Expert: Marc Rubin, RPh Asthma Educator - 8/2/2009

Question
Dear Marc,

I have not felt good since December; I have had repeated respiratory infections and have had a lot of antibiotics including Augmentin 4 grams daily for 10 days.  As a nurse, I decided that it was extremely urgent to to to an immunologist to see why i have been repeatedly sick.  I was positive for all types of skin testing and have always had bad allergies.  this past year I have never been so sick in my life.  I guess it's a pumishment for not being sick as a child.  The doc gave me symbicort which seemed to make things worse.  The last straw was the shortness of breath that had developed after the last infection.  It was the icing on the cake after an uneblievable cough in whic I barked like a dog.  I thought I had croup or whooping cough.  As I said the Symbicort made things worse so I was put on flovent which seemed to be fine and albutero in case I got tight.  That made my throat close so They switched me to Xoponex which I have had to use very rarely.  When I did use it, Within an hour I had some tightness still.  My throat feels like it is constantly going to close, always spasming during which I can sing Soprano notes and not feel like being choked.  The majority of the time I can get a full deep breath in through a very small opening in the trachea.  The cough left me with a wheeze in my trachea only not in my lungs.  I have no nocturnal episodes.  I often thought about vocal cord dysfunction since the s/s are very similar.  I also have Gerd very bad and have failed four medicines.  I just got a endo test and sigmoid done; nothing remarkable showed other than bad gastritis and esophagitis.  When the doc did PFT/s,  I hardly showed a reversible response.  I felt just as tight after the brochodialator than I did before.  There was a slight increase from 78 to 82 percent.  He told me a had a very mild asthma and to just stay on the flovent bid.  However, I have had chest tightness for days and chest pain, but i's not as if I had to go to the ER if I didn't use the Xoponex.  No one with mild asthma should have chest pain and tightness throughout the day every day.   To me that's severe ashtma.  And, as I said the brochodialator doesn't do much.  I have read that Gerd can cause asthma, but people have been misdiagnosed with asthma or should I say ashtma symptoms because the presence of acid in the esophagus can cause wheezing.  I swear I am ingesting acid.  What I go thru after eating is beyong phonemenal. with gas indigestion, etc even it taking Carafate.  Yesterday, it seemed like I was coughing up milk or cereal, and I have acid up to my eyeballs;  I can't drink enough water to keep the sourness down.  I am also tasting acid and wondering if it is poisoning my lungs.  I decided to seek a second GI opinion.  As far as The asthma,  I would have thought that the doc would have put me on singulair or Zyflo.  He thought that would be jumping the gun when I asked.  I can't imagine why.  Why let s supposed mild asthma become something worse.  Do you think that I might have an nresolved respiratory infection or lingering bronchitis?  I have been in perfect health most of my life.  All I've done is go to doctors and take pills.  My job demands too much of me to endure this.  I think it's time to see a pulmonologist?  What are your thoughts?  Sorry so lengthy.    Thanks, Colleen T. Gormley

Answer
Hi Colleen,

I have concerns regarding the pft's. Most practitioners have not taken the NIOSH certified course for spirometry, but rather a short 2-4 hour training session. In pulmonary research, it is mandatory that the people doing the test must be NIOSH trained to insure the validity of the procedure. Done correctly, it could clarify issues as to VCD, COPD, asthma, CF, sarcoidosis, other interstitial lung diseases, etc. I've been to a couple of courses (non-NIOSH), and a presentation by the NIOSH instructor here in Illinois, and the instructor, Dr. Robert Cohen, made it clear that without proper training, all you get are cosmetic results. Yes, you obtain values, but they are not valid.

That being said, there are two approaches to take on determining the diagnosis of asthma. First, the basic spirometry with albuterol bronchodilation, like you had. For the diagnosis of asthma to be made, you must show an improvement in FEV-1s, greater than 12% post albuterol, and a 200ml volume improvement. Of course, if you take the test while in excellent lung health with minimal inflammation and no bronchospasm, that approach would be negative, Then you would also do a methacholine challenge, whereas you receive methacholine after the baseline spirometry, and  evaluate for pronounced bronchoconstriction, which would be seen in an asthmatic. Although your atopic history points to asthma, there may be other co-morbidities that are complicating the matter.

Other factors are genetic. There has been a lot discovered on the phenotypical variations that are present in asthma which result in therapeutic failures. Some asthmatics, although predominantly in Afro-American population, have a variant beta-2-agonist receptor where at site 16, rather than being glycine-glycine or glycine-arginine, are homozygous arginine (arg-arg), and do not respond to the short-acting b2-agonist rescue, such as albuterol, but the patients do respond well to the anticholinergics, e.g.ipratropine and tiotropine. This could be the case for you. This arg-arg does not appear to prevent the efficacy in the long-acting b2-agonists, as seen in Symbicort. This is where I get concerned whether the differential diagnosis was properly evaluated when it pointed to asthma. In addition to this beta-agonist issue, there are also genetic variations which effect the efficacy of the different steroids & leukotriene inhibitors.

And speaking of steroids, when you first presented, or at any time thereafter, where your breathing was compromised, did your physician ever put you on a short course of oral steroids?

Regarding your GERD...are you a coffee drinker, or heavily into chocolates? If yes to either, elimination is necessary. Also, recent studies are questioning the value or proton pump inhibitors (Aciphex, Protonix, Prevacid, etc.)in having any benefit to asthmatics, or those with bronchospasm triggered by reflux. Personally, I prefer Aciphex in the morning and famotidine (Pepcid) in the late evening top control the acid, with the possibility increasing the famotidine to twice daily.

Do you have any sinus issues going on? Rhinitis and sinusitis will trigger increased inflammation and bronchoconstriction. If this is the case, the sinuses will need to be treated with nasal steroids to get them under control also. Fortunately, improvement is seen within just a few days.

Additionally, have there been any changes in your home environment prior to the onset of all this?

Do you smoke?

Personally, while the above may help to guide you, I really feel you need to see a pulmonologist which will look at your case and do a complete differential diagnosis from square one. The infections you have had, in combination with being a healthcare provider may indicate an increased risk for sarcoidosis. This is where a co-morbidity may come into play, and the lack of response you are seeing towards some of your therapy. In no way should you misconstrue this as my diagnosis, but your presentation is anything but black and white.

Let me know how this goes, and when the diagnosis is clearly nailed, then we can go from there.

Sincerely,

Marc