Expert: Marc Rubin, RPh Asthma Educator - 12/22/2009

Question
QUESTION: I was diagnosed with asthma about 10 months ago at age 20, this is my first fall/winter with it and it sucks.  I don't feel like I have control over the symptoms lately and can't understand why.  The last 2 weeks I've been using ventolin 2-4 puffs a day on top of my Pulmicort 400, 2 puffs a day, which I've been on for roughly 8 months.  I have gone a full month in the summer with no ventolin use (June).  

I have allergies to dust mites and cats, however I'm almost to my maintence dose with allergy shots and haven't had any allergy symptoms in ~3 weeks.  I have very little ability to breathe out of my nose (ENT appointment in end of december) and my doc thinks it might be nasal polyps.  So at night and during any exercise I have to breathe through my nose.  I have using nasacort every day (2 puffs each nostril once daily), with about a 60% improvement.  

I live in Calgary, Alberta with 2 cats.  The temperature has dropped in the last day or so with a small dump of snow (4-5 inches I think).  This snow fall came down quick at 3-5pm and the roads turned to ice.  It took me 4 hours to get home (2 1/2 being on buses until the third one got stuck and I gave up).  I had my worst asthma attack when I tried to run a couple of blocks and have been very tight chested all night and today.  

I was placed on advair 250 HFA (2 puffs twice daily) last wednesday.  So at the moment I'm using advair 250, nasacort and ventolin.  The problem is that my peak flows are still hitting 350-380 (personal best=450) even though I feel like crap and couldn't sleep at all last night because I was so breathless.  Even now at 3pm, I'm coughing my head off everytime I try and walk up and down the stairs.  

Is there anything I can do to get the control back or is it all anxiety causing the problems (doesn't feel like it though)?  Shouldn't my asthma get better since my allergies are better?  Thank for any suggesstions.

ANSWER: Hi Tamara,

Asthma may vary seasonally, with some having worsening symptoms from October through the winter months. This has a few reasons: cold, dry air, with the dryness, increasing dust levels, increase in cold and flu (I hope you have had your flu shots, both the seasonal as well as H1N1), as well as a couple of lung infections which can trigger worsening asthma. Also, have you ever been evaluated for acid reflux? This irritation to the esophagus (right above the stomach), can trigger your asthma also, and the reflux is aggravated by anxiety. If you sense this sort of discomfort, you want to try Prevacid in the morning (it just went non-Rx).

I realize the cats are a part of your life, and that you are getting allergy shots to build your immune tolerance. One point that was probably stressed was to keep the cats permanently out of your bedroom. Lung function goes down at night, and inflammation in the lungs increases (just one of those biorhythms), and having the presence of animal dander in your bedtime living space just aggravates the situation. Of course, unlike with dogs, keeping cats out of ANYTHING larger than a pop bottle is easier said than done, as well as the issue of getting the cat dander out of the room, should you be successful. I know this point isn't very realistic, but it would be inappropriate to to mention it.

Do you have forced-air heating? If so, when did you last change your furnace filter? Use a good quality filter with folded membranes, rather than the cheap fiberglass ones.

Do you have a humidifier in your home? The heated element type produce a sterile mist that doesn't develop bacteria. Definitely belongs in the bedroom, plus other living spaces you are in most of the time.

Has your home been evaluated for mold? This is most common in homes with basements, but the mold may also occur under sinks, should there be any leakage. Again, the dry, winter air makes it easier for this to get airborne.

Now, on your device technique. When you use your Ventolin-HFA and Advair-HFA, you should be taking in long, slow deep breaths. You actuate the unit AFTER you have begun to inhale. It also helps if you are looking somewhat upward, like at a clock on the wall. This also improves the flow of air into your lungs, rather than looking straight ahead, where the airflow must turn 90 degrees, and more medicine is deposited on the back of the throat.

As I stated earlier, the cold, dry air aggravates the airways. It is really important to increase your fluid intake to keep your lungs moist. When outside under these conditions, I suggest you get a neck gator. It is like a turtleneck sweater, but w/o the sweater. They are generally made of PolarFleece, are inexpensive(~$10.00), and available at sporting goods stores, or online (http://www.activesportswearoutlet.com/unisex_ski_apparel/neck_gators.htm  > one of many sites). You pull it up over your mouth and nose, allowing you to breath in warmer, moister air,

I am concerned that, if all of the above is being properly executed, you should get in contact with your physician soon, not in a month. It is probably advisable to have you go on a short course of oral prednisone (3-7 days) to get you under control.

Besides the EENT, are you also seeing an allergist? I seriously advise it, especially if the EENT doesn't address your immediate situation without you having to wait a month.

Also, have you been provided with an "Asthma Action Plan"? It is a tool that guides your therapy during periods of worsening. You would already have the prednisone at home, and would only use it based upon the plan that you and your physician jointly agree to. Follow this link to download for yourself.

http://tinyurl.com/q5j2v

It is based upon both peak flow readings as well as symptoms. Just sometimes, breathing is so bad that just doing a peak flow can be very stressful.

A breathing technique has come out of Russia that seems to help some asthmatics. It is slow, shallow breathing. There are a number of links at YouTube, and here is one:

http://www.youtube.com/watch?v=dMixzD5GHJs&feature=related

While I personally don't endorse it yet (needs further study), without a doubt, the relaxation aspect IS important during an attack, so anxiety is lowered. It is worth looking at, although you may have some trouble due to your nasal issues.

This is a starting point. Let me know whether this helps, and we can go on to further steps.

Sincerely,

Marc


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

QUESTION: Thanks for the quick response.  I'm still on weekly allergy shots so I end up seeing a GP once a week before the shot.  I brought up the increasing ventolin use last wednesday and the doc gave me the advair to start using.  I saw an allergist last december for allergy testing and starting shots if possible but according to him I don't have asthma.  I was 81% of normal or higher when they need peak flow tests (fancy one that did 5 or 6 measurements).  I pushed my GP because I thought something was going on, got full pulmonary function tests done and it was noted I had air-trapping.  We then did a trial of advair diskus and massively improved my symptoms, then switched down to pulmicort on my request (due to cost).  

I have been using a heat humifier a lot the last couple of weeks, but I was told by both my allergist and GP not to use it because dust mites prefer high humidity.  

The furance filter is changed every 2-3 months and we recently did switch from the cheap ones.  

I tried the tip you gave about looking up during inhalation and it seems to have helped alot, my peak flow is back up to 400 (personal best 450) and I do feel better.  so thanks!! :)  I will be back to a doctor next wednesday for my shot (maybe, if asthma settles down) so I can touch base and see if I need to try anything else or just give more time for the advair to work).

I have a similar thing to the turtle neck, I just have to find it.

ANSWER: Hi Tamara,

Glad to see the improvement in your breathing with proper technique.

Regarding the humidity, you live in Calgary, not Miami!. I have trouble getting the humidity in my house up to 26%, and I live outside of Chicago. Mites are more of an issue if you have humidity above 40%. Last time I checked, you are not surrounded by a body of water, unless you are reading this in the bath. (A little humor here). I wouldn't necessarily run the humidifier all day, but I would turn it on about an hour before bedtime, for your bedroom. Also, humidistats are inexpensive, so you can monitor your room environment.

http://www.amazon.com/dp/B001QFZ3U0/ref=asc_df_B001QFZ3U0974116?smid=ATVPDKIKX0D

ADDITIONALLY, there are mattress covers made specifically to reduce the risk of dust mites. Here is a site for product reviews:

http://www.allergybuyersclub.com/compare-dust-encasings.html

Let me know how things go next week.

Sincerely,

Marc

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

QUESTION: Little update here.  Saw an ENT yesterday for possible nasal polyps and sinsitus, no polyps but a pretty good deviated septum and large turbicates(surgery to fix it is scheduled for June) and he ignored the post nasal drip problem, grumble.  

Still having some problems so I'm trying symbicort to see if it helps more than the advair and if not then my doctor says we are going to oral next week.  

I got the mattress, box spring and pillow covers as soon as I found out I had dust allergies.  

My final exams are done for the semster so hopefully the lowered stress will help :).  Thanks again.

Answer
Happy Holiday Tamara,

In reviewing all the posts, we never addressed whether you are on a nasal steroid spray, like Flonase or Nasonex. If you have NOT been on addressing the sinus issue, this is most likely the reason behind your inability to get the asthma under control. Inflamed sinus passages can and will trigger asthma flare-ups. So, if you are not being treated for the sinuses, this is definitely the next step. You would begin to get results in 3 days.

If not, and he prescribes one, get back to me so I can give you a link for proper techinque.

Second, unless the MD is thinking short-term oral steroids (less than 14 days), and you are already on a nasal steroid, the next step would be a trial of the oral medication theophylline, dosed at 5mg/kg/DAY. So, if you weigh ~ 135 lbs, which is ~ 60kg, your daily dose would be a time release theophylline , 300mg, once a day. Some patients genetically have a resistance to steroid therapy, and adding the theophylline, which is not a steroid, breaks the resistance.

Discuss this with your doctor, and lets see if we can start the New Year, with a New Tamara!

Sincerely,

Marc

Have a Happy and Healthier New Year!  :)