Expert: Marc Rubin, RPh Asthma Educator - 1/15/2009

Question
QUESTION: Hi, I was diagnosed with asthma around 9 weeks ago after a cat causing a
tightness in chest with wheezing. These symptoms persisted for about a
week, so went to the doctors. I am 20yrs of age, 5ft 7" and have my own
personal peak flow meter. I use this three times a day, and at worse has been
290 (when I had a chest infection in November 08) and highest has been 510!
That I understand is very high compared to the guide average of 430 for my
age height ect. I take ventolin when I need it, and have been using it much
more in the past two-three weeks.I have also in the past two weeks been put
on a cortisteroid after a few times of having a sudden restriction in airways,
and only needed one puff of ventolin to ease it. For a few other episodes,
despite my peak flow being fine, peak flow under the 20% variant (I think
thats how you say it). I have bouts of  breathlessness (where sometimes I
would have to take really deep breath every 3-5 breaths or yawn if I persist
to take deep breath), and feel a restriction sometimes in my neck (happened
last night and for some of today. When I finally had the ventolin, it did seem
to help, but for only about 30mins or so). I hear my chest when taking a
breath and sounds a bit raspy. It is not wheezing, although I sometimes hear
a slight high pitch sound on exhalation when in bed, cough or turn over, and
will go...then comes back again and repeat. Could that just be pulemn
building up in my throat etc? Also to note, I have a cough, a dry cough,
sometimes productive, no longer creamy white froth (ewww, lol). I am aware
that a while ago I felt that mucus was tracking down, tried to cough it up, but
has barely brought up anything since! Could this be asthma? I had a really
bad day where my breathlessness was so bad, i was almost stuck on my front
living room as i would feel physically drained and out of breath. My ventolin
did not seem to help at all, and so just hoped for it to calm. This did all
happen over a week where my symptoms were worsening, but peak flow was
slightly over the place within a 100 of each other! So why is my peak flow
fine? They never even gave me a spirometer test! My main and annoyance is
the shortness of breath and chesty feeling i have where my peak flow is
fine...Is there any advise on questions i should ask when i next see my
asthma nurse? (on the 15th of jan 09)....
Thank you so much :) Very much appreciate any help and advice... Tried to
explain all to get a picture of my symptoms lol.

ANSWER: Hi Megan,

Let me address a few issues to give you some clarity about tools and evaluations.

It is great that you have a peak flow meter to help you monitor your status, but to get the best information from it, there are things you need to know.

First, the guide average is just that, a starting place that may or may not give a true picture because it is based upon the averages of a large number of people. It is not based upon YOUR personal best, which would be determined during a period of good health. And since you are under 25, when you are feeling better, you'll need to establish your personal best every 6 months until you reach 25 (and full lung growth). It is obvious you have done some research, since you question the fact that spirometry was not done. It is a difficult test to administer when you are under duress, but it is one the the diagnostic tools to determine the presence of asthma.

Second, a natural steroid that reduces inflammation in your body, cortisol, varies through a 24 hour period. It is at its lowest levels around 4am, begins to rise around 6am, reaches its highest levels early afternoon, and then begins once again to drop down after midnight. This variation has a lot to do with your lung function. It will be at its worst in the very early morning, and at its best about 2pm. So ideally, when we determine personal best with a peak flow meter, it is using the numbers achieved in the early afternoon. What you look for is, upon awakening in the morning, the value that you get is within the 80 to 100% range of your personal best. If it is less than that, but above 50%, you would take an albuterol treatment. You should then find shortly thereafter, lets say 30 minutes, you are back in the "Green Zone" of 80 to 100% of ideal.

Now, your asthma specialist should work TOGETHER with you to create an "Asthma Action Plan". This would be an instruction guide that, based upon peak flow numbers and/or symptom presentation determines what course of action you should take with your therapy. Do you need a rescue treatment? Do you need a short course of oral steroids? Should you contact your doctor or go to the ER? Should you be treated with a daily "controller" medication? An easy guide for this need is the "Rules of Two". If you require using your rescue inhaler more than twice a WEEK in the DAYTIME (other than pre-exercise), or more than twice a MONTH due to nighttime awakenings, or use more than 2 rescue inhalers per year, you should be on a continuous daily therapy. This may not mean permanently, since, with seasonal variation, you may not need it year round. But at times, it may require more than 1 drug taken daily. At the end of this, I'll give you links to an Asthma Action Plan, Peak Flow Testing and an Asthma Control Test.

Third, asthmatics not only have where the muscles around the airways constrict, making the breathing more difficult, but they also have swelling of the tissue of the airways, and this is not relieved by albuterol. And finally, asthmatics have a much greater number of a specific type of mucus producing cell, goblet cell, which increases the amount of secretions you have to deal with. Products like Mucinex and Robitussin (Guiafenesin), are not effective in thinning out this type of mucus. You need plenty of water. This may explain why you are not always fully relieved when using your Ventolin. Other considerations are that 1) has your inhaler technique been observed and verified as correct? Patients frequently inhale rapidly,and looking down, rather than inhaling slowly and looking up a bit. Also, anxiety can make asthma worse (as can laughing and crying), so it is very important, as difficult as this may seem, to remain calm, and breath slowly, standing or sitting, but NOT laying down.

Now, with those things covered, lets get back to you.

When yo were growing up,
>did you have any history of waking in the middle of the night coughing or wheezing?
>any history of asthma or allergies for you or members of your family?
>any eczema or psoriasis?
>runny nose, itchy eyes?
>acid reflux?

How old is the place you live in now?
>does it have a basement or crawl space?
>any pets at home? Do they have access to your bedroom?

Do you smoke? Friends smoke?

Are you on any medications, prescription or over-the counter?

Let me know about these things, if you would, it may give me a clearer picture on how to better help you.

Here are the links for the three items I discussed before:

Asthma Action Plan: http://tinyurl.com/q5j2v
Asthma Control Test: http://www.asthmacontrol.com/
Peak Flow Meter: http://tinyurl.com/6h4g9

Please let me know how things go.

Sincerely,

Marc




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

QUESTION: Hi Marc, thank you for your detailed reply. To answer your questions:
-I do not remember any waking when young, except in summer because of hay-fever generally coughing, but have been told (that I never new from my
asthma nurse) that it is not solely hay-fever when you are out of breath
during this season as i always am.
-My dads side of family mostly have asthma, allergies like hay-fever for my
mums side of family, hayfever, rhynitus which i both have also.
-I have eczema (since teens has worsened in recent years), both contact
eczema also.
-If acid reflux is like heart burn or indigestion, sometimes (both to these).
-House was built in 50's (asbestos check was done when loft was built).
-It has a loft conversion (which is my bedroom!!!!very damp and dusty I
know!).
-No pets.
-I do not smoke, heavily sporty and respect my body, so avoid any smoke
inhalation.
-On Dermovate Cream for Lichen Sclerosis in a place you would not want it!!
ha ha. Apart from that, nothing else except your normal paracetamol, Suda-
fed or ibroprofen.

Thanks once again
Megan.



ANSWER: Hi Megan,

I feel that it is time for you to see an allergist for a proper and complete workup. You do present as an asthmatic patient, but this still should be confirmed by a few tests that the specialist would administer. One of those you are already aware of: spirometry. Not just what your present status is, but they will also give you a breathing treatment to assess what degree of improvement, if any, results from that treatment.  It is also extremely important to assess specifically what you have allergies to, since a big part of controlling asthma is avoidance of "triggers", or, at the minimum, pre-treatment to prevent your airways from reacting.

Family history sure points in this direction. Having your home, and especially your room tested for mold is imperative. Even patients without asthma are affected by mold.

A couple of more points that should be addressed,the approach to control your condition should include resolving your allergic rhinitis, and GERD. Both of these can worsen your breathing. The allergic rhinitis, since inflammation there may trigger the lungs to react, and acid reflux in the lower esophagus will irritate nerves that make the muscles in the lungs spasm. If you drink coffee, tea or caffeinated soft drinks, by eliminating them,or at least cutting back significantly, you may resolve the reflux.

I hope this helps you more, and please, let me know how your full evaluation goes.

Sincerely,

PS: Keep up the "Sportiness"...it is great for your lungs.

Marc

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

QUESTION: Hi Marc, I went to my appointment earlier today, and she was very concerned
about my symptoms. She said that even though I am reaching high peak flow
numbers, she expected to see them not so scattered and much closer
together. Since my new high score of 530, it brought the zone numbers much
higher than before, and did enter in the yellow zone without knowing for a
while. I got a new peak flow meter as i was concerned that when i washed it,
that it may have damaged it. I have a much more stable one now, and can't
get as high score as before! (450 so far! So will have to start fresh with the
new set of readings for a high result now as i think the readings will be a bit
lower). She said that if my GERD continues, to see my normal doctor, and i
will ask about an allergist as well. She was going to change my coticosteroid,
but changed her mind and am still on the Clenil Modulite 100mcg (two puffs
twice daily) and now added a green Salmuterol inhaler 25mcg (same amount
as other inhaler). Is this what you were referring to for a breathing treatment?
Thank you for your help, if i have any questions again, is it ok to run it past
you through adding another question?

Answer
Hi Megan,

The breathing treatment I was referring to was a single treatment with salbutamol, a short-acting bronchodilator, to be followed after 15 minutes with another spirometry test to see how much improvement.

Here is a short, down and dirty guide to asthma therapy:

Asthma Stages:

1: Mild , intermittent asthma: two or less rescue treatments/WEEK during the daytime, or two or less night-time awakenings due to breathing difficulty/MONTH

2: Mild, persistent: more than two, but less than daily use of rescue medication/WEEK, or night-time awakenings of more than 2/month, but less than 5/month. Regarding the daytime use of rescue...this does not count using rescue as a pre-treatment before exercise.

3: Moderate, Persistent: daily daytime symptoms, and waking up more than once a week

4: Severe, persistent: daytime: continuous symptoms with frequent severe attacks and limited physical activity. Night-time: frequent awakenings.

Treatment:

1: Rescue inhaler, but no daily therapy. May take a daily antihistamine

2: Daily controller medication, like your Clendil, and rescue inhaler as needed. Sometimes use alternatives to the steroids, but the inhaled steroids are the "Gold Standard".

3: Inhaled Steroids: may increase the dose, or add a long-acting bronchodilator to the daily regimen. Assess the need for nasal steroid inhaler and/or GERD treatment. Assess the use of "allergy shots"

4: More drugs, and possibly oral steroids.

Critically: even from the beginning, must identify and eliminate as best possible those triggers in your environment

There is a lot more to this, but treatment is a step-by-step approach to control, and the treatment can vary through the year depending on how well you are doing, and how much seasons play a part in your health.

You are always more than welcome to ask further questions! :)

Sincerely,

Marc