VERY confused

right heres a puzzler for all those who are wise in this department.

I went to see new cons today and we did some tests.

Excersise Test:

Basicly for 6 mins i had to wear a sats meter on my wrist. nurse recorded my rest sats at 98%. By the end of the test this had dropped to 94%, bearing in mind that i was wheezing and she even recorded that in the notes and was somewhat concerned as i was just walking.

it took 5 mins for me to return to rest point and had to use my inhaler afterwards.

ABG:

she then took some blood for an ABG, from my ear lobe of all places which i was a little bemused from. this showed that my blood oxygen was 95% at this point.

then heres the confusing part, i went in to the consultant, heres how the conversation went:

C: so how have thinge been since we last saw you?

W: in all honesty not so good, i had another attendance at A and E back in stafford, ended up havin 2 nebs, a steriod jab and pred for a week

C: well i'll have to take your word on that one, as it was in another hospital and i wasn't there

W: ok fair enough, so whats going on from here then?

C: well, i really dont think your asthmatic at all, (looks through notes) but theres a confirmed diagnosis from your previous consultant so as the medications arent doing you any harm, we'll keep them going as you may have asthma underlying but its not causing the problems at the moment, your spiros are staying at 82% and i dont think theres any obstruction

W: so what is wrong then?

C: your just hypoventilating and overbreathing is all, its a mental thing, but its easier to get out of situations when you can say oh i have a medical condidtion, look how uni students drop out using ME as an excuse. to differentiate between your hypoventilation and asthma, id suggest trying to ignore it at first, see if it goes away on its own, THEN medicate as needed.

am i wrong in thinking that theres something a little off here? or am i really going completely loco

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Hi Wendy,

Sorry to hear that you've had such a confusing and off-putting consultation. It must be extremely frustrating, when you've been told one thing, to now be being told something completely different.

I'll just explain a bit about hyperventilation and about the tests that you had, if that's alright, then I'll talk about your consultant. I know you realise that no-one can or should try to diagnose you over the internet, but perhaps some general comments will be useful.

Hyperventilation (over-breathing, breathing more rapidly than normal) is extremely common - most asthmatics will have done it at some point - and can occur in conjunction with asthma and also on its own without coexisting asthma. To an extent, breathing more rapidly is a normal response to being wheezy or having an asthma attack - it is the body's way of trying to maintain your oxygen levels in the face of lungs that can't get air in quite as well as they should. In fact, people who don't hyperventilate somewhat during an acute attack tend to be the ones who run into problems with high carbon dioxide levels and acidosis (blood that is too acidic), which ultimately can lead to needing intubation and ventilation. A degree of hyperventilation, during an acute attack, is therefore a good thing!

The problems start when people hyperventilate when they are not having an asthma attack, or hyperventilate too much during an attack. This can happen as a response to anxiety, or just as a learnt response to difficulty in breathing - a 'bad habit', if you like. This causes problems for several reasons - it means that your carbon dioxide levels can go too low, causing symptoms like pins and needles, numbness and cramps in your hands, numbness around your mouth, and a general feeling of unwellness and panic. Breathing too rapidly can also irritate your airways and make any coexisting bronchospasm due to asthma worse. The unpleasant symptoms of low carbon dioxide, and the worsening asthma, then makes you panic more and possibly over-breath more, so the whole thing can become a vicious circle.

Hyperventilation can be very difficult to distinguish from asthma, and as I said, the two can exist together. It's important to treat both, if you have both, as they both have slightly different treatments. Hyperventilation is usually treated by a physiotherapist, who will first assess your breathing patterns, and then may suggest some breathing exercises to retrain you to breathe more appropriately.

The diagnosis of hyperventilation is usually only made after a thorough review of the history of your episodes, and several tests to look at the way your lungs are functioning. Obviously, I don't know exactly what history and tests your consultant had access to when he made that diagnosis, so I can't really comment on whether he was correct or not - and it wouldn't be very appropriate for me to try to do so. A blood gas when you are having an episode is often helpful - if it shows a low carbon dioxide level, a normal or high oxygen level, and a high pH (ie, blood that is not acidic enough) this can be suggestive of hyperventilation, in conjunction with other tests and the physical examination. It may be that your consultant saw this sort of pattern in the blood gas you had - you don't mention what the other results were.

The fact that you were wheezy and dropped your sats slightly on the exercise test would seem to suggest that you do have asthma, with or without hyperventilation, although as I said it's impossible - and potentially dangerous - for me to try and make a diagnosis over the internet. This does seem to be supported by what your previous cons thought, though.

Incidentally, the blood gas you mention, done from the ear, is a Capillary Blood Gas (CBG) rather than an Arterial Blood Gas (ABG) - it's more or less equivalent to an ABG, but slightly less accurate, which is why it's not often used when you're acutely unwell.

Now - in terms of the issue with your consultant. I'm sorry you've gone through this and have been left feeling so confused. It certainly sounds like his manner leaves something to be desired. Even if he does feel that some or most of your problem is hyperventilation, the comment about it being easier to get out of situations seems a bit uncalled for. You have a right to be listened to and treated with respect, and if you don't feel that you are being, or you are unhappy in any way, you have a right to ask for a second opinion.

There are a few things you could do to try and get a clearer picture of what is going on and convince this cons that there is a problem, though. Do you keep a peak flow diary? A diurnal variation in peak flow, and peak flows before and after medication, would be a good way of getting to the bottom of how much of your problem is asthma. Another thing that would be well worth doing is to try and get copies of your blood gases if you have an admission or A&E attendance at another hospital - gases when you are having an acute attack will be very useful to your cons. If he persists in thinking that hyperventilation is the main problem, then you could ask to be referred to a physiotherapist to be taught breathing exercises - this may be of benefit to you, and will also help to make the diagnosis.

Please don't attempt to do breathing exercises without being fully assessed by a doctor or physio first - doing them unsupervised or doing the wrong kind of exercises can be dangerous.

Hope this helps a bit

Take care

Em H

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Hii!

I have been in a similar situation.

Before I was diagnosed I kept having these attacks during PE class where I was having lots of trouble breathing, and then my face turned blue, then I went to the doctors, and they did a peak flow test, and concluded that it was hyperventilation, and that i should beathe into a paper bag if it happened again. And so it did, and I got a paper bag, and I started breathing into it and eventually went unconscious. Back to the drs. then suddenly I had a problem with my heart, and they did lots of tests on my heart, but no problem there. Then I moved to a different country, got a new doctor, he told me I had exercise induced asthma. Later on it worsened and I had symptoms while i was not doing exericise, then I got sent to a consulant and have been under once since then.

I have not done the exercise test, but I have done loooots of other ones. Have you? if so, did they show signs of asthma? My advice would be to go to see a different consulant/doctor if possible, to get a 2nd opinion. I think that ruling out asthma and saying it is all psychological could be very damaging in different ways. Firstly, asthma is dangerous, and if it is not controled it could be life threatening. Secondly, I think it is completely absurd suddenly telling your patient that ""it is psychological"" becaue that alone could also lead the patient to ignoring the symptoms etc. which would not be good.

I don't think that it is you going loco, but rather your consulant. Especially if your sats dropped that much, and you were clearly wheezing.

I would be so annoyed if I were in your position right now.

I hope you sort it out, and let us know how it goes!

Good luck!

Haagz

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thanks Em and Hagandaz

just as long as its not me being silly, he made me feel like a right old hypochondriac. I am goin to see the GP soon to get copies of all the notes from episodes, and take them to next appointment in september, as well as any future ones which may occurr.

been looking at hypoventilation online, now, for someone who just hypoventilates i dont get ANY of the symptoms, is that a little odd? the only time i get pins an needles is in my feet cos ive been sitting on them

I do keep a peak flow diary and have started doing a before/after medication result just to show how well meds are working.

thanks for the support, i am just very frustrated, its like 2 steps in the wrong direction, its taken this long for other doctors to convince me theres something wrong, so why should i have to convince someone else whose supposed to know what hes doing when all my tests and other examinations have flagged up signs of asthma

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well today ive tired the ignore it tactic and after it got past the point where i could ignore it no more, i did a peak flow, it was about 300, took my reliever and felt it loosen then tried the peak flow meter again, got about 410

methinks i need to either get a new cons or go back to old one

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Wendy, as I'm sure you know, your drop in peak flow and response to your reliever are highly suggestive of asthma. Was your spirometry done after a period of time without using your relievers, and then after having an inhaler or neb? (reversibility testing)

By the way, the condition that your consultant is suspecting is HYPERventilation (over-breathing), which is anxiety related and causes pins and needles etc. HYPOventilation (under-breathing) is a lot less common and more problematic, and is not related to anxiety. The two are commonly confused, though!

Em

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sorry about the confusion, simple spelling errors, you can tell spelling isnt my strong point lol.

ive done spiros everytime ive been to see the cons, never after reliever though, ive only ever done that with my peak flow meter.

i understand that the cons wants to rule anything else out, but when its already been confirmed, why would he make out that i was only doing it for poops and giggles or to get out of anything. i want my old cons back lol, he was a bit abrupt but he never told me i was faking or make such speculations about ME suffers, i know someone with ME and she really suffers because of it