Expert: Marc Rubin, RPh Asthma Educator - 9/2/2010

Question
QUESTION: Hello, I am a 19-year-old female living in Hawaii; my suburban community is located sort of on a hill. I am a college student with a dog at home. I was born at 25 weeks premature, but the only thing that seems to be affected is my vision (I have ROP).

Because I was born so early, I was put on a ton of medications I don't know the names of as well as given all the tests needed to make sure everything was working. I had something fixed in my heart, however, and only recently has the new doctor I'm going to found a heart murmer. I just had an EKG done but I haven't got the results back yet.

When I was younger, I remember being on the nebulizer for athsma, but as I got older, I stopped taking it for some reason. My pediatrtion has also diagnosed both of my younger brothers with athsma, but it's very mild -- so mild that I think they're only on meds if they're sick. When I was probably around twelve or so I remember developing a cough; it was a wet cough probably due to a coold or something, but my pediatrition put me on advair and albuteral for it. That worked. The cough came back whenever I was sick and the same treatments were prescribed.

But now -- for the past few years -- I've had this dry cough that I was never too concerned about. Lately, within the past year or so, however, it's become much more chronic. Along with this, I do experience chest tightness or heaviness sometimes. In addition to the cough, I have some gastro issues that I had initially thought was GERD (which would also explain the cough). But I had ultra sounds done that came back normal so that's still up in the air.

Another issue I have is thirst; I can drink more than a gallon of water a day because I'm always thirsty and I...pee a lot because of it. My mouth does not feel necessarilly dry, but my throat feels like it needs to be soothed by water, warm or cool. I was checked for diabetes melidus and I don't have that; I have a meeting with an endocrinologist coming up soon to see whether it's diabetes insipidus. What I think, though, is that my cough has something to do with it.

My cough is a dry, deep cough that sort of sounds like a bark. Sometimes, when I drink tea with milk in it, it helps to losen the cough. My doctor put me on advair again (which I take twice a day) as well as an emergency pro-air enhailer (which I've been having to take for the chest tightness more frequently than I probably should). I think my doctor did that because of my athsma history, but I'm wondering if it's cough-varient athsma.

Another symptom I have is that sometimes, very randomly, my nose sounds like it's congested. Like, if someone is sick, you can hear the congestion when they talk; only, my nose isn't running...it just sounds like it. I do notice, however, that I have mucus in the back of my throat that I often swollow. The thing is...the coughing is dry so it doesn't expell anything but I know something's in there because I'm having to swollow it.

I had a chest x-ray done and the only thing it showed was that my sternum is bowed -- how much so, I don't know. I've been tested for TB and the results were negative. The athsma treatment, which I've been on for about a week now, seems to work for a little while -- I don't feel like I have to cough. But then, after a few hours, the cough comes back. Sometimes it comes back with chest tightness, which prompts me to take the pro-air; that works for a little while, too, but then it flairs up before the time I am supposed to take either of the meds again. (Advair is every twelve hours, pro-air is every six).

Recently, I've been noticing that I wake up with a dry, sore-ish throat and a slightly horse voice. I also am not able to sing much now and it takes a bit of effort to speak without the scratchiness. This concerns me because I'm a singer. I think this is due to all the coughing. I don't know if my throat is inflamed or anything, but it very well could be. The coughing seems worse in the morning, mid afternoon, and late evening; sometimes I cough so much I get light-headed. It's beginning to hurt when I cough – that could be the chest tightness but I can't say for sure.

One thing i've noticed about my nasal congestion is that it sometimes begins in the shower. I figure it's because of the humidity, but even once I'm out of the shower, it's back. Other times it just randomly sounds congested. I don't think foods agrivate anything really...if anything, it's the stomach problems not the sinus/chest problems. My grandma has been talking to me about maybe going back to the nebulizer because my cough is that bad, but I don't want to do it before I talk to my doctor. And I'm going to change doctors soon because the one I'm with now doesn't seem to be the right fit. My family has a history of athsma and allergies as well.

So...I guess my question would be...what's wrong with me?

Thanks so much for reading my rant.
Yana

ANSWER: Hi Yana,

It may be that your cough is being triggered by allergic sinusitis. You made no mention of taking any nasal spray, such as Flonase, Nasacort Aq, Veramyst, etc. The tissue in the sinus airways, when inflamed, can also trigger your asthma, to give you that tight chest feeling.

Regarding your albuterol rescue inhaler, when you are having a flare-up, does it resolve the attack, and in what time frame from administration?

In addition to ROP, premies are also much more likely to get RSV: respiratory syncytial virus, an asthma-like infection that in many cases is outgrown by 5 years of age.

I don't know if you have been tested to determine what allergens you are sensitive to, but in regards to you dog, it should NEVER be in our bedroom. Lung function naturally goes down overnight, and inhaling the dog dander compromises your lungs even further. My wife learned this the hard, obstinate way. She was down 35% from normal, at which point, I installed a movable gate, shampooed the carpets, wiped down the walls and changed all the linens. That night was the first night since we first got the dog that she slept w/o even her nose getting stuffed up. Prior to that, she had insisted she was allergic to me. So if your dog spends time in your room, follow what I did on this issue, and you should show improvement.

Good luck in regards to the endocrine workup.

Please get back to me in regards to your sinus issue, and if you are on any other medications, please list them with your dose and frequency.

Sincerely,

Marc

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

QUESTION: Hi, Mark, thanks so much for getting back to me so quickly.

As far as the nasal sprays go, I've never taken any. As far as the enhailers go: I take the advair in the morning and the cough remains for maybe less than an hour before it goes away (with minor coughing throughout the day). The cough usually comes back about two hours before my second doese is due. As for the rescue puffer: that works within seven minutes and I feel better -- my breathing is easier -- but then the cough comes back within four hours.

I'm wondering if I should ask the doctor to switch me to a different daily enhailer or something.

Yes, my dog is my roommate...I probably don't keep my room as breathing-friendly as possible, though.

Oh, one more thing I forgot to mention--my coughing generally gets worse in the evening (maybe 5:00 or 6:00) as well as around 1:00 or 2:00 in the afternoon.

Can sinuses be inflamed without mucus? I do sometimes get very mild, less-than-a-minute-long headaches.

Sorry if this is a bit disjointed, I just have a lot to ask. Can I tell you a little more about my cough? It's sort of barkish and coming from my chest; it may be from the strain of coughing, but my chest sometimes hurts for a little while (not a major pain, just a tinge). Sometimes (actually, most times,) my cough will get better for an hour or two after taking the puffers but then it'll just come back almost as bad as before. And it doesn't just happen at home, either; I could be anywhere, and I'll still cough.

I hope I answered what you'd asked me to, Mark. Again, I'm sorry for the ramble of thoughts, but I felt that I had to explain...hopefully I did a good job.

Thanks again,
Yana

PS- I haven't been tested for alergic triggers.

Answer
Hi Yana,

The doctor should try a course of steroid nasal inhaler, such as fluticasone. It is used once a day, with one spray into each nostril. You would see improvements within 3 days. If this does not work, then I'd advise you to see an allergist for a full evaluation to get to the bottom of your problem, so it can be resolved.

Should the physician prescribe the spray, here are the directions for proper administration:

http://www.flonase.com/use/howto.html

Let me know how this goes.

Sincerely,

Marc