Expert: Marc Rubin, RPh Asthma Educator - 4/7/2011

Question
QUESTION: Marc,
I was diagnosed with asthma back in 2008 as moderate asthma.Less than three years later noticed my asthma getting worse due to not getting enough air.I was originally prescribed qvar in 2008.In oct of 2010 allergist gave me a pred for a week and advair.Slight improvement in fev1 69%.Then less than a month 67% so he put me on prednisone burst for a month total but checked me after 2 and ahalf weeks fvc 85% fev1 67% and fev1/fvc 78% and was told i have asthma with copd and put on advair 150/50 discus and spiriva and told steroids didn"t work for me and a referal to a pulmonologist.Went to pulmo and did spirometey and my fvc was 97% and fev1 was 76% and fev1/fvc was 78% he said i had mild asthma and almost close to normal and that the prednisone had aggrevated my gerd and that was what the allergist thought i had copd due to low spirometry readings.I also live in a medium size town i have non allergic asthma diagnosed in my early thirties.I have a father with adult on set asthma a half sister who had asthma as a child and a mother who has copd along with many other family members.I smoked for 15 to 16 yrs a pack a day and quit a year and a half ago.I have been clearing kind of coughing up clear phleghm for months after a upper respitory infection and usually due from oct to march due to cold weather.My triggers are smoke,stong perfume or cleaning products,cold air,maybe dust.Can spiriva make lung function better on spirometry after 2 weeks?And do i have copd?I want to believe the pulmo and think it's mild asthma but the coughingup clear phleghm scares me.My chest x rays are normal but allergist said they would be with mild copd.I do use my albuterol once maybe twice a week in bad weather months.I have been taking omeprazole for over a month now for gerd and i have noticed late in the day i usually lose my voice.At night  i do cough a little but not when i'm asleep.I do feel a little congested but it feels like post nasal drip but i had a xray done on nose and came back clear.I'm at a loss i want to feel good and live a long healthy life.I am an overweight female and joining weight watchers soon.Any help advice would be grateful.I want my life back.Thank you,D

ANSWER: Hello DaShara,

I apologize for getting back so late. Escaped Chicago before the blizzard, but forgot to indicate that on this website.

To address our first question regarding the Spiriva, yes, Spiriva, which last more than 24 hours is a great drug to add to Advair when there is difficulty with control.

In regards to your second question, based upon the numbers you gave me, no, you do not have COPD....yet. If the FEV1/FVC ratio is lower than 70%, then you would clinically have COPD, and then the FEV1 would indicate which stage you would be at.

The fact that your mom has COPD is a strong indicator that your genetics would lead you in that direction. It is great that you quit, and I only hope you are not being exposed to second hand smoke. Over the next few years, more of your lungs will be clear of the tars, improving your oxygen exchange. The fact that you quit smoking does not necessarily keep you from developing COPD later, but the progression will be much slower, allowing a much longer quality of life. Keep in mind that, while there is a chance you may not develop COPD, the long term exposure you had to the smoking still increases your risk of lung cancer, so I'd strongly advise yearly preventative check-ups to evaluate your lung function.

Has your physician prescribed a steroid nasal spray for you? This would help to resolve your post-nasal drip, as well as keeping your asthma under better control. Nasal issues can and do trigger asthma attacks, so it is important to address that.

Also, there are two more prescription drugs to consider: 1) Vitamin D, 50,000 units, once a week. Low Vit. D levels are associated with poorer asthma control, and 2) statin drugs used for cholesterol have also been shown to lower lung inflammation in smokers and asthmatics.

I'm happy to see that you are planning on starting a weight loss program. That is outstanding! Consider this...when you lay on your back, all that weight is pressing down on your abdomen and diaphragm, making it more difficult for you to inhale. As you shed the weight, you'll sleep better, and awaken with more energy! Include an exercise program with the eating changes. Remember, this is a lifestyle change that should be permanent. Also, when you begin, take body measurements: hips, butt, waist, chest and arms. Note your clothing sizes. Don't get overly hung up on the weight scale. If you do commit to the exercise, note that muscle weighs more than fat, and as you build muscle, you burn more calories doing exactly the same everyday activities. In the beginning you'll see a pretty  quick loss of ~ 10 lbs, then it slows as you build muscle. But note the measurement changes! Clothes will be looser, eventually necessitating a freshened wardrobe to go with your shrinking figure. You'll look great, breath much easier and have more energy!! That's a win any way you look at it! Finally remember...those pounds didn't appear overnight, so just shoot for 1-1.5 pounds a week.

I hope this helps you to set your goals and keep them. To me, quality of life is EVERYTHING, and you seem to be on that road. Best wishes for your success!

Sincerely,

Marc

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

QUESTION: Thank you so much for your response.I'm curious though you said there's still a chance i could get copd.I thought copd was a smoking disease?If i have quit smoking and never smoke again is there still a chance of copd or could my lungs get stronger?Also,those last numbers i gave you with the pulmonologist i had been on spiriva for two weeks is that why my numbers improved?I have an appointment to go to a pulmonery function lab and scarred that now i'm not taking spiriva anymore my numbers will be lower.I'm glad you mentioned that my lungs are still geting rid of stuff in my lungs.I thought maybe it was chronic bronchitis.How long after you quit smoking do you cough or clear your throat of sputum and what color can it be?mine is always clear and more salivia than phleghm and sudafed seems to work the best.Thank you so much for this site and for your answers.D

ANSWER: Hi DaShara,

Quitting smoking does not reduce the risk of developing COPD, just as a non-smoker chronically exposed to the smoke may also develop the condition. There are genetic issues involved. 40% of smokers have the genetics that will result in the development of COPD due to exposure. 60% won't, but that does not mean that they are not susceptible to developing lung cancer or other cardiovascular condition like heart disease. 87% of patients with COPD are the due to smoking, 3% from a genetic defect with chemical deficiency, and the other 10% is environmental (like one of my customers who works in an auto painting shop).

Stopping smoking can dramatically slow the progress of thee disease, and improve quality of life, with less lung impairment and better breathing. But the tissue that was destroyed is gone, and that is not reversible. Depending on how much you smoked and for how long plays a role in how long it takes to get the lungs clear. Let's say 5 years would be a good point, with each successive day being another step in the right direction. As you progress, the color of the mucus will become clearer, and the greater fluids is helping to move the junk out of your lungs.If Sudafed helps, unless you deveolp a blood pressure issue, don't worry, just keep tabs on it with your doctor.

Continue your path in the right direction, but always follow up yearly with a chest exam to avoid other problems that can deveolp, like the bronchitis.

Good Luck!

Sincerely,

Marc

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

QUESTION: Marc,
You have been so helpful in the past that i was hoping you could answer a couple of questions for me?I have seen a pulmnologist and had a lab work up done.The doctor told me i have mild asthma with obstruction not sure if it's reversable.They did get my fev1 to 82% with albuterol 4 puffs.He said that i would only have problems from time to time and would not have to ever be on oxygen because of my lungs.The thing is since oct i have been sick every month except feb.I have been on 4 rounds of antibiotics and prednisone and even on a good day i feel like i have mucous in my chest and have developed a chronic cough since oct also.I have been tested for all allergies including food and have none.My regular doctor has given me medicine for possible gerd.I do get a feeling once in awhile of mucous running down the back of throat especially after being outside.I constantly cough up mucous and have tried claritin,sudafed,zertec,mucinex dm,antibiotics,benadryl.Please i need help and answers my regular doctor seems to be at a loss and the pulmonologist wants me to stay on the advair 250/50 discus.I want to start living my life and if it's mild asthma why am i having so many complications.Is there something i can take or not take to help me?How long will i continue to cough up mucous is this due to previous smoking?I also get mild chest pain and pain in middle to upper back.Thank you for your help,you are a godsend!D ..p.s..could it be the advair or possible candida due to the steroids?

Answer
Hi DaShara,

I just attended a conference, and a study regarding the use of Spiriva vs. Advair was discussed. There was a lower frequency of infections on the Spiriva therapy, and in fact, from initial diagnosis of COPD, the time to the first bronchial infection was significantly longer. It may be a better medication for you. The doctor may want to prescribe Pulmicort with it to reduce the lung inflammation. An advantage of Pulmicort is the ability to use it once a day, with the once-a-day Spiriva. Once the infections are fully resolved, you may be able to stop the Pulmicort until the fall.

In regards to the candida, it is extremely important to rinse your mouth after each inhalation. That generally eliminates the possibility of a mouth infection. The doctor can run tests regarding if the lung infection is candida, although I would doubt it.

It sounds as if you may have bronchitis. If this scenario repeats at the same time next year, then the correct diagnosis would be chronic bronchitis (two or more years in a row, at the same time each year). To possibly avoid this occurrence, I'd start the Pulmicort at the start of September, a full month before the weed and mold pollens really hit.

The mucous, as I mentioned before, may take quite some time to resolve to a more normal level. Keep in mind, asthmatics have an increase in the number of the type of mucous producing cell (goblet cells), which results in greater mucous production. You did not mention if the doctor put you on a steroid nasal spray. If not, I'd add it to your therapy. You'll begin to notice in just a few days the effect on post-nasal drip, and hopefully, less coughing and mucous to spit up.

The back pain may be due to poor oxygen exchange, although it may be unrelated. For the doc to investigate further.

Hope this helps!

Hear from you soon.

Sincerely,

Marc