Unexplained Breathing Problems

[Tesse]

Last December, I got a bad cough.  Two weeks later, I began having significant breathing problems, and I have had them ever since.  I have asthma, but it has been well controlled for years, and my peak flows have been fine throughout this whole process.  Prednisone seems to have no effect, and nebulizer treatments and my rescue inhaler seem to help sometimes and not help at all other times.  Pulmonary function testing, blood gases test, x-rays, C/T scans, echocardiogram, stress test, echo stress test, allergy testing, and a bronchoscopy have all come back normal (the pulmonologist who did the bronchoscopy said my brochial tube looked somewhat transparent and irritated but said that could be normal - the bronchial wash revealed nothing).  I've had multiple blood tests (thyroid problems, Lymes, etc.), and the only thing that showed up was that I have low iron (iron counts have been slowly improving since I've been on an iron supplement).  My doctor says "anxiety", but I have been on Celexa for months and am still having problems.  Nothing about my personality or life situation suggest anxiety issues, and I have a difficult time believing that someone who has never had anxiety problems could get a bad cough and suddenly develop anxiety issues so severe that they cause daily, persistent breathing difficulties.  If anyone has suggestions as to what I can do next, I would greatly appreciate it.  In the meantime, I will continue to trust in the sovereign control and provision of God - I know He has all of this in His hands.  Thank you!

[Tesse]

Thank you very much for responding - I appreciate your insight!  You asked what my breathing problems were like.  It varies a little bit, but mostly it's chest tightness and heaviness - sometimes it feels like there is something sitting on my chest.  It feels most uncomfortable to breath in - breathing out usually isn't an issue.  I do get out of breath more easily, especially if I sing or read aloud, but exercise doesn't seem to affect things any more than normal (which I find strange).  I still experience symptoms, when I exercise, and, of course, I experience the normal heavy breathing that accompanies exercise, but my symptoms don't seem to get any worse when I exercise.  It does take me a longer to recover from exercising than it normally would, but unless I'm having a very bad day, I'm generally able to exercise.

The vocal cord dysfunction is a good thought, but I'm afraid I may have had that checked already.  I went to an ear/nose/throat doctor, and he stuck a camera down my throat to check my vocal cords...I'm assuming such a dysfunction would show up on that test?  The ENT doctor said my vocal cords are ok.  I'll bring this up with my doctor again, though, since I will be having an endoscopy at the beginning of March.  Perhaps they can double check the vocal cords too.

I do have one more question for you regarding the possibility of this being anxiety-related.  I have been on Celexa for months, and I am still having daily problems.  If I have an anxiety problem, would this be normal?  Shouldn't I be getting much better after being on an anti-anxiety medication?  Thank you, and if you have any other thoughts, please share them - any help I can get is MUCH appreciated!

[David Tinkelman, M.D.]

You have provided a fine summary of the course of your illness and testing.  One manifestation of underlying asthma is so-called cough variant asthma, with which the sole or primary symptom is cough in the presence of normal or near normal air flow (normal peak flow measurements).  However, it is highly unlikely that this variant would be totally unresponsive to prednisone.  Also the normal results of cardiac testing suggests that your problem is secondary to occult cardiac disease.

I am uncertain about what is meant by “significant breathing problems”.  Is this a problem of breathing in, breathing out (in the presence of seemingly normal peak flows), or both?  And, did you experience these “breathing problems” during the stress ECHO?  

I assume that your breathing problems involve shortness of breath with exertion and that the bronchoscopy ruled out any kind of fixed airway obstruction as a cause of the shortness of breath.  Given that, seemingly normal pulmonary function and presumably normal cardiac function it is not surprising that your doctor might raise the question of anxiety, possibly the hyperventilation syndrome, being the cause of your symptoms.  But you do make some convincing points about anxiety being an unlikely cause.  

For me that still leaves the possibility that your “breathing problem” may be secondary to variable airway obstruction at the laryngeal level; that is to what is called vocal cord dysfunction (VCD).  This condition not infrequently develops after a harsh viral respiratory infection), or with the onset of Gastroesophageal reflux, (either potentially the cause of your cough).  Routine pulmonary function testing, that often does not include an inspiratory flow-volume loop, would thus be interpreted as normal.

I suggest that you raise this question with your pulmonary physician.

Good luck