Asthma advice

[Dilbertian]

I'm being investigated for asthma, and have a telephone appointment with the asthma nurse in a couple of weeks, but, with the redeployment of nurses, there's no guarantee that an actual asthma nurse will be available.

I've been on Pulmicort 1 puff twice daily for 5-6 weeks. When I started, my peak flow varied between 300-400, a couple of times below 300, never hitting 400. (The chart was only marked in 50s, and I didn't know to record the actual number.) Now it is always 410-450. Is that a significant difference?

I'm coughing much less. Would I expect to stop coughing completely?

I barely cough at all after riding my bike - I used to cough a lot after it. But yesterday I cycled first thing in the morning (my cough was always worst first thing in the morning) and was coughing afterwards. Also felt a slight tightness/pressure in my chest. Should I have taken the blue inhaler? The discomfort and coughing passed after a while without any treatment, and I was able to keep working fine.

Also, the coughing usually starts a few minutes after I stop cycling, not while cycling. Is this normal for asthma?

I feel so ignorant and confused by this asthma business. I have already had very poor advice about asthma from a GP - and it's only thanks to MN that I discovered this - that I am quite worried about this review and potential diagnosis being carried out by another non-specialist.

[Flossie44]

I’d say you have noticed an improvement since taking the pulmicort.
It is high pollen count this week which may have an effect on asthma. Maybe try the blue if this happens again, and see the result. It won’t hurt you by trying it.

[ShirleyPhallus]

I have no proper advice but I have to say that my asthma has been significantly better since lockdown started, to the point that I don’t think I’ve taken my blue inhaler once

I wonder if the lack of pollution is having an effect and worth mentioning

[SirTobyBelch]

Your peak expiratory flow rate (PEFR) has improved significantly on budesonide (Pulmicort). Has the difference between morning and evening measurements got less?

It's probably worth using the salbutamol inhaler immediately before cycling if you know the exertion makes you cough. As long as you don't need to use it when you're not exercising, and particularly not at night, occasional use isn't likely to be a concern. It's generally breathing of dry air that triggers the cough but while you're cycling you'll have higher levels of circulating adrenaline, which keeps your airways open (adrenaline has the same action in your lungs as salbutamol). It might be that you start to cough as you continue to breathe heavily but your adrenaline levels drop.

As others have noted, air pollution is much lower than normal during lockdown, but there is a lot of tree pollen around at the moment.

[emmathedilemma]

I quite often cough after cycling or running but not during, it's usually worse in winter when it's cold or windy, or when the pollen count is high. I don't really know why but it's definitely an asthmatic sort of cough.

[Dilbertian]

I'm sure my adrenaline levels are high while I'm cycling - I find it terrifying!

Does it matter if I don't use the reliever? The coughing and tightness passes after a while. Yesterday I was able to work, and didn't really notice when it stopped. How do I know when I need to use the reliever?

If this actually is asthma, then I've had untreated asthma for at least 35y. Does it matter? Are there any health implications from not having treated it?

I can only think of one occasion when I might have had an episode where I was really struggling to breathe: on a ski slope, aged 16 or 17. But days later I arrived back home running a temperature, and was laid up for a fortnight with bronchitis.

Re hayfever, my nose runs on-and-off, and I sneeze from time to time. Not enough to bother me, and I wouldn't normally think of taking antihistamines. But if I am reacting to pollen, could it be affecting the asthma? Should I take antihistamines, even if I'm not in any particular discomfort?

Thank you very much for your advice!

[Dilbertian]

Has the difference between morning and evening measurements got less?

I think so, but can't confirm it because my previous tracking was so approximate.

[SirTobyBelch]

A >15% variation in PEFR between morning & evening is one diagnostic feature of asthma, but if you don't really know what your variation was before treatment I wouldn't start trying to work it out now.

Incidentally, if you go to www.mdcalc.com/estimated-expected-peak-expiratory-flow-peak-flow you can see what the predicted peak flow for your height & age is. Enter your age in years, your height in centimetres and your actual peak flow (your measurements are in L/min, so you'll have to change the units in the calculator from the default of L/s) and click on the correct sex. It will show your predicted value (i.e. what someone with healthy lungs should blow), the lower limit of the normal range, and your value as a percent of the predicted value (ignore the word "variability" in the results: that shouldn't be there). If you do this for your peak flow before treatment and your current peak flow it should give you an impression of how big an improvement you've seen.

You shouldn't worry about whether you've had undiagnosed asthma for a long time. It would have to be quite a bit more serious than yours to have much likelihood of having caused any permanent damage.

You need to use the reliever when you feel you need to use it. If you feel you need to use it several times a week you should probably have your budesonide dose increased or have a combined steroid/long-acting beta-agonist inhaler (e.g. budesonide + formoterol; brand name Symbicort) instead. If you have slight breathlessness that you're confident will pass, you don't need to use the reliever inhaler just for the sake of slightly shortening the period of breathlessness. Just keep it with you in case the breathlessness becomes more severe or doesn't go away.

[SirTobyBelch]

Sorry, forgot to say that antihistamines don't generally have much (or any) effect on asthma, although they obviously control allergic rhinitis and conjunctivitis (runny nose and sore/itchy eyes). But your asthma may well be triggered by an allergic reaction to something in pollen, house dust mite faeces, cat saliva, etc.

[Dilbertian]

Thank you for your explanations. That website is very interesting and helps me understand where I sit in terms of what is normally expected.

[Dilbertian]

@SirTobyBelch , if asthma can be triggered by an allergic reaction, wouldn't anti-histamines damp down that reaction and therefore complement the preventer inhaler and reduce the need for the reliever inhaler?

[SirTobyBelch]

Not really. The mast cells in the airways are largely of a type that contain smaller quantities of histamine than the ones in the skin, for example. (A bit of an oversimplification but a factor in how asthma is treated.) The bronchoconstriction caused by inhalation of allergen is more dependent on leukotriene C4 and prostaglandin D2 than histamine. This is why leukotriene receptor antagonists (LTRAs, e.g. montelukast and zafirlukast) are used in asthma that isn't controlled by low-dose inhaled steroids & long-acting beta agonists but antihistamines aren't.

[Dilbertian]

Thank you for your explanations. You are giving me the cues and the vocabulary to do my own research, as all the information I can find without these is extremely simplistic.

I have some allergies that respond to anti-histamines, and others that don't. Information is always that an allergic response involves release of histamine. I have never understood why some of my allergies do not. Now I may have another to add to my collection! At least this one is beginning to make more sense to me.