Bronchospasm v inflammation

[ccccc]

Hi everyone

I had a bronchoscopy a few weeks ago and got the results letter on Friday. The consultant basically said everything was normal (I have severe asthma) and couldn't see any inflammation but did see bronchospasm in the bottom of the right lung and has suggested Spiriva.

I've tried Spiriva in the past and it just made me cough, but I'm confused as I thought bronchospasm was caused by inflammation? He did say in his letter I was on the last day of an emergency course of Pred which may explain the lack of inflammation. My next appointment is the end of April so won't have any clarity until then.

[Lysistrata Administrator Community Ambassador]

Hi,

Cynically speaking, you might not get any clarification even then! Many consultants don't seem to be great at explaining things.

The lack of inflammation may well be due to the pred - did they take any samples or do something called a lavage (putting saline solution in during the procedure to collect fluid samples from your airways)? I think that's how they tend to assess airway inflammation.

Bronchospasm is kind of the 'end result' of asthma, put crudely - ie the thing we actually experience as 'asthma' and take reliever to treat. However, it can be caused by a variety of things. The inflammation that pred usually treats is one (often called Type 2 inflammation because of the type of white blood cells involved; this includes allergic and/or eosinophilic inflammation).

However, that's not the only thing that causes bronchospasm! Asthma is complex and has various underlying mechanisms, but the tendency of airways to be 'twitchy' and narrow in response to triggers (airway hyperresponsiveness) is not the same thing as, nor automatically linked to, airway inflammation.

Studies about treatment are starting to show that you can get better results if you don't assume everyone with asthma has both Type 2 inflammation and ongoing airway narrowing, and for example treat by increasing inhaled steroids for people who have inflammation, and more long-acting treatments which directly address the airway narrowing itself for people who don't have ongoing inflammation, but do have airway narrowing. That includes long-acting beta-agonists (LABAs) like the one in combination inhalers eg formoterol in Symbicort and Fostair, or salmeterol in Seretide. (Please note that people with asthma do still need some inhaled steroid, this study was just about whether you increase the dose of it or not depending on whether someone has inflammation).

Spiriva is another long-acting treatment for airway narrowing, but it works slightly differently from, and in combination with, LABAs. Spiriva (tiotropium), is related to Atrovent (ipratropium), which you may have been given in nebs during attacks; Spiriva lasts longer. This post has more detail about Spiriva if you want it, including more on how it works: healthunlocked.com/asthmalu...

I've found it really effective in the Respimat form (a tall inhaler with a soft mist), but didn't get on with the Handihaler (one where you insert powder capsules). Did you have the Handihaler maybe? If you try it now you should be prescribed Respimat - worth asking someone to show you how to use it as it isn't always obvious, but works well when you know.

I wonder if your GP could prescribe the Spiriva now for you to try, since the consultant has suggested it - would it be worth asking them?

Hope this helps to clear up a bit of the confusion!

[ccccc in reply to Lysistrata]

Hi Lysistrata.

Thanks for your reply. I've heard the term "twitchy" in relation to my asthma many years ago. I've actually tried Spiriva three times now (each time with a different respiratory team) including following this latest letter - it's the the Respimat type and each time I have the same reaction - I have an initial sense of relief in my breathing then a wheezy cough develops after a few days, which gets worse, then my breathing also gets more constricted. It's as if I'm having a reaction to something in it. I've tried Xolair without success, they want to work me up for other mabs but my eosinophils aren't high enough in my blood tests, so it's very frustrating trying to find a treatment that works!

[Lysistrata Administrator Community Ambassador in reply to ccccc]

Oh that's annoying re the Spiriva (and mAbs, I get the feeling!) I wonder if it's something in the propellant? Would it be worth asking to try a different LAMA if you tell the consultant what's happened previously?

[ccccc in reply to Lysistrata]

I was thinking about that, I mentioned it last time I spoke to them (it was a locum rather than the usual specialist and she didn't really say anything) so hopefully at my next appointment I'll see someone else who will try me on a different LAMA. Even considering asking to switch to Seretide Accuhaler instead of the MDI just to see if that makes any difference (perhaps not but I don't have many other options and summer is coming when I really struggle).