Sudden change after years of controlled asthma

I am looking to see if anyone has found themselves in my situation.

I am a 40 year old women and have suffered with asthma since childhood. It has always been managed using qvar and salbutamol . My trigger was always laughing ( not a bad thing) but my asthma was controlled and did not impact on my quality of life. 5 months ago this changed.. I suddenly felt my breathing was laboured, chest was tight, I was coughing and wheezing more and having to use my salbutamol regularly. Also after being able to run 6 miles I could only run 1 until I had a full on attack where my salbutamol was ineffective. Over the last 5 months I have had several gp appointments and gave worked my way through, various change in meds. Oral steroids for 5 days and antibiotics for a chest infection (exacerbation), seritide, then fostair, now montelukaust together with the fostair. My asthma is improved but by 3 o'clock every day I am in need of meds. I can be at rest and my airways just close up,! I am still only able to run 1 mile before suffering an attack. I have had a lung function test which I'm told was good.

Nothing in my life has changed ie environment, pets etc and I know there are asthma sufferers that are far worse of than me. I'm wondering if there could be something the gp is missing... Any advice would be appreciated. Many thanks Wanda

[Hidden]

Hi Wanda,

sorry you're having such a crap time... unfortunately asthma just seems to behave this way sometimes. I was well controlled for around 6 or 7 years and then it suddenly became bad.

This year we've had record levels of pollen and pollution, which could be at the root of your problem... or it could be hormonal - in our 40s women tend to become generally more 'allergic' as our hormones start to run lower. If you notice any kind of cyclical change in how twitchy your lungs are then that might be worth mentioning to your GP.

Once the inflammation is firmly in place it can take a long time to get back to where you were before this setback, but it is possible - it's largely a case of trying to minimise your exposure to anything that causes symptoms to be worse, while also adhering to your preventers and so on. Obviously there's an element of luck / physiology as well - for some people it's not possible even if everything lines up perfectly.

The GPs follow the BTS asthma 'steps' for treatment - as you're on reliever + long acting reliever + inhaled steroid + montelukast you are already on step 4. This is as high as your GP can go, unless they're a GP with a special interest in respiratory medicine. Step 5 is long-term prednisolone, but in reality doctors do everything possible to avoid this now, and will look at all sorts of alternatives instead.

So - It seems like the next step for you would be a referral to a specialist (required to move above step 4). They will do some tests for things like aspergillus allergy (a mould spore that you can also get a localised infection of), and can also do some tests to determine whether your asthma is highly allergy driven, which then can direct your treatment. It might be that your GP can do some of the tests just with advice from the specialist. The respiratory doctors usually also do some lung function tests beyond peak flow, which tell them more about what kind of asthma you have.

There are quite a few extra meds options - tiotropium is an inhaled drug that is used mostly in COPD but helps to reduce the tendency for bronchospasm, and it is likely to be the next big 'common' treatment in asthma. You usually know within a week or two whether it's going to make a difference for you or not, and compared to most medications it has very few side effects. For me it made a difference after about 3 days - for some people it's not that great. You may know whether you've ever had an atrovent nebuliser when you've had a bad attack? Tiotropium is the slow acting equivalent of atrovent, so if you found atrovent useful then that's a strong hint that it may help you.

I'm guessing that you are already on an antihistamine in addition to the montelukast? I use hydroxyzine but lots of people like the newer ones, including telfast (fenofexadine).

Do you take your fostair through a spacer? If not, that would help you to receive it into all the various parts of your lungs more reliably (as well as being kinder on your mouth and throat).

When you go running, do you take your salbutamol before you start? I take mine (via a spacer) about 15 minutes before starting, and then roughly every 15-20 minutes once I've started exercising. I know how frustrating it is to go from being fit and active to coughing your way up a single flight of stairs - my own asthma goes through cycles of being excellent where I can run 10k, and cycles of being rubbish. Swimming is good for keeping things ticking over when you're not able to run but aren't totally bed bound.

Given that by 3pm you're struggling, have you tried taking salbutamol at - say - 1pm? If you can keep the airways as open as possible for a while then you're breaking the cycle where the tighter you get the more damage each cough / wheeze does to the unhappy airways. Generally, if you're having to use your inhaler by the afternoon each day, it would be better to anticipate that and avoid getting tight.

Also... asthma is ""the three Ss"" - swelling, spasm, sputum. (Sorry, gross but true). If you know that you experience one either first or most then that can be a good place to tackle. In one kind of asthma that I get, I get a sticky cough first, so a drug which thins mucus (carbocisteine) is helpful to me in tackling that part. I also get a totally different kind of attack that comes on in seconds and is mostly spasm - which is why they thought tiotropium would help me (and it does).

If you get a lot of sticky cough then your GP should probably send you for a chest CT anyway, as asthma can overlap with a condition called bronchiectasis, which is basically where the lungs, over time, develop a widening of the airways, and the airways have more sticky mucus than average, which makes them more prone to infection but can also present as worsening asthma. If you get a lot of swelling / spasm then allergy testing might reveal some clues. Your GP can check something called your IgE level - again this gives them clues about what flavour of asthma you have.

If you like your GP then maybe you could just book a double appointment to talk it all through, discuss a possible referral and/or further treatments they'd like you to try - in our area a referral to the difficult asthma clinic can take a good few months, so if you find something that improves it during that period you can always cancel the referral.

It's important to stress to your GP that you are taking all your medications properly and doing everything you can to help yourself. I think one of the reasons that sometimes Drs are a bit passive about treating asthma is that so many patients don't take their medications as they are intended. If you're doing the whole deal as perfectly as you can and you're still not well controlled then that's significant.

Before you see your GP you could check out the asthma UK surveys about asthma symptoms - for example are you having night time waking to take your inhaler as well as your 3pm tightness? Keeping a peak flow and symptom diary for a week or two would be a great idea as well - some people get asthma after eating, and so a trial of a PPI like omeprazole or a drug that stops gases from your stomach from escaping into your lungs, like domperidone, can be worth doing, even if you don't have any symptoms of reflux.

I hope you start to get better soon,

Cx

[Hidden]

Hi C, I really appreciate your time in replying to my post.

I have and still am considering the effect of the high levels of pollen and pollution on my asthma as this change started around the same time as 'the dust cloud' from the Sahara. My asthma nurse has mentioned a twitchy lung and the fact that it can take some time to return to normal. I am hoping this is the case and that I will eventually return to where I was.

I did forget to mention that I have allergic rhinitis and take flicsonase and fexofenadine. So I suppose the likelihood is that my asthma is allergen related

I do take my fostair with a spacer.

Before I run I take 2 puffs of salbutamol. But will try 15 mins before when I go out next. Although I'm going to keep the runs short for the moment to avoid an attack.

I am very good with all my meds, especially now!! And will try the salbutamol around 1pm as you said.

Interesting about the three s's When the change first started my breathing had just become laboured but only enough for me to notice tiredness, tightness if the chest and muscle weakness. As I've increased in meds, when I now suffer an attack I can feel my airways closing, lots of wheezing, then comes the cough. Which I know is good because it means my airways are still open enough for me to cough then it's just a vicious circle.. Salbutamol does not work. So I have a puff of fostair. I then feel rubbish for 24 hours. Tight chest, slight wheeze. About 1/2 hour following an attack comes the sputum.

I was signed up for the great south run this year which won't be happening, but I am determined to complete it next year....

I will be seeing my gp who has been great in wanting to help me and I am keeping a peak flow diary.

You have really helped me emotionally for which I am truly grateful

Wanda

[hb1977]

Hi

I'm in a similar position to you; this year has been my absolute worst, only had 1 exacerbation in 2013 but this year I've already had 4 courses of steroids and 4 courses of antibiotics not to mention quite a bit of sick leave.

I'm now on Seretide 250 2 puffs twice a day plust Montelukast and add in Salbutamol and Atrovent when poorly.

I had my first appointment with a respiratory consultant last week who did chest x ray, spirometry, ECG and lots of bloods and sputum tests.

He's doing me a new written plan and has talked to me about considering Fostair and to also think about Tiotropium.

Hopefully we'll get to the bottom of the frequent exacerbations and find a way to manage them better.

Good Luck