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Medical Forum / Diseases and Disorders / Asthma / October 2006exercise induced A is back, wheezing, albuterol not working
I have learned a lot from this group and I regularly check it on new ways of dealing with asthma. I was wondering if anyone can share what they feel when an exercise-induced attack occurs, how the attack develops, and how long it takes to end. I am trying to relate to an experience I've had today. Last winter I have developed asthma after a viral sinus infection (the current theory of my docs). THe asthma has gradually improved over the last ~8 months (I've tried all standard things - prednisone, Singulair, Advair, antibiotics, sinus rinses, so it's hard to tell what helped, this could also be just my body adapting). I even was able to start running and cycling again, I am very athletic. For the last couple of months I've been just taking Adviar, nothing else, and I figured I should try racing agin. Today I decided to give it a shot and joined a low-key bicycle race - an all-out effort for <20 min up a hill. Half way into the race I started feeling a spasm/soreness in my upper throat. Nothing special, nothing that can slow me down, and I've felt that before; it usually did not cause an attack. So I pushed all the way to the end. The soreness/pain in the throat remained after the finish, and mostly went away after 30 min. However, I have developed a nasty weeze in my chest several hours after the race, of magnitude I've never had before. It's been lasting for the whole day after the race and it would not go away no matter how many puffs of Albuterol (chamber) I take. I can still blow 700-750 on the peak flow compared to a firm 750, and keep coughing up yellow chunks of flem. I am puzzled why this stuff took so long to develop. If I had started wheezing during the race I'd have stopped. But a soreness in the throat did not seem like a big deal. Does an event like this mean that the full-blown asthma is back, and I am now back to point A? It's also disappoinitng that I was able to finish the race no problem, but paying the cost many hours after the race, and that Albtureol does not do anything. Are nebulizers more efficient? >I have learned a lot from this group and I regularly check it on new > ways of dealing with asthma. [quoted text clipped - 32 lines] > the cost many hours after the race, and that Albtureol does not do > anything. Are nebulizers more efficient? Usually exercise induced asthma (EIA) starts soon after the start of the exertion and then lets up after 15-30 minutes. You symptoms may be asthma and may have been brought on by the exercise in some way but they don't sound classic for EIA. It sounds like you should try going back up on the preventative meds. At the very least you could try taking the albuterol before the event (and maybe 6 hours later in your case - or just take one dose of Serevent/Advair). Nebulizers do deliver more medicine and they take out the issues of inhaler technique. For most people they medicine in two puffs of the inhaler is more than enough and the extra medication delivered in the neb does not do much more good. Some people do do better with the nebs. Have you checked out www.asthmastory.com and considered an infection cause to your asthma?  Signature00doc oodoc, Yes, I have gone through a complete course of antibiotics with Dr. Hahn, with no effect. I wonder why I was never proscibed a nebulizer - only inhalers. I've been on preventive meds before this happenned (advair 500/100), and it did not prevent the attack. I did discontinue Singulair though. I am getting progressilvely worse every day after the recent asthma relapse, even though I have quit exercising. > >I have learned a lot from this group and I regularly check it on new > > ways of dealing with asthma. [quoted text clipped - 48 lines] > Have you checked out www.asthmastory.com and considered an infection cause > to your asthma? BTW, I just found out that in competitive athletes inhaled steroids have no effect on asthma, as opposed to the effect in the sedative patients (reviewed in SPorts Medicine, 2005, 35(7) p 565-). This is sort of consistent with what I have experienced once. I once have discontinued the Advair and replaced it with Spyreva (which is just the steroid, w/o the beta-agonist - right? I think my doc was concerned about deaths caused by the b-agonist). I ended up in ER in the next few days after switching to SPyreva. Going back on Advair has stabilized me again. So, is it just the long-acting beta agonist that keeps me running? Scary. So, if the inhlaed steroids don't remove the inflammation, then, what does? Should I travel out of California and stay away for a month, and come home? Did a 10-day trip like this once, felt completely cured, and everything returned once I got back to the Bay area In addition, I am used to seeing that treatment strategies are built around the inactive patient. No matter how bad I am feeling, my volumes are still ~30% better than the predicted. But I am feeling worse relatively to my own self, not to the "average". If I suddently got the average lung volumes I'd probably drop dead. Some of the docs I've stopped seeing just could not get it. > BTW, I just found out that in competitive athletes inhaled steroids > have no effect on asthma, as opposed to the effect in the sedative > patients (reviewed in SPorts Medicine, 2005, 35(7) p 565-). > > This is sort of consistent with what I have experienced once. I think that depends on what you are looking at. I can believe that steroids to not prevent exercise induced asthma if that is really all that is going on. I think for many asthmatics the exercise symptoms are part of a bigger picture of generally out of control asthma. As I discussed in a previous post your symptoms are not classic for simple EIA. > I once > have discontinued the Advair and replaced it with Spyreva (which is > just the steroid, w/o the beta-agonist - right? Spiriva is not a steroid. It is a long acting dilator that works in a different way than the beta agonists. It is in the same class as ipatropium (Atrovent). > I think my doc was > concerned about deaths caused by the b-agonist). I can understand that. I think he should feel only slightly more confortable with the Spiriva. The long acting agonists may be a problem because they are being used instead of anti-inflammatories and leaving people less controlled than they think. Spiriva may be no better in this regard. Some of the problem may be that they keep the beta receptors saturated and so less responsive to rescue meds. In this regard Spiriva would be better. Or there could be something else going on. > I ended up in ER in > the next few days after switching to SPyreva. That is not surprising. Meds like Atrovent and Spiriva are usually more useful in smoking related lung disease and not as effective in asthma. > Going back on Advair has > stabilized me again. So, is it just the long-acting beta agonist that > keeps me running? Scary. I don't know. It could be the steroid or the agonist. The only way to find out would be to experiment with then individually. > So, if the inhlaed steroids don't remove the inflammation, then, what > does? I don't know how much of an evaluation you have had. Seeing a pulmonoloigst to confirm the diagnosis and make sure it is nothing else would be a start. You also could try looking for other triggers like allergies and GERD. Lastly you could try other preventatives like Singulair and other steroid products. > Should I travel out of California and stay away for a month, and > come home? Did a 10-day trip like this once, felt completely cured, and > everything returned once I got back to the Bay area It sounds like that would be a short term solution. > In addition, I am used to seeing that treatment strategies are built > around the inactive patient. No matter how bad I am feeling, my volumes > are still ~30% better than the predicted. That is the pitfall of using the stadardised norms. It applies mostly to peak flows. With full spirometry they can compare the flows at different points to each other and come tot he diagnosis even if you are starting at 130%. For instance, if your peak flow, FEV1, and FVC are all at 120% of expected but your FEF 25-75 is only 100% thent hat would be a possitive test for obstruction. > But I am feeling worse > relatively to my own self, not to the "average". If I suddently got the > average lung volumes I'd probably drop dead. Some of the docs I've > stopped seeing just could not get it. That is sad. I think people who have never been athletes have a hard time understanding that kind of thing. Ask them how they would feel if they suddenly found that they could understand the articles in People Magazine but not the ones in The New England Journal of Medicine. In that case I would keep looking for opinions. Signature00doc 00doc, Thanks for the great response. May I ask how I can separate the steroid and the beta-agonist? Which drug is the steroid analog of Advair, but does not containthe beta-agonist? What are the classical symptoms of EIA, then? I am definitely allergic to something in the Bay Area. E.g. going to the High Sierra in the summer fro 1 week has almost cured me (reversibly). Another doc I am seeing prescribed me with sinus rinses which I've been doing for a month by now (no effect though). I was also considering exercising in a mask. I am currently been treated by arguably the best pulmonologist in CA, so I can't see how the expertice of the doc can get any better here. At the same time, I am amazed how many things I discover online on my own which he never told me. E.g. the Spyreva thing - how could he not know that it works mostly for smokers? He did figure out that he needs to use my base line. He compares my own volumes, takes ratios, and finds that from day to day I can vary by ~15%. Thanks again, I truly appreciate your attention. > 00doc, > [quoted text clipped - 3 lines] > drug is the steroid analog of Advair, but does not containthe > beta-agonist? Serevent/salmeterol is the beta agonist (long acting version of albuterol). Flovent/fluticasone is the steroid that is in Advair. In the US two puffs of the 110 would be equivalent to the 250/50 of Advair. > What are the classical symptoms of EIA, then? Usually wheezing starts shortly after the start of exercise (within 30 minutes) and then usually goes away shortly after that (again, within 30 minutes) and then does not return (it enters a refractory period). Some asthmatic athletes manage their EIA by doing a vigourous warm-up about an hour before competition to the point of wheezing and then stop until it goes away. It generally will not return during the competition. Simply pre-treeating with albuterol or other meds is the easier and more often solution and is usually very effective. > I am definitely allergic > to something in the Bay Area. E.g. going to the High Sierra in the > summer fro 1 week has almost cured me (reversibly). I agree. Have you seen an allergist? > I am currently been treated by arguably the best pulmonologist in CA, > so I can't see how the > expertice of the doc can get any better here. At the same time, I am > amazed how many things I discover online on my own which he never told > me. E.g. the Spyreva thing - how could he not know that it works mostly > for smokers? I'm sure he did know it. He probably just didn't explain that when trying you on it. It is reasonable to try different things if the normal stuff doesn't seem to be working. Signature00doc > Have you seen an allergist? Yes, I had skin tests done and I am allergic to tree and glass pollen. This was not news to me: I've been allergic to pollens all my life, and my sinuses are usually full, especially in the spring. But I guess in CA it's always spring. The doc who has prescribed the sinus rinses has mentioned that the amount of stress put on sinuses is 10K higher than in places with season change. Is CA known for being an especially stressful place for allergics/asthmatics? And is it accepted that a permanent inflammation going in the sinuses can produce a full-blown asthma? Before the asthma the sinuses were just a meer nuisance, nothing that could ruin my day. |
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