Expert: James Lee Barlitt, RN, LNC, NREMT-P, CRT - 3/25/2001

Question
I am a 68 year old male.  Normally in pretty good health.  Having problem with a treadmill stress test, went to respitory doc, did tests and she said I had a little emphysema.  Put me on Azmacort, Atrovent and Albuterol.  Used all for a few weeks, but began to lose my voice EVERY DAY as the day progressed.  Respitory doc sent me to an ENT who said I was having 'occult reflux'.... Don't feel any reflux symptoms (day or night) but the voice continues to disappear.  Stopped using the Azmacort, but still am losing my voice daily apparently due to the effect of the "hidden" reflux. (No one but my ENT seems to know what 'occult reflux' is..) I have followed all of her recommendations to stop the reflux to no avail.

I read on the net the possibility of meds that opened airways also effecting the sphyncter that controls reflux.  Can you verify this for me, and/or point me to the article or one that discusses this possibility?  Have you heard of any problem like this before?  I am driving my family and myself insane with this voice (and lack thereof.)  I would like to find the article again and print and take it to both the ENT and the Respitory doc for their assessment.

Any comments, based on your experience, would be appreciated.


Answer
I just wanted to follow-up with you after your reply.  Especially after your comment on the ENT doc. Raising your head of the bed is good advice.  These Doctors, atleast some of them, take patients apart over ridicolus things, getting blown off is a good example, he should have told you again stressing why he was suggeting it.  But ego's get in the way, he probably wrote in your chart you were non-compliant because you didn't follow each and every detail.  The bad part of it is, if another doctor or nurse sees that, they don't give their all because you won't follow advice because you're non-compliant, so they don't give their best to you.  I hate that phrase and I get into with doctors and nurses all the time.  "well he didn't take the medicne I prescribed, so he's no complaint" No you arragant 2@#%%#@@%^, it's because he doesn't have insurance and the drug you ordered doesn't have a generic and cost $300.00 a month, he not non-complaint, he's broke.  One of my pet peeves, can not stand that word.  If he blows you off, get another Doctor, what they sometimes forget in their hurried practise with only 5 minutes for a patient, is that they may be professionals, but they work for you.  You don't have to put up with an employee who has an attitude, and their supperoity complex are too much at times.  If he doesn't see you, he doesn't make money, therefore he works for you.  It is supposed to be a partnership, you, the nurse, the doctors all of you working together as a team.  It is good advice to raise you head at night, as it will help with the reflux.  Anything else I can do let me know.  Thanks for your nice comments, Jim







Hi Fred,
 OK here it goes, the term "Occult Reflux" is just a term that the ENT is using, but there is some significance of this, but first;  (to follow the URLs listed below, just copy them and put them into your browser window and punch go.)

occult
Obscure, concealed from observation, difficult to understand.
reflux
A backward or return flow.

So essentially the ENT doc is saying that you have GERD, Gastric Esophageal Reflux Disorder or sometimes referred to Disease, however Disorder is more appropriate.

GERD
Stands for Gastroesophageal Reflux Disease, a disorder in which there is recurrent return of stomach contents back up into the esophagus, frequently causing heartburn, a symptom of irritation of the esophagus by stomach acid. This can lead to scarring and stricture of the esophagus, which can require stretching (dilating).10% of patients with GERD develop Barrett's esophagus which increases the risk of cancer of the esophagus. 80% of patients with GERD also have a hiatal hernia.

Here is an URL that describes Barrett's Esophageal,
http://www.medicinenet.com/Script/Main/art.asp?li=MNI&ArticleKey=2056

http://www.gerd.com/articles/abstracts/35.htm  This article, though technical, references specifically occult and reflux.  This is where the ENT is getting from the terminology of "Occult Reflux".

Essentially the reflux, though you claim no symptoms, can cause the distal end of the esophagus at the entrance of the stomach, which is referred to as the cardiac sphincter, is weaken which is allows more GERD, which causes more weakening, and so on, but because of the constant reflux can turn those cells into another type as outlined by Barrett's Esophageal.  These cells can become cancerous.

Now reflux can also irritate the voice box and cause Reflux Laryngitis, which could be one of the reasons for losing your voice.  Note these articles can be printed and taken to your doctors.
http://www.medterms.com/script/main/art.asp?articlekey=5272

http://www.medicinenet.com/Script/Main/art.asp?li=MNI&ArticleKey=464 this URL ties Reflux Laryngitis & Gastroesophageal Reflux together.

Now let move on to the medications; Atrovent list hoarseness as a potential side effect, all of them can cause an upset stomach, and all three could be causing a subtle allergic reaction, which is affecting your voice.  Just in case you were not told, rinsing your mouth out after using Azmacort needs to be done after you use it, as it is a steroid and can kill off all the good bacteria in you mouth and cause a fungus growth (thrush).  Do not stop taking Azmacort suddenly if you have been taking it for a few weeks. You may need a gradual reduction in dosage before you stop taking this medication, because it is a steroid.

Azmacort - triamcinolone
  
Pronunciation: trye am SIN oh lone
Brand: Aristocort, Aristopak, Azmacort

What is the most important information I should know about triamcinolone?
•  Do not stop taking triamcinolone suddenly if you have been taking it for a few weeks. You may need a gradual reduction in dosage before you stop taking this medication.
•  Take triamcinolone with food or milk to lessen stomach upset.
•  Carry some type of medical identification that will let others know you are taking triamcinolone in the case of an emergency.

What is triamcinolone?
•  Triamcinolone is in a class of drugs called steroids. Triamcinolone reduces swelling and decreases your body's immune response.
•  Triamcinolone is used to treat many different conditions. It is used to treat endocrine (hormonal) disorders when the body does not produce enough of its own steroids. It is also used to treat many immune and allergic disorders, such as arthritis, lupus, severe psoriasis, severe asthma, ulcerative colitis, and Crohn's disease.
•  Triamcinolone may also be used for purposes other than those listed in this medication guide.

Who should not take triamcinolone?
•  Do not take triamcinolone if you have a serious bacterial, viral, or fungal infection. Triamcinolone weakens your body's immune response and thus its ability to fight infection.
•  Before taking this medication, tell your doctor if you have
     · high blood pressure or heart disease,
     · kidney disease,
     · diabetes mellitus, or
     · any other medical conditions.
•  You may not be able to take triamcinolone, or you may require a lower dose or special monitoring during treatment if you have any of the conditions listed above.
•  Triamcinolone is in the FDA pregnancy category C. This means that it is not known whether triamcinolone will harm an unborn baby. Do not take this medication without first talking to your doctor if you are pregnant.
•  Triamcinolone passes into breast milk. Do not take triamcinolone without first talking to your doctor if you are breast-feeding a baby.

How should I take triamcinolone?
•  Take triamcinolone exactly as directed by your doctor. Do not take more or less than is prescribed for you. If you do not understand these directions, ask your pharmacist, nurse or doctor to explain them to you.
•  Take each dose with a full glass of water.
•  Take triamcinolone with food or milk to lessen stomach upset.
•  Measure the liquid with the dropper provided or with a special dose-measuring spoon or cup. Ask your pharmacist for a dose-measuring spoon or cup if you do not have one.
•  If you are taking one dose daily, take that dose before 9 a.m. if possible, so as to follow your body's natural cycle. If you take more than one dose daily, space the doses evenly throughout the day as directed by your doctor.
•  Do not stop taking triamcinolone suddenly if you have been taking it for a few weeks. You may need a gradual reduction in dosage before you stop taking this medication.
•  Carry some type of medical identification that will let others know you are taking triamcinolone in the case of an emergency.
•  Store triamcinolone at room temperature away from moisture and heat.

What happens if I miss a dose?
•  If you take one dose daily, take the missed dose as soon as you remember. However, if you don't remember until the next day, skip the dose you missed and take only your regular daily dose.
•  If you take more than one dose daily, you can either take the missed dose as soon as you remember, or you can take two doses (the one you missed plus your regularly scheduled dose) when it is time for your next dose.
•  If you take one dose every other day, take the missed dose as soon as you remember, then go back to your regular every-other-day schedule.

What happens if I overdose?
•  Seek emergency medical attention. A single large dose of this medication is unlikely to cause symptoms or death. An overdose is more likely to be caused by a chronic overdose--large doses taken over a period of time.
•  Symptoms of an overdose include obesity (especially around the stomach); a round face; increased hair growth (especially around the face); acné; bruising; increased blood pressure; swollen hands, feet, or ankles (fluid retention); and sore or weak muscles.

What should I avoid while taking triamcinolone?
•  Use alcohol cautiously. Acting together, alcohol and triamcinolone can be very damaging to your stomach.
•  Avoid sources of infection. Wash your hands frequently and keep them away from your mouth and eyes. Your immune system may be weakened while you are taking triamcinolone.
•  Avoid immunizations during treatment with triamcinolone unless your doctor approves.

What are the possible side effects of triamcinolone?
•  If you experience any of the following serious side effects, stop taking triamcinolone and seek emergency medical attention:
     · an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives);
     · increased blood pressure (severe headache or blurred vision); or
     · sudden weight gain (more than 5 pounds in a day or two).
•  Other, less serious side effects may be more likely to occur. Continue to take triamcinolone and talk to your doctor if you experience
     · insomnia;
     · nausea, vomiting, or stomach upset;
     · fatigue or dizziness;
     · muscle weakness or joint pain;
     · problems with diabetes control; or
     · increased hunger or thirst.
•  Other side effects that occur only rarely, usually with high doses of triamcinolone, include
     · acné,
     · increased hair growth,
     · thinning of your skin,
     · cataracts,
     · glaucoma,
     · osteoporosis,
     · round face, and
     · changes in behavior.
•  Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect triamcinolone?
•  The following drugs may decrease the effects of triamcinolone:
     · barbiturates such as amobarbital (Amytal), secobarbital (Seconal), and phenobarbital (Luminal, Solfoton);
     · cholestyramine (Questran);
     · ephedrine (used in many over-the-counter cough, cold, allergy, diet, and energy preparations);
     · phenytoin (Dilantin) and ethotoin (Peganone); and
     · rifampin (Rifadin).
•  Triamcinolone may not be as effective if it is taken with any of the medicines listed above.
•  Other drugs may increase the effects of triamcinolone and lead to side effects:
     · birth control pills;
     · estrogens such as Premarin, Ogen, and others;
     · ketoconazole (Nizoral); and
     · erythromycin (Ery-Tab, EES, E-Mycin, others), azithromycin (Zithromax), and clarithromycin (Biaxin).
•  Before taking this medication, tell your doctor if you are taking any of the medicines listed above. You may require a lower dose of triamcinolone.
•  Drugs other than those listed here may also interact with triamcinolone. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines.

Atrovent - ipratropium inhalation
  
Pronunciation: ih prah TROE pee um
Brand: Atrovent
What is the most important information I should know about ipratropium inhalation?
•  Do not use ipratropium inhalation if you have a soya lecithin allergy (e.g., an allergy to soybeans or peanuts).
•  Ipratropium inhalation is not intended for use during acute bronchospastic attacks (asthma attacks or difficulty breathing). It may not be able to open your airways and allow you to breath. Ipratropium is better used to prevent these attacks.
•  It is very important that you use your ipratropium inhaler properly, so that the medicine gets into your lungs. You doctor may want you to use a spacer with your inhaler. Talk to your doctor about proper inhaler use.
•  Seek medical attention if you notice that you require more than your usual or more than the maximum amount of any asthma medication in a 24-hour period. An increased need for medication could be an early sign of a serious asthma attack.

What is ipratropium inhalation?
•  Ipratropium inhalation is used to prevent bronchospasm. By preventing narrowing of the airways, ipratropium increases air flow to the lungs.
•  Ipratropium inhalation is used to treat lung diseases such as chronic bronchitis, emphysema, and sometimes asthma.
•  Ipratropium inhalation may also be used for purposes other than those listed in this medication guide.

Who should not use ipratropium inhalation?
•  Do not use ipratropium inhalation if you have a soya lecithin allergy (e.g., soybeans or peanuts).
•  Before using this medication, tell your doctor if you have
     · glaucoma (narrow angle), which may get worse if you use ipratropium; or
     · an enlarged prostate or a bladder obstruction, which also may get worse if you use ipratropium.
•  You may not be able to use ipratropium inhalation, or you may require a lower dose or special monitoring during treatment if you have either of the conditions listed above.
•  Ipratropium inhalation is in the FDA pregnancy category B. This means that it is unlikely to harm an unborn baby. Do not, however, use ipratropium inhalation without first talking to your doctor if you are pregnant.
•  It is not known whether ipratropium passes into breast milk. Do not use ipratropium inhalation without first talking to your doctor if you are breast-feeding a baby.
•  Ipratropium inhalation is not approved for use by children younger than 12 years of age.

How should I use ipratropium inhalation?
•  Use ipratropium inhalation exactly as directed by your doctor. If you do not understand these instructions, ask your pharmacist, nurse, or doctor to explain them to you.
•  Shake the inhaler several times and uncap the mouthpiece. Breathe out fully and place your lips around the mouthpiece. Take a deep, slow breath as you push down on the canister. Hold your breath for several seconds, then exhale slowly.
•  Rinse your mouth after each use of the inhaler.
•  It is very important that you use your ipratropium inhaler properly, so that the medicine gets into your lungs. Your doctor may want you to use a spacer with your inhaler. Talk to your doctor about proper inhaler use.
•  Seek medical attention if you notice that you require more than your usual or more than the maximum amount of any asthma medication in a 24-hour period. An increased need for medication could be an early sign of a serious asthma attack.
•  Keep your inhaler clean and dry. Keep the mouthpiece capped to avoid getting dirt inside it. Clean your inhaler once a day by removing the canister and mouthpiece and immersing it in warm water or alcohol. Allow the parts to dry, then reassemble the inhaler.
•  Store ipratropium inhalation at room temperature away from moisture and heat.

What happens if I miss a dose?
•  Use the missed dose as soon as you remember. However, if it is almost time for your next regularly scheduled dose, skip the missed dose and use the next one as directed. Do not use a double dose of this medication.

What happens if I overdose?
•  An overdose of this medication is unlikely to threaten life. If you suspect that a very large dose has been taken, call your doctor or poison control center for advice. No symptoms of an ipratropium inhalation overdose have been reported in the past.


What should I avoid while using ipratropium inhalation?
•  Avoid getting this medication in your eyes. If this happens, rinse your eyes with water.

What are the possible side effects of ipratropium inhalation?
•  If you experience either of the following serious side effects, stop using ipratropium inhalation and seek emergency medical attention:
     · an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives); or
     · a racing heart rate.
•  Other, less serious side effects may be more likely to occur. Continue to use ipratropium inhalation and talk to your doctor if you experience
     · headache or dizziness;
     · dry mouth, cough, or hoarseness;
     · nausea, vomiting, or constipation; or
     · blurred vision.
•  Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect ipratropium inhalation?
•  The following drugs may increase the side effects of ipratropium:
     · atropine,
     · belladonna,
     · clidinium (Donnatal),
     · dicyclimine (Quarzan),
     · popantheline (ProBanthine),
     · mepenzolate (Cantil),
     · methantheline (Banthine),
     · methscopolamine (Pamine), and
     · scopolamine (Transderm-Scop).
•  Before using ipratropium inhalation, tell your doctor if you are taking any of the medicines listed above.
•  Drugs other than those listed here may also interact with ipratropium inhalation or affect your condition. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines.

Albuterol- albuterol inhalation
Pronunciation: al BYOO ter ole
Brand: Airet, Proventil, Proventil HFA, Ventolin

What is the most important information I should know about albuterol inhalation?
•  It is very important that you use your albuterol inhaler or nebulizer properly, so that the medicine gets into your lungs. Your doctor may want you to use a spacer with your inhaler. Talk to your doctor about proper inhaler and nebulizer use.
•  Seek medical attention if you notice that you require more than your usual or more than the maximum amount of any asthma medication in a 24-hour period. An increased need for medication could be an early sign of a serious asthma attack.

What is albuterol inhalation?
•  Albuterol is a bronchodilator. It works by relaxing muscles in the airways to improve breathing.
•  Albuterol inhalation is used to treat conditions such as asthma, bronchitis, and emphysema.
•  Albuterol inhalation may also be used for conditions other than those listed in this medication guide.

Who should not use albuterol inhalation?
•  Before using this medication, tell your doctor if you have
     · heart disease or high blood pressure,
     · epilepsy or another seizure disorder,
     · diabetes,
     · an overactive thyroid (hyperthyroidism), or
     · any type of liver or kidney disease.
•  You may require a lower dose or special monitoring during therapy with albuterol inhalation if you have any of the conditions listed above.
•  Albuterol inhalation is in the FDA pregnancy category C. This means that it is not known whether albuterol inhalation will harm an unborn baby. Do not use this medication without first talking to your doctor if you are pregnant.
•  It is not known whether albuterol passes into breast milk. Do not use albuterol inhalation without first talking to your doctor if you are breast-feeding a baby.
•  Albuterol inhalation is not approved for use by children younger than 4 years of age.

How should I use albuterol inhalation?
•  Use albuterol inhalation exactly as directed by your doctor. If you do not understand these directions, ask your pharmacist, nurse, or doctor to explain them to you.
•  To use the inhaler:
     · Shake the inhaler several times and uncap the mouthpiece. Breathe out fully and place your lips around the mouthpiece. Take a deep, slow breath as you push down on the canister. Hold your breath for several seconds, then exhale slowly.
     · If you take more than one dose at a time, wait for at least 1 full minute, then repeat the procedure.
     · Keep your inhaler clean and dry. Keep the mouthpiece capped to avoid getting dirt inside it. Clean your inhaler once a day by removing the canister and immersing the mouthpiece in warm water. Allow the parts to dry, then reassemble the inhaler.
•  To use the solution for nebulization:
     · Measure the correct amount of medication with the dropper provided or select the prescribed number of ampules. Transfer the liquid into the medication chamber of the nebulizer. If your medication has a dropper, do not allow the dropper to touch any surface including your hands or the chamber of the nebulizer. Dilute the medication with normal saline if prescribed by your doctor.
     · Attach the mouthpiece or face mask to the drug chamber. Then, attach the drug chamber to the compressor. Sit upright, in a comfortable position, and put the mouthpiece into your mouth or put the face mask on, covering the nose and mouth. Breathe slowly and evenly until all of the medicine has been inhaled (usually 5 to 15 minutes). The treatment is complete when no more mist is formed by the nebulizer and the drug chamber is empty.
     · Clean the nebulizer after a treatment as directed by the manufacturer.
•  If you also use a steroid inhaler, use your albuterol inhaler or nebulization solution first to open up your airways, then use the steroid inhaler as directed.
•  It is very important that you use your albuterol inhaler or nebulizer properly, so that the medicine gets into your lungs. Your doctor may want you to use a spacer with your inhaler. Talk to your doctor about proper inhaler and nebulizer use.
•  Seek medical attention if you notice that you require more than your usual or more than the maximum amount of any asthma medication in a 24-hour period. An increased need for medication could be an early sign of a serious asthma attack.
•  Carry your inhaler or nebulizer and solution with you at all times in case of emergencies. Get a refill before you run out of medicine and before going on vacation.

What happens if I miss a dose?
•  Use the missed dose as soon as you remember. However, if it is almost time for your next regularly scheduled dose, skip the missed dose and use the next one as directed. Do not use a double dose of this medication.

What happens if I overdose?
•  Seek emergency medical attention.
•  Symptoms of an albuterol overdose include angina or chest pain, irregular heartbeats or a fluttering heart, seizures, tremor, weakness, headache, nausea, and vomiting.

What should I avoid while using albuterol inhalation?
•  Avoid situations that may trigger an asthma attack such as exercising in cold, dry air; smoking; breathing in dust; and exposure to allergens such as pet fur.

What are the possible side effects of albuterol inhalation?
•  Stop using albuterol inhalation and seek emergency medical attention if you experience any of the following serious side effects:
     · an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives); or
     · chest pain or irregular heartbeats.
•  Other, less serious side effects may be more likely to occur. Continue to use albuterol inhalation and talk to your doctor if you experience
     · headache, dizziness, lightheadedness, or insomnia;
     · tremor or nervousness;
     · sweating;
     · nausea, vomiting, or diarrhea; or
     · dry mouth.
•  Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

What other drugs will affect albuterol inhalation?
•  Before using albuterol inhalation, tell your doctor if you are taking any of the following medicines:
     · a beta-blocker such as atenolol (Tenormin), metoprolol (Lopressor, Toprol XL), propranolol (Inderal), and others;
     · a tricyclic antidepressant such as amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), and others;
     · a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), phenelzine (Nardil), or tranylcypromine (Parnate);
     · another inhaled bronchodilator; or
     · caffeine, diet pills, or decongestants.
•  You may not be able to use albuterol inhalation, or you may require a dosage adjustment or special monitoring during treatment.
•  Drugs other than those listed here may also interact with albuterol inhalation or affect your condition. Talk to your doctor and pharmacist before taking any prescription or over-the-counter medicines.

Just to let you know, On Exp.com, Inforocket.com I answer these questions for money, this is my self-imposed civic duty, I just wanted to bring this to your attention, not suggesting you owe anything, but It would have cost you a pretty penny on those other sites. With that said, with a smile on my face, if you need any further information or if the information is confusing, just let me know and I'll try to simplfy the answer, so feel free to reconact me if you have ANY questions at all.  Your doctors are not explaining things to you, they work for you, your paying their salary, make them tell you these things so you understand, you should never walk out of the doctors office with questions. Pharmacist sometimes appear pretty busy, but they are a geat resource when it comes to the medications.  I've pack alot of info, remember to print off those web pages, to bring into your doctor.  Because they rush you, you sometimes forget to ask questions, the night before, write them all down and hand them to your doctor and tell them to drop the medicalize and explain it so you understand.  Best of luck, and again, please feel free to contact me.  One more note; If you develop any worsening of your problem, seek immediate attention by contacting your doctor. Do not attempt to change medication or start self-treatment without first consulting your doctor. Thank you for contacting me, you made me think, I like that! Jim      (www.nac4you.com)