Broncholidator Reversibility Test

[LottieB36]

Hi, I posted a few days ago about my team wanting to do a broncholidator reversibility test and FeNO before they put me forward for biologics. I wasn't going to do the test, then decided to do it, incase it did show reversibility to save time waiting for a referral to Wynthenshawe as my current hospital is only secondary care. So I've done the test today and it doesn't show reversibility (although I've provided peak flow readings from January to December which demonstrate >20% variability in readings, which also match times when I have a chest infection, have a flare or I'm struggling due to hayfever/mould) and FeNO was only 5 (I know inhaler, nasal spray and steroid nebs will supress this). I could only withhold my Seretide inhaler as was tight chested/coughing lots this morning. They had me doing x8 spirometry readings, even though I was coughing and a bit wheezy, they gave me x4 puffs of ventolin, waited 15 minutes, then I had to do another x6 spirometry readings to see if there was reversibility but had to stop due to coughing and increased wheezing. I queried the ventolin as I'm on 2.5mg maintenance salbutamol nebs and have been for 8 1/2 years, but was told that's what your consultant has requested and they didn't know if that would make a difference! Surely that won't do anything to open up my airways when I'm used to the nebs? They said maybe he'll ask you to come back and use nebs. I also asked if there's no reversibility surely that shows the treatment I'm currently on is working and I'm well controlled, and they said maybe. I'm not convinced they've even performed the test using the correct guidance, as I was only told to withhold Seretide for 12 hours and salbutamol and ipatropium for 4 hours (which I couldn't do anyway), they didn't say anything about the other meds. I really don't want to do it again as I know I'll end up struggling later because of the tests. Other meds for asthma are steroid nebs which are budesonide 2mg twice daily and ipatropium nebs 250mcg, plus the usual montelukast 10mg x1 daily, fexofenadine 180mg x1 twice daily, dymista nasal spray, acetylcysteine 600mg (mucolytic for chest clearance), Doxycyline 100mg x1 daily (prophylactic antibiotic), colomycin 2M unit x1 twice daily (pseudomonas infection management), esomeprazole 20mg x1 twice daily, aerobika chest clearance and saline nebs if required and methotrexate 10mg injection once weekly for UCTD/Lupus SLE but also helps asthma. The steroid load from inhalers, nasal spray and nebs I've been told is around the equivalent of 15-20mg prednisolone - I've been advised by the ADSHG and Pituitary Foundation if requested to withhold all meds, to not withhold all the meds which contain steroids, as this will place me at risk of an adrenal crisis due to the steroid load and abrupt stop I'm a Addisonian. I feel like I've been set up to fail the test so that they can avoid putting me forward for biologics, even though positive reversibility test and FeNO are not in guidelines - NHS England have said it's reasonable to have a definite diagnosis of asthma, prior to being put forward - I have pointed out that there isn't one gold standard test that gives a definite diagnosis, and that it's given on clinical judgement. I've got spirometry readings which show FEV1/FVC ratio of 90% when I'm settled and 83% mid-summer when I'm maxed out with meds and the addition of 40mg prednisolone. I know a reversibility test doesn't rule out asthma, and test results should be used taking everything else into account, my peak flow should back up my diagnosis, alongside when my treatment is stepped down I become symptomatic and have a positive response when stepped back up. I don't trust my team at all and I'm now concerned about what they're going to say. I don't want to go through reducing meds again when everytime we do it, I become symptomatic and end up on pred for 2-3 months until I'm better again. I feel they're adding their own criteria to pass before they'll put me forward, when surely they should be following the actual guidance from NICE. I've asked my GP if we should either go with the referral or if I write them a letter which I've already drafted, or do we do both? Thanks in advance

[Lysistrata Administrator Community Ambassador]

Hi, sorry I was going to reply to this, and realised I hadn't!

It does sound to me like your current team are looking for reasons not to give a biologic. It's reasonable to check eligibility but not to keep on coming up with different reasons, especially when the diagnosis of asthma is confirmed, you aren't controlled and already meet the criteria. The point of the biologic is surely to replace your current medication (well, some of it anyway, I assume not all!) but they forget that what you're on currently will still affect tests.

I personally struggle to do spirometry correctly when I'm symptomatic with asthma, and might also need a bit more salbutamol. If they didn't use a spacer I would also find it doesn't go in well if I'm coughing and struggling.

I also thought it was stopping ipratropium for 6 hours not 4? At least, that's the spacing in hospital so not sure why they said 4. I've had some very odd instructions for tests in the past and have taken to double checking.

It sounds like this test just wasn't particularly useful. And if it's not needed then I can understand why you don't want to repeat it especially if the same thing is likely to happen again.

Is the letter to your current team to explain all this? I would still go ahead with the referral but if you want your points on record with your current team, a polite letter setting all this out may be worth it. I've sent letters/emails before not really expecting a response, just wanting my points on record because my clinic letters never reflect anything I actually say, they always get turned round.

Hope this helps!

[LottieB36 in reply to Lysistrata]

Hi - don’t be daft! You don’t need to say sorry 😊, I’m just grateful you take the time to reply 😊. Yep, I always thought it was 6 hours for ipatropium, I asked if they take your other meds into account and mentioned my steroid nebs and they said well they aren’t an inhaler 🙄 no but they still help to keep my airways open! they had me doing 8 readings and said my technique wasn’t very good because I was too hesitant at the start and didn’t blow out quick enough! Then said I was breathing out with my throat instead of my chest and could I not cough! They gave me 4 puffs of ventolin through a spacer, sent me to the waiting room, came back after 10 minutes, then we started again - I said the 4 puffs wasn’t enough, but they wouldn’t give me anymore because that’s what the consultant told them to do. Still said my technique was poor, but how do you do spirometry when you keep coughing 🤷🏼‍♀️ I said I felt like someone was squeezing my lungs and then she kept saying have you got an infection, you’re coughing a lot - they all seem so focused on wheezing and FeNO and seem to forget that coughing is a symptom as well! Yes the letter I’ve drafted is for my team, like you say, just so that I’ve everything on record. Thanks as always 😊

[coral12 in reply to LottieB36]

I'm on biologic and are taking all my inhaler to .

[hilary39]

By reversability test, do you mean the methocholine challenge? It is so frustrating when you have a mostly normal FEV and FeNO but still have constant symptoms. I don't know why so many doctors trust and value those tools over the patient experience.

[LottieB36 in reply to hilary39]

Hi, it’s the reversibility test, where they do your spirometry, then give you a broncholidator to see if your spirometry improves. The methocholine challenge is where you have to breath something in to see if your airways become irritated. My FeNO will never be high due to the steroid load from my inhalers and nasal sprays/drops x