in me and see how I feel later this morning.  I am debating between going in this afternoon or just waiting till tomorrow to go back.  Tomorrow morning, I have a block of open paperwork/testing time so It would be a good way to ease back into things.  My question after this long rambling post is

How do I know when I can safely go back to work without triggering an increase in symptoms?

Answer
Hi Amy,

Sorry for not getting back sooner, I'm on overnights this week.

I will first make the assumption that you do not have a peak flow meter. It is an inexpensive device that helps to determine airway resistance. As inflammation increases, the airways swell, and the movement of air decreases. The benefit of this tool is so you can, at home, monitor changes taking place. AS your function goes down, you can then aggressively treat it to recover. As your numbers return to the normal range, you are safe to resume normal activity. Follow this link to learn about peak flow meters: http://www.aaaai.org/patients/publicedmat/tips/whatispeakflowmeter.stm

Next up, while Singulair is a good drug, it is not the first choice for asthmatics, especially considering your work environment. While it is good at reducing the release of chemicals in the tissue that increase inflammation, it does not reverse the inflammation that acutely occurs to a great extent. While on one hand, adding Advair was a wise choice, the steroids used for inhalation, like that in Advair, can take at least a couple of weeks to truly have the beginning of a beneficial effect. What is needed is aggressively reducing the inflammation with oral steroid (for an adult: usually 40 to 60mg of prednisone/day for 3 to 10 days). It is not necessary to give by injection, since it works no faster. Injection is saved when a person cannot keep oral medication down, or post-operatively, when the digestive system is not fully recovered from the anesthesia. Your spasms, in all likelihood were due to the degree of inflammation, not the bronchodilator in Advair. It was a good move by your physician to give you the steroid, just would have been better sooner. There has been research looking into starting an asthmatic on oral steroid much sooner in the course of a viral trigger, so you don't get to the point of a severe bronchospasm.

Regarding bacterial infections:sinus infections, as you are aware, can trigger the airways, so getting that under control was important, and using the nasal spray to keep inflammation down, equally so. In the lungs, the majority of "bacterial" infections do not trigger asthma (unlike viruses), with the exceptions being Chlamydia pneumonia and Mycoplasma.

Bottom line: I believe you are fine to return to work if you are sleeping uninterrupted through the night. Keep your rescue inhaler with you during the day, and use as needed. Get yourself a peak flow meter (allergists frequently get them for free from the company that manufactures Advair. Therapeutically, I would change you from Singulair to an inhaled steroid during the part of the school year when viruses are hitting. Begin 1 month ahead of the season, so the steroid has a chance to best protect your lungs. After the season is over, if you have seasonal allergies, you may want to resume Singulair, but you may find your breathing significantly better on the inhaled steroid, and may want to stay on it. A new steroid is about to be released: ciclosonide...end of this month under the brand name Omnaris. Once a day nasal spray where the side effects are no greater than placebo. The oral inhalation product will come in later. Dramatically reduced risk of nosebleeds, thrush, hoarseness, etc.

I realize this is a review that is more suited to keep you from going through this in the future. Hopefully this will be helpful to you. Feel free to get back to me if you have any further questions.

Take care.

Marc