Am I under-medicating my attacks?

[nscangal]

Hey,

I'm a 22-year-old female with what may seem like an elementary question for this community. I've had asthma since I was a kid, but it became mostly asymptomatic when I was a teenager, so I'm having to re-learn a lot of how to manage it (when I was little, my parents did most of the "work" of managing my asthma). I caught the flu, then a cold, and wound up with my asthma going from mild, intermittent asthma to moderate-to-severe persistant asthma in less than a month. Suffice to say that, after six months, I'm only just starting to get it back under control. Currently, I'm on Advair 500, Singulair, and nasonex and an anti-histamine to manage the allergies that aggravate my asthma.

My doctor has told me to use my inhaler whenever I feel I need it, but I'm not sure what that means, exactly. I always use it when I'm having a really bad coughing fit or if I'm feeling very short of breath, but should I be using it every time my peak flow drops into the yellow or if I feel even a little short of breath? If that's so, then I'm under-using it a lot... normally I don't feel I really need it until I'm in the lower half of my yellow zone.

Thanks.

[ill13632]

my problem is I wheeze when I exhale and my FEV1 is 69.  is FEV1 a better measure of lung function than peak flow meters?  I'm afraid I have airway remodeling.  I've also been trying spiriva and it seems to help

how high a dose of prednisone do you have to take to get adrenal fatigue?  I could finally sleep ok on 50mg

[nscangal]

To be honest, I've been on inhaled steroids off-and-on since infancy. I've never had serious effects from them. I -have- had serious effects from asthma - including hospitalization, pneumonia, and complications of anaesthesia during surgery.

Given my choice between a small risk of steroid side-effects versus the much larger risk of disability or death from uncontrolled asthma, I'll take the small risk of steroid side-effects, thanks. I rather like breathing well enough to function.

As it happens, though I'm not a medical professional, I do have a firm grounding in pharmacology. I've read the information available in the journals I have access to about the medications I'm on. I've decided that for me, the benefits outweigh the minimal risk of steroid side-effects. As I said, I like breathing well enough to function.

[Victoireh]

Steroids are the mainstay of asthma. They are extremely effective, and are prescribed at the lowest dose needed to control symptoms. If asthma remains out of control then Permanent damage may result or death in rare cases. This is not an option. Also steroids are so effective in controlling asthma that many patients can lead normal lives with very few symptoms.

The doses used in steroid inhalers do not cause adrenal fatigue. It is a rare occurrence when it does happen. Adrenal fatigue occurs primarily when one is taking oral steroids over longer periods of time. Particularly at higher doses.

Steroid inhalers are used in other conditions, but are not nearly as effective as for asthma. The difference lies in the different components that are present in the mucous of other lung disorders. Asthma has a proportion of eosinophils, which is very responsive to steroid inhalers. Where as the mucous in COPD is comprised mainly of neutrophils, which is found to have a very low response rate to steroids. Only severe COPD patients who have a degree of eosinophils in their mucous are given steroid inhalers, as they will have some benefit for them.

[allmymarbles]

I am really worried about you using Advair (an inhaled steroid plus salmeterol). It affected my adrenal glands which resulted in adrenal fatigue, I grew facial hair (unfortunate for a woman), my head hair thinned, I developed coughing that escalated to choking (so bad I feared one day I would choke to death), and I even started to develop eye problems. These symptoms started to appear after a couple of years, but I did not realize they were side effects; I just thought I as getting sicker.

So I got off it. Now I take natural anti-inflammatory and mucolytic (mucus thinner) supplements that work better than Advair ever did, and without any side effects. I take 1000 mg. of vitamin B5, a full dropper of mullein extract, and 1/2 tsp. of MSM daily. My coughing is much relieved, my sinus headaches have disappeared, and the hair fell off my face. My breathing is better than it has been for years. However, I am being  treated for the adrenal fatigue, and the eye problem is being resolved (I hope). Pharmaceutical houses can't make any money from supplements and doctors, brainwashed by drug house detail men, don't recommend them. (Well, doctors were never trained in nutrition anyway, were they?)

The only medications I am using now are an anti-histamine and nebulized albuterol. I have a portable nebulizer which fits into my purse. It is about the size of an inhaler and runs on batteries. The advantage to a nebulizer is that you can take as little as you need to get the asthma under control Mine is put out by Omron and is really great. I don't use an inhaler anymore.

By the way Nasonex is also a steroid. Has your doctor ever warned you of the side effects of steroids? No? I didn't think so.

[nscangal]

I know. I've been working with my doctor to try to figure out what's up. She says it's really wierd - I'm compliant with asthma treatments (to the point of giving up my pets), I avoid allergens, and so on. There's nothing either of us can think of that may be behind the stubbornness of my asthma to get back under control, except that I do have a history of difficult-to-control asthma. When my asthma is good, it's really good, like no-medication-needed-to-control-it good, but when it's bad, it's really bad and practically nothing will get it to behave completely, though inhaled steroids do help a bit.

The main issue I experience is fatigue. If I'm having a bad day, I have to go home from work just because I'm too tired - even walking around can be exhausting (like today, which I'm glad is a day off). My other major symptom is coughing, which shows up if I'm anywhere lower than about 90% of my peak flow, and gets worse the lower I go - if I'm down to 70% or so, I'm coughing almost uncontrollably, and the coughing fits themselves are enough to give me a headache, sore throat, and a sore chest, and they just exhaust me.

As bad as my attack was on Thursday, I'm much better than I was in the summer (I was using my rescue inhaler 5-10 times a day then; now even on a bad day, I rarely hit more than 3 or 4, and about one day in two I don't need to use it at all). I think I'm slowly starting to bring it under control. It's just taking a while.

Part of the problem is that it had a good month or so to get going before I got onto the right treatment (I was misdiagnosed by doctors that wouldn't listen to my medical history a few times - I was told it was everything from a stubborn chest cold to another flu to a bacterial lung infection), and then I was fairly controlled until my allergy season in June made my lungs go crazy again. So now my lungs are really inflamed and the inflammation isn't going down easily.

[Victoireh]

Your asthma is definitely not in control. Even on days where your peak flows are stuck in the yellow zone will make you feel tired and miserable. You don't have to be just about dead to start considering a problem. To be in the Red zone is bad. Especially for those of us whose lungs fill up with so much mucous that it takes a number of weeks before you even see the green zone again. It's debilitating.

Using peak flows is useful in the sense that it lets you know that you are out of the green zone. I will admit that I don't even notice when I am in the yellow zone, except for feeling tired. I don't sense my other symptoms well, and that is why I use the peak flow meter. Yes it is just a rough indicator of how much obstruction in going on in your lungs.

Just keep up with the doctor visits and continue trying to find ways of getting your asthma under control and your quality of life back, which is very important for feeling good about your self and those around you.

[Tammy2009]

I'm the other way around.  I get symptoms of chest tightness and coughing before my peak flow really drops that much.  A quick drop of 10% will cause me to have trouble breathing and need my inhaler.  If I don't take it then I'm coughing and tight for 3-4 hours and it normally rights itself.  

Never had a super bad attack so I'm not sure about any of that, just the mild symptoms.  

Unless I have a lot of smoke exposure, my peak flow in the morning tends to tell me if it's going to be a rough day or not.  My symptoms tend to hinge on how much I was able to breathe during my nose and get a good night's sleep.  No sleep and lots of muscous drainage = normally chest tight day.

[nscangal]

As for peak flow staying in the yellow.. it doesn't so much to that as swing wildly - in a day, I can go from 520 (near my best) all the way down to 330, and back up to the low 400s. I never seem to hit the red zone - always in the lower part of the yellow zone when I have a bad attack, but then again, I can be blue with a pO2 of 80% and still have a peak flow in the yellow  (as seen yesterday, when my doctor called an ambulance because I had a nasty attack in her office). But it doesn't even swing wildly consistently lately... In a week, I might have a day or two where I stay in the green zone consistently, a day or two where I'm mostly in the yellow, and three days where I swing all over the place. I don't really know what's going on with it - I take all my meds, avoid my allergies, and so on (heck, I even gave away my cats because they're triggers for me). It's frustrating.

My symtoms are mostly coughing, chest tightness and shortness of breath... I don't wheeze unless it's so bad that I'm about to pass out and peak flow isn't that great an indicator for me (yesterday I was blue with a pO2 of 80% and my peak flow was 340... not even in my red zone). I keep track of my peak flow for my doctor, but I take the number with a grain of salt.

[caregiver222]

I would not worry a bit about the "peak flow meter". Use medication when you feel the need for it. The problem with asthmatic attacks is that you can go downhill very, very rapidly, like "falling off a cliff". Once everything becomes constricted an intubation may be the only treatment that can open the airways. The sudden onset of a severe attack can make you unable to even get into the house to find your inhaler. Generally speaking "sooner is better". I am a bit enthusiastic over Foradil, which acts very quickly and lasts a long time. The Foradil acts just about as quickly as albuterol, although the package inserts specifically state that Foradil is NOT an emergency medication. Even if you don't use Foradil regularly, I think it is best to keep it in reserve.

[choo_choo]

I was told today that I under-medicate my attacks.  I don't always use my inhaler when I meet yellow zone criteria, sometimes I kind of "wait it out" and use it if I've been in the yellow zone for a while.  My doctor was clear that sooner is better than later and I shouldn't be hanging out in the yellow zone.  I don't get in the red zone very often at all, but if I do, it's at night and I wake up in a pretty bad state in which case I'm fast to react.  No hanging out in the red zone for me.        

[Victoireh]

Large diurnal swings, such as you have with going into the red zone, is a definate lack of asthma control. My dips into the yellow zone are because I have lost a bit of lung function,  and so I probably should adjust according to my new best peak flow number. My specialist said that this is something I have to live with. Probably due to airway remodeling.

But if you have been able to reach your best peak flow number and still dip into the yellow, then yes I agree it is a sign of a lack of asthma control.

[Super_sally888]

Hmmm.... I have something similar.  Lately I've been well into the red zone in the early mornings - nearly every morning.  Last night woke up feeling difficulty breathing and I was about 25% (about 90, when my max is about 350).  But I have found that if i do nothing and don't worry about it, it will improve after a while. Last night, however I did take ventolin, which worked and I was fine for the rest of the night.

But that is not what the drs would recommend.  They would want you to take meds when you are in Yellow zone.  You will have to listen to your body.  No need to use meds if it is 'mild', but you need to be in tune nad if it is getting worse not better should take action.

[Victoireh]

Yup, I do the same thing. Some shortness of breath with exertion clears on its own. Coughing doesn't bother me either, unless I get sudden shortness of breath with it. I only take it when I really feel I need it. Like you I have the long acting bronchodilator, which helps keep you in the green zone for most of the time. If you go out of it sometimes and after taking your fast acting inhaler, you should be fine. But if your peak flows stay in the yellow zone for more then a day or two, it means you need more aggressive treatment.