Expert: Marc Rubin, RPh Asthma Educator - 12/19/2010

Question
QUESTION: Hi actually i am having intermittent cough for last two years and mostly at night time , Always my nose block and most of the time and I feel the irritation in my throat with sputum after that dry cough start also I develop cough on exposure to perfumes,dust,bleach and specially smoke and I never feel difficulty in breathing just only cough in bouts.
Now and then I develop upper respiratory tract infection for that I am using antibiotic frequently. The Pulmonologist diagnosed me asthma I used simbicord inhaler but no improvement at all I used this almost one year but still the condition is same.
I am completely feed up from my cough   


ANSWER: Hello Dr. Mustafa,

If you can provide me with some additional information, I can probably narrow down some of the issues that are preventing you from achieving therapeutic success.

1)How old are you, and did you have any allergy issues growing up?
2)Do any of your family members have a history of allergies, asthma or eczema?
3)Do you have any eczematious or psoriatic skin conditions?
4)What city/region do you live/work in? Is it arid or semi-arid?
5)Do you have any pets at home?
6)Are you on any other medications of any type?
7)Did the pulmonologist do any skin testing for allergen identification?
8)Was spirometry performed with salbuterol?
9)Were your sinuses examined?
10) Regarding the Symbicort, if you could, explain the technique you use, including whether you inhale quickly or slowly.

Right now, for starters, I'd have you put on a nasal inhalation steroid such as fluticasone or budesonide. What may be occurring is that your sinuses are inflamed, and with the inflammation and sinus secretions, your throat is getting irritated, triggering the cough. There is a direct tie-in between rhinitis and asthma, and you cannot control asthma if the rhinitis is not brought under control. If spirometry was not done, or not done with salbuterol, I'd question the diagnosis of asthma, since rhinitis by itself may be responsible for your symptoms.

If you do begin the nasal steroid, it is very important that:
1) you first prime the inhaler the first time you use it insuring a fine mist. You'd first gently shake the bottle, then spray into the air ~ 5 times or until a fine mist is generated. After that, you'd only have to re-prime if you had not used it for a week or so, although you would shake the unit each time.
2) the spray should either be directed into the nare, or, with the bottle perpendicular to the floor, look straight down, and with the tip slightly inserted in the nostril, spray against the back wall of the nose.
3) Never spray up into the turbinaires. This increases the risk of nosebleeds and fungal sinus infections.
4)After spraying, sniff gently, and do not blow your nose for 15 minutes.

Looking forward to hearing back from you.

Sincerely,

Marc

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

QUESTION: Hello,

Thanks for your kind response.Actually i were out of country and with limited internet access that's why late response.
Here are the answers to your questions.

I am 32 years old and i am becoming allergic to everything,sometimes i feel that i will become allergic to even food and water also. i cannot tolerate cold, dust, and smoke. i am also allergic to cold water, cold drinks, fried things, perfumemes ,clorex.
My cousin having eczema and my 2 aunts and my uncle having asthma.
I dont have any skin problem except my skin is dry and i am frequently using moisturizer.
I live in Khobar city of Saudi Arabia.
I dont have pets at home.
I am having mild hypothyroidism for that taking 12.5 mg of thyroxin started 1 month back.
pulmonologist did not do any skin allergy test, he did pulmonary function tests ( with salbutamol), that were mildy decreased.
I also went to ENT doctor 1 year back she did not do my X Ray PNS, she started me with fluticasone inhaler and anti allergic medicine which i used for 1 month but no improvement.
I am rotating the inhaler to right and then left and then inhaling quickly.
i used sigulare tablet that is mast cell stabilizer for 1 month and i found little improvement, i could not judge either it was from inhaler or tablet.
i left using the inhaler now for almost 1 month and my condition same as before. meanwhile i developed pharyngitis also, took antibiotics fpr that.

Looking forward for your reply.
Thanks
With Regards

Answer
Hi Dr. Mustafa,

Well, for starters, and I'm sure you are already aware, you have a strong atopic family history. Not surprising is your strong response to dust/smoke and chemical irritants. Here is what I'd like to look at objectively:

1)skin testing for allergens

2)cbc w/ differential: looking at elevated eosinophils and, due to your hyper-responsiveness to non-atopic triggers, also neutrophils and macrophages.

3)IgE level: I'm concerned about the potential of an immune disorder

4)Do they do eNO (exhaled nitric oxide)? If so, it is a quick test for pulmonary inflammation.

Regarding the drug therapy:

a) Fluticasone inhaler therapy: improvements first become noticeable at 4-6 weeks, and reach maximum benefit at 6 months. When initiating therapy in a patient with moderate symptoms, I prefer to add a long-acting beta-adrenergic bronchodilator such as salmeterol, then re-assess after 30 to 60 days, and, if doing well, step back to fluticasone alone.

b) Singulair works for ~ 40% of the patients. I don't know how it was prescribed for you, but it should be in the evening before bedtime. If it was taken in the morning, I'd expect a lower response.

c) your doctor may want to try a different nasal steroid ( and for that matter, inhalation steroid> I'd recommend budesonide for both. In the area of pharmacogenomics (the role that genes play in drug response) you may potentially have a better response to this than the fluticasone. I'd first try switching the nasal spray. If, after 1 week, your sinuses are improved, then I'd go ahead and also change over on the inhaler.

Further:

If available, I'd get a portable HEPA air filter for home and office, to reduce the dust loads. In addition, if the relative air humidity is very low (due to the prevailing winds out of the west), if yo don't already, I'd have a humidifier in your home, or at least your bedroom.

Let's see how the tests and everything else goes.

Sincerely,

Marc