How to give good directions.

I will have another asthma education month post up tonight hopefully, but there is a thing I wanted to write about unrelated to asthma because it is relevant.

I hate, hate having conversations that go like this:

Them: I need you to do A.
Me: Okay, I’ll go do A.
T: Wait, you have to do B!
M: Erm, B? Okay. I’ll go do B, and then I’ll do A.
T: But you said you were going to do C like three days ago!
M: Wait, what? I did? I don’t remember that, but okay, I’ll do C next, then.
T: But we need to get D done today! You can’t do C right now!
M: … *headasplode*

That’s around the point where my brain is grinding its gears and going, “WHAT ARGH WHAT DO?!”

Gah.

If you need me to get A through D done today? Say, “We need A, B, C, and D all done today.” If you have a preferred order, add, “D is highest priority, so do that first.”

I can handle that.

What I can’t handle is four contradictions from a person in four conversational exchanges. Be clear, concise and consistent in your directions.

Lifestyle for Asthma Control 1: Trigger avoidance

So, I’ve had three posts on asthma treatment on the medical end of things. This post and the next post will be on lifestyle factors that the literature strongly supports: Namely trigger avoidance and exercise.

Asthma triggers are things that provoke asthma symptoms. Some things are very common, while others are a bit weirder. I’m going to talk a bit about how to find out what your triggers are, the most common triggers, and then talk about steps you can take to avoid them.

There are two main ways that triggers can be discovered: The first is through self-monitoring of symptoms and looking for patterns in your asthma flareups. The single most beneficial way to self-monitor symptoms and look for patterns is through keeping an asthma diary.  An asthma diary is a place where you record your peak flow (if you have a peak flow meter), how often you’ve needed your inhaler, and anything you think might’ve had something to do with your symptoms that day. If you notice that the same thing keeps popping up in your diary, try avoiding that thing and see if your diary entries after avoiding it show improved control. If the improvement is substantial, then it’s probably a trigger. Your asthma diary can either be a hard copy or be electronic. A number of asthma apps exist if you like mobile record-keeping. Personally, I like using a spreadsheet – a bit less user-friendly, but I can include everything I want on it.

The second way you can try to figure out what triggers you is through allergy testing. Most people with asthma who also have allergies find that their allergies trigger their asthma, so avoiding things you’re allergic to is a good way of helping out your asthma control. There are five different types of allergy testing: Skin prick testing, intradermal testing, oral challenge, patch testing, and blood testing. What type of test is used depends on the type and severity of the allergy suspected. All allergy tests except blood tests carry the risk of anaphylaxis, a type of very serious and potentially life-threatening allergic reaction, and so in people with a history of anaphylaxis to the suspected allergen, blood tests are usually preferred.

Asthma triggers fall into two general categories: Inflammatory triggers and symptom triggers. People with non-allergic asthma are only bothered by symptom triggers while people with allergic asthma are usually bothered by both symptom and inflammatory triggers, though the exact set of triggers will vary person to person.

Symptom triggers include:

• Smoke – including wood smoke, tobacco, and incense
• Exercise
• Cold air
• Car exhaust
• Strong scents
• Chemical fumes
• Air pollution
• Intense emotions
• Certain food additives, including sulphates and nitrates

Common inflammatory asthma triggers include:

• Dust and dust mites
• Animals
• Cockroaches
• Mould
• Pollen
• Viral infections (especially upper-respiratory tract infections)
• Certain air pollution
• Food allergies

Note that these lists of common triggers are by no means exhaustive. I’ve met people for whom laughter is an asthma trigger, and others who find that foggy days or bad weather trigger them – if a trigger isn’t on these lists, that doesn’t mean it doesn’t trigger a person’s asthma. It just means that it’s a bit less common a trigger.

How you avoid triggers will depend on the trigger in question. For pollen and air pollution, look up your region’s pollen count and air quality. In Canada, air quality is measured through the Air Quality Health Index. Other countries have their own monitoring systems. Once you’ve found what the air is like that day, decide accordingly: On high-pollen and/or low air quality days, I don’t exercise outside. If it’s medium, I might exercise with premedication, and then change clothes and have a shower when I get inside.

Where animals are concerned, the most effective way of avoiding the trigger is to avoid the animal. I had to give away my pet cats. On that note, there is no such thing has hypoallergenic pets. If you don’t want to give away your pets, this website has a list of ways to reduce pet dander.

Where dust is concerned, make sure you clean regularly and wash bedding and curtains weekly in hot water.

For other triggers, strategies for trigger avoidance can be found online, but in general it all boils down to: avoid it where possible, and take steps to mitigate it if it’s impossible to avoid.

The previous post in this series is here.
The next post in this series is here.

Asthma Treatment 4: Maitnenance meds

So, yesterday, I talked about what asthma control is.

Today, and for the next two posts, I’m going to write about how you get and maintain asthma control. There are three pillars to getting good asthma control: Medicine, exercise, and trigger management. Today, I’m going to talk about medicine.

Most people with asthma need at least one maintenance medicine. Only the mildest of asthmatics can maintain control with just a rescue puffer. Maintenance or preventer meds are taken every day, usually twice a day, to help control asthma. There are several main classes of maintenance asthma medicines:

• Inhaled corticosteroids
• Inhaled non-steroidal anti-inflammatories
• Long-acting bronchodialators
• Leukotriene receptor antagonists
• Methylxanthines
• Antihistamines
• Oral corticosteroids
• Humanized antibodies

Inhaled corticosteroids (abbreviated in papers as ICS) are finely-ground anti-inflammatory steroid that you inhale. They work by reducing the inflammation of your airways, making them less swollen and twitchy. They’re the single most common type of asthma maintenance med, and most people who are on other maintenance meds will be on one or more ICS drugs as well. They’re typically delivered either through a dry powder inhaler or through a metered dose inhaler. Sometimes, they’re delivered through a nebulizer. There are too many ICS drugs to list, but a list of common drugs in this class may be found here.

Inhaled non-steroidal anti-inflammatory drugs are an older class of asthma medicine, still used in those with steroid-resistant asthma or those who have a history of bad reactions to inhaled corticosteroids. They work by stabilizing mast cells and preventing the allergic reaction that leads to swelling, inflammation, and twitchy airways. There are two drugs in this class: cromolyn sodium and necromil sodium. They’re not used very often anymore because they’re inconvenient (you need to take them four times a day) and are held to be less safe than ICS and leukotriene receptor antagonists. Since MDIs stopped being produced in 2010 when the CFC propellant was banned, they can only be delivered through a nebulizer. This class has mostly been replaced by the leukotriene receptor antagonists discussed below.

Long-acting bronchodialators (abbreviated LABAs) are a class of drugs that works by binding to a receptor on the outside of the cell, which causes relaxation of the smooth muscle. In this way, they work exactly like asthma rescue medicines, but they last longer. This longer lasting action comes at a price: they usually aren’t fast acting, and so with one exception (formoterol), they can’t be used as asthma rescue medicines. They stop, reverse, and prevent bronchospasms. These medicines are not without risk: The benefit of LABAs to quality of life and asthma control must be weighed against a small but significantly increased risk of sudden, severe and life threatening asthma attacks. This increased risk is either greatly reduced or eliminated entirely (literature is contradictory on this point) in people who are taking inhaled corticosteroids, and therefore these medications are contraindicated in asthma patients who are not taking ICS therapy. What that means is that if you are asthmatic and your doctor has you on a LABA without an ICS, you should talk with your doctor about whether it’s a good idea.

Leukotriene receptor antagonists (abbreviated LRTAs) are a class of drugs that work by inhibiting the action of leukotrienes. In short, they stop allergic reactions before they begin. Common drugs in this class are montekulast, zafirlukast, and zileuton. LRTAs come with a warning for possible neuropsychiatric side effects, the effects of which can be delayed by several years. As such, LRTAs, like LABAs, are a class of drug that is approached with caution and only when a risk-benefit analysis indicates that the potential benefit outweighs the potential risk.

Methylxanthines (also called theophyllines) are a class of drug that is related to caffeine. They are stimulants, anti-inflammatories, and bronchodialators. They work by relaxing the airways and possibly by reducing the inflammation that causes asthma symptoms. There is also some evidence that theophylline might reverse steroid insensitivity in severe asthmatics. Theophylline has a relatively narrow therapeutic window, and when I was on it as a kid, I had to go for weekly blood tests to make sure it wasn’t building up in my system to toxic levels. Due to their side-effects and potential toxicity, theophyllines are only used in people whose asthma is very severe and uncontrolled. On a completely-unrelated-to-the-medicine note: theophylline syrup tastes absolutely terrible, and I learned to swallow pills at four so I wouldn’t have to take it anymore.

Antihistamines are drugs which prevent allergic reactions by either preventing the production of histamine or preventing the binding of histamine to its receptor. It is a broad class which includes many different sub-families but they all work by preventing the allergic reaction from completing by stopping the action of histamine on cells. This in turn prevents allergic inflammation and bronchospasm. Some people with allergic asthma (me included) have allergy medicines included for some asthma attacks (I’m supposed to take diphenhydramine if I think allergies might be playing a role in my asthma attack). There are far, far, far, far, far too many antihistamines to even try to list all of them, but a partial list of antihistamines may be found here.

Oral corticosteroids are the pill version of inhaled corticosteroids, and work in a similar manner, except throughout your whole body rather than just at your lungs. Due to systemic application, they come with a lot of very nasty side-effects, and the risk of side-effects increases as the length of time you’re on them increases. For this reason, doctors try to avoid treating people with oral steroids, and won’t prescribe them except for serious flares or for those who can’t control their asthma any other way.

Humanized antibodies represent the only class of asthma drug I’ve never been on. The only asthma drug in this class is Omalizumab. There is a not-unsubstantial risk of anaphylaxis associated with humanized antibody treatment, and for this reason, humanized antibody treatment is only prescribed to those with moderate to severe asthma that is unresponsive to steroid treatment. They work by blocking cell receptors that lead to serious allergic reactions, including severe allergic asthma and anaphylaxis. Xolair is also very expensive. Depending on dose, it can cost up to $2,000/mo.

For asthma treatment, doctors usually follow a stepwise approach to treatment: This means that asthma medicine is increased if you’re doing badly and if you’re doing well for more than six months, they will try reducing your medicine to see if you can manage on lower doses. This allows for the fact that asthma can change in severity and may actually get better over time, while allowing doctors to respond if your asthma control is lacking. Canadian Thoracic Society sets the guidelines for asthma treatment in Canada, while equivalent organizations set similar guidelines in other countries.

The previous post in this series is here.
The next post in this series is here.

Asthma Treatment 3: Asthma Control

So, today’s post is late because I had planned to write tomorrow’s post instead, but I couldn’t make it make sense, until I realized that you have to know what asthma control is to understand it. So I’m going to write about asthma control.

Put simply, good asthma control happens when your asthma is managed with medication and lifestyle to a sufficient degree that your asthma has the minimum possible impact on your life.

Bad asthma control happens when your asthma is inadequately managed with medication and lifestyle, such that your asthma has a larger impact on your life than necessary.

For the vast majority of asthmatics (all mild intermittent and mild persistent, and most moderate asthmatics), that means good control according to their country’s asthma control guidelines. In Canada, this means all of the following:

• No daytime attacks
• No night-time symptoms
• Reliever medication use <4x/wk
• No school or work absenteeism due to asthma
• Normal lung function tests

For a minority of people with asthma (me among them), textbook asthma control is not possible. In our cases, good control is defined by our doctors.

Improving your asthma control is not only helpful to your quality of life and mental well-being, it’s also important for your personal safety. Poor asthma control is a risk factor for fatal and near fatal asthma. Asthma control is thus a safety issue in addition to a wellbeing issue.

If you have asthma, you might be wondering how to tell if you have poor asthma control? Here’s some signs of poor asthma control:

• Waking up at night one or more times a week because of asthma
• Rescue puffer does not work as quickly or as completely as it used to
• You’re using your puffer more than three times a week
• Your asthma is stopping you from regular activities, like exercise or housecleaning
• If you have a peak flow meter, your peak flow is regularly <80% of your personal best
• You’ve needed oral steroids for an asthma flare twice or more in the past year

If you prefer quiz-format monitoring, there are several quizzes around the internet for checking your asthma control. Sites with asthma control quizzes include WebMD,and the Asthma Society of Canada.

What things help asthma control (maintenance treatments and lifestyle changes) and hinder it (triggers) will be discussed in later posts.

The previous post in this series is here.
The next post in this series is here.

Asthma treatment 2: Acute care

So, maybe you’re an author wondering how to write hospital treatment of an asthma attack. Or maybe you’re an asthma patient who’s never been to the ER/A&E before but has had a few times where they think they should have gone but didn’t because they were scared of what would happen. Or maybe you’re someone who is wondering whether or not those difficulty breathing spells they take sometimes are asthma attacks. Or maybe you’re just curious what they can do at an ER/A&E for an asthma attack. This post is for you.

I discussed in a previous post what standard first aid treatment for asthma is, and I also talked about what asthma flareups feel like to me. According to my asthma action plan (I’ll discuss those in a few days – short version is written instructions on how to manage flares from my doctor), severe and above flares that don’t respond to inhaler are ER-worthy. Mild and moderate flares can be handled with watchful waiting, applying my action plan, and seeing if it resolves the flareup. But what actually happens in the ER?

If you have anxiety, or if you’re a person who hates disruptions to their routine (hi), or if you have any of a number of disabilities that make handling new situations more difficult (also hi), the unknown factor might be enough to turn you away from seeking help at the ER. That’s why I’m writing this post: To try to take some of the fear and uncertainty away. Because as scary as it is to go to the ER and acknowledging the existance of ER docs who don’t know how to handle asthma well, the ER is still the safest place for a person to be during a severe attack.

So, let’s say you’re having a bad asthma attack. You’ve never had one this bad before, and your inhaler isn’t helping. You go to the hospital. I suggest bringing someone you trust with you, if possible, because if your asthma is bad, you might not be in good condition to advocate for yourself. I would also recommend bringing a copy of your last lung function tests if you have them and your asthma action plan if you have that (a list of your medications will work just as well for this). Remember to bring your health card or insurance.

The very first thing you’re going to have to do is check in. Look for a sign that says “Check-in” or “Registration” or something that looks like an administrative desk. Usually these have seats beside them and are in a little corner to shield the sound. Some very big hospitals have more than one. If you can’t find it, there should be a nurse monitoring the waiting room to keep an eye on those still waiting. Ask the nurse where to check in.

In check-in, they’ll ask you questions: When did symptoms start? Are you having chest pain? How much asthma medicine have you taken? Do you have any allergies? Etc. They’ll ask you some seemingly-unrelated questions to make sure it is asthma they’re dealing with. Answer all questions honestly, and include any other things you may have taken (even alternative medicine and illicit drugs: Alt med stuff because it can interact with medicines they might give you, and illicit drugs for the same reason. Don’t worry about legal troubles: in most areas, hospitals are not allowed to tell the cops whether you’re on drugs or not). The triage nurse will use these answers and your vitals to assign you a priority in the system.

The triage nurse will take your vitals next. This will probably include probably your temperature, blood pressure, heart rate, and blood oxygen saturation at the registration desk. Temperature should be old hat to anyone who’s used a thermometer before. Blood pressure is a cuff that goes around your arm. They inflate it until they can’t hear any circulation below the cuff, then slowly let the air out until they can first hear your pulse and then hear your venous flow. It shouldn’t hurt but might if you’re sensitive to pressure. It is somewhat uncomfortable. Heartrate is measured either by them holding your wrist and looking at the clock or with a pulse oximeter. The pulse oximeter just goes over a finger (they might have you hold something warm for a few seconds if your hands are cold to ensure an accurate reading). It works by shining a light through the tip of your finger and detecting how much of a certain frequency is absorbed. More absorbance = more oxygen bound to your blood. This test should not hurt at all. If it does, they’re doing it wrong. You will then show insurance and get your hospital bracelet, either at the registration desk or at another desk.

Depending on how severe you seem and how much room they have, they might take you back immediately at this point, or they might send you to the waiting room. If you’re sent to the waiting room, try to be patient and stay calm. If your breathing continues to worsen while in the waiting room, inform the nurse when they check on you. If you feel like you might pass out, inform the nurse immediately.

You will eventually be called to a room when they have a space for your priority. They might have a respiratory therapist visit you to take your lung function. This is essentially a set of specialized breathing exercises into a machine that measures how much air you can move. It might cause more muscle pain if you’re already experiencing chest wall pain from the attack, but the test shouldn’t hurt on its own. In smaller hospitals, they might just have a nurse take your peak flow, which is not as accurate, but is cheaper and faster. Tell the RT or nurse your personal best numbers if you know them and offer a copy of your recent lung function tests if you have them. The RT or nurse can get a more accurate idea of how well you’re breathing with your personal numbers than they can with average charts. If you don’t have that information, they’ll compare your numbers to predicted numbers based on averages for your height, weight, and ethnicity. The doctor who sees you will use this information along with your vitals and their examination to decide what treatment is most appropriate.

If an RT saw you, a nurse might come in and start an IV. Otherwise, the existing nurse might start an IV at this point. They may also draw some blood for blood tests, if the doctor has reason to suspect an infection. Needles obviously hurt a bit. It might hurt more than normal if your blood pressure was low, as that can make it harder to find veins. If your breathing is very bad, they won’t have time to use anesthetic cream or stuff like that if you’re hypersensitive to the pain, unfortunately. If your oxygen saturation was low, they might start you on some oxygen to bring it up to normal, usually with a nasal cannula (this is a tube with prongs that stick up your nose. It’s uncomfortable and might make you sneeze, but it doesn’t hurt).

Next, a doctor will probably come in to examine you. They will listen to your chest with a stethoscope, and they might do some percussion tests (tapping on your chest as they listen through a stethoscope, also doesn’t hurt). The doctor will probably chat with you a bit and might ask some questions you’ve already been asked. They’re not trying to waste your time, they’re trying to get a feel for how short-of-breath you are.

I can’t predict the order of stuff that might happen after this, so I’ll just describe the things that might happen, as how they treat you will depend on how badly you’re breathing and whether or not it’s responding to first line treatment.

They might order a chest X-ray. They will give you a lead apron for your abdomen. Then they will have you stand or sit in front of the backdrop of the X-ray machine. They’ll ask you to raise your arms, take a deep breath and hold it, then they’ll take the X-ray. They will have you turn 90 degrees and repeat the process. This will let them see whether your lungs have the normal shape or whether they’re hyperinflated or collapsed and will let them see whether you have scarring or fluid in your lungs. Chest X-rays don’t hurt at all, but the room and machine are both usually cold.

They will probably give you one or more breathing treatments. This might be through a nebulizer or through an inhaler with a spacer. The nebulizer makes a mist of asthma medicine, which you then breathe in. It might have a mask (which will go over your mouth and nose) or a mouthpiece (which you hold in your mouth). Just try to breathe normally while you’re taking it. Nebs don’t hurt at all.

They might give you steroids, magnesium, or bronchodialators through an IV. These are all strong asthma medicines. Aside from the needle part, it shouldn’t hurt. The steroids will probably make you irritable, emotional, and insomniac. They really suck. I’ve never had magnesium so I can’t say what it’s like. Bronchodialators will make your heart pound and your hands shake.

If your attack is severe, then to get an idea of how tired you’re getting, they’ll measure the levels of different gasses in your blood. To do that more accurately than allowed by a pulse oximeter, they need to get an arterial line – this is a needle that goes into an artery. This does hurt. They will probably bring someone who’s good at it in to make it as painless as possible, but it will hurt.

If none of that works and you’re getting very tired or your blood gases are showing that you’re not moving air well enough, they might put you on BiPAP or CPAP. BiPAP and CPAP are both forms of non-invasive ventilation – they will help you breathe when your muscles are too tired to do it yourself. I haven’t been on it since I was a very little kid and I don’t really remember much except the mask digs uncomfortably into your nose and it feels really weird. Finally, if all of the above fails, they might intubate you and take you to the ICU. You probably won’t be aware of anything, as they will sedate you before they intubate you. Only the most serious of attacks need ventilation, and usually attacks can be turned around at the hospital before it gets to that point.

Most asthma attacks that result in a trip to the ER are treated successfully with breathing treatments and maybe some steroids. Once you start to improve, they will probably keep you for a few hours to make sure the attack doesn’t come back as soon as the bronchodialators start to wear off and they will probably give you a prescription for oral steroids. These come with some not pleasant at all side effects, but the benefits of being able to breathe outweigh the risks, so you should take them. Take them exactly according to the instructions given to you (this will probably include a taper) because if you don’t, you could induce an adrenal crisis.

I hope this helps take away some of the fear, uncertainty and mystery factor surrounding going to the ER for asthma. Hopefully you will never have an asthma attack serious enough to need hospitalization, but if you do, now you know what to expect.

The previous post in this series is here.
The next post in the series is here.

Asthma Awareness Month: What an asthma flareup feels like for me

My asthma flares start off at very mild, progress to mild, then moderate, then severe, and finally life-threatening. At each stage, if I recognize a flare is underway, I can treat and prevent it from progressing (usually), or it might just spontaneously decide to resolve itself. Very mild flares are more common than mild, which are more common than moderate and so on. Plus, it usually progresses through each stage on a scale of hours to days, so there’s plenty of time to recognize I’m building to a big one and head it off. Unless it’s induced by an environmental trigger that really affects me, like dust or scents or cats, when I seem to skip the first two stages and jump straight to moderate.

At the time I wrote this a few months ago, I was having a mild flare, and was being too lazy and enjoying my coffee too much to want to go treat it, but I did anyway because I had martial arts in an hour and want to be breathing well for it. And I could get a refill of coffee while I was at it.

Very mild:

It starts with a sensation that I can’t get all my air out. This one hard to describe, but imagine holding your breath until your lungs start to burn, and then you exhale as much as you can, but you still have the lung-burny stale air feeling. This sensation, while unpleasant, is easily overlooked if I’m not paying attention. I might also have a lower exercise tolerance – hit exhaustion sooner than normal, that sort of thing. This stage is watchful waiting – I wouldn’t even call it a full flare, more warning signs that a flare is coming. I should, if I recognize it, increase my control meds and step up to my yellow plan, but I don’t need to treat the acute symptoms yet.

Mild:

If I don’t treat the can’t-get-air-out feeling, it progresses to feeling like the inside of my chest is stretching. This one is also hard to describe. Somewhat similar to trying to exhale while holding your breath, only with a feeling of mild pain throughout the chest cavity attached. This one, while unpleasant itself, is also easily overlooked if I’m doing something else.

Then comes shortness of breath on exertion. This is when a brisk walk across campus has me breathing as if I took it at a run. I often mistake this for poor cardio and grumble that with as much cardio as I do, I shouldn’t have a hard time with [activity]. I don’t, when I’m well, but it’s a hard thing to recognize as an asthma thing, given that I really was out of shape a few years back.

Then comes coughing. Intensity at this stage is usually weak coughs that are intermittent. I need to treat this with short-acting “rescue” medication and a step up to my yellow zone plan, if I recognize it. I can treat this easily on my own, and don’t need help from anyone for treatment, though sometimes I have a hard time recognizing a mild flare, so if I sound like I’m having asthma stuff, let me know.

Moderate:

Then pain. When I struggle to breathe because my airways are tight, my chest muscles work out more and harder than normal. My entire chest wall lights up with moderate pain at this point. I notice the pain far more than I notice shortness of breath, but that worsens at this stage, too, to moderate, where even with light activity, I’m a bit breathless.

The coughing gets worse as my body tries valiantly to clear a blockage that’s part of my anatomy. At this point, I sound like I have bronchitis from hell.

The shortness of breath gets worse, to the point that if I have to climb more than one flight of stairs, I’ll be very out of breath and might have to stop for a break on the way up.

I start exhibiting prolonged exhalations, where breathing out takes over twice as long as breathing in. That’s a sign of substantial airway obstruction, where your airways are so obstructed, you can’t get enough air out to breathe again in the normal amount of time. My discomfort makes it difficult to concentrate on anything, and my work productivity suffers.

I need to treat this with a higher dose of short-acting “rescue” medications, a step up to my yellow plan, and possibly a visit to my doctor if it doesn’t go away. I don’t need any help at this stage, but if you notice it, keep an eye on me, because I might progress to the next stage.

Severe:

The shortness of breath then becomes severe. I can’t finish a long sentence without stopping for breath at this point, and I get breathless even when just walking on a level surface. Imagine how you feel during the hardest workout you’ve had in your life. I guarantee, the shortness of breath I feel at this stage when doing anything is worse. My discomfort makes it impossible to concentrate on anything, and my work productivity plummets.

At this point, I should go to the ER. I usually don’t. Because there was a time in this city when I was blue and they stuck me in a room to “calm down” and so I don’t believe they’ll do anything for me that I can’t do at home. Which is wrong, I know, since they have crash carts at the ER but given that it took them two hours to come check on me when they thought cyanosis was an anxiety attack, if I passed out there, I would’ve been just as dead as if I’d passed out at home. It comes down to this: I don’t trust them to take care of me in a bad asthma flare. I trust me to take care of me. So I’ll wait until the point of no return now. My doctor gets angry every time I do, because it’s like playing Russian roulette. I know. But she doesn’t get that going to the ER before I’m that bad is also like playing Russian Roulette unless I’m wheezing, because being a young woman means I’m either faking or having anxiety to the ER staff. I know, because I had one say as much to my face. “Shortness of breath in a young woman is anxiety or malingering until proven otherwise.”

Then I start wheezing. Wheezing at first feels like somethings rubbing/vibrating inside my chest. Then it has that feeling plus a squeaky whistling noise on exhalation. I usually stop it before this point and until I got influenza, I didn’t tie the chest-rubbing feeling with my wheezing until I had the life threatening flare I mentioned above where they locked me in a room while cyanotic and I noticed I squeaked when the chest-rubbing feeling happened.

Potentially life threatening:

My shortness of breath gets to the point where I’m *breathe* talk- *breathe* talking *breathe* like *breathe* this, and avoiding multisyllabic words because they’re harder to say. If I can, I answer non-verbally, and if someone’s making small-talk, I ignore them because it’s not worth the horrible breathlessness talking brings on to answer. I feel out of breath even sitting still, and walking is exhausting, if I can walk unassisted at all. I consider this my point of no return, and will at this point go to the ER. I might start having paroxysms of coughing where I cough to the point of gagging, or cough to the point that I can’t breathe because I’m coughing too damn much. I have coughed badly enough to burst blood vessels in the whites of my eyes so I was going around with red eyes for the next three weeks, and also coughed badly enough that I blacked out. My wheezing might get so loud that people can hear me across the room. My chest pain is severe at this point, and I’m very anxious. If I look calm, it’s a lie. I’m trying to make sure ER docs don’t write me off as an anxiety case, but I usually fail at looking calm because I usually start crying because suffocating is scary – and make no mistake, suffocating is what I’m doing.

I resist well-meaning comforting hugs and tear off constraining clothing because they make the suffocating feeling worse. I can put up with a nebulizer mask, IF I get to hold it. If I don’t, I’ll tear that off, too, instinctively, because it feels like suffocating even though I know it’s there to help me breathe. My exhalations can take 4-10 times as long as inhalations, so I’m gasping between wheezy exhalations. I’m probably sitting in the “tripod” position to help myself use accessory breathing muscles, because my chest wall muscles and diaphragm are exhausted. I can’t lay down at this point because I can’t breathe when I lay down, and I might stand up and move around in a panic because I’m too anxious to sit – even though it makes the feeling of suffocating worse. If you try to make me sit, I will fight you. I will not mean to, but I’m in too much of a panic at this point because I can’t breathe to think straight. Stay clear of me, don’t try to grab me or make any sudden movement towards me. Let me do what I feel at the time like I need to do to help myself stay calm – you know that so long as I’m moving and/or talking, I’m breathing, so get me to stay close whilst we wait for an ambulance and keep an eye on me in case I pass out.

My discomfort is so severe at this point, it’s difficult to focus on anything at all. You might have to ask me something three or four times before I can parse what you’re asking because I’m so preoccupied with breathing.

Life threatening:

My lips and fingernails turn blue. Exhaustion sets in. I’m still anxious, but I have no energy to express it. I will weakly protest attempts at sticking stuff over my face, but I don’t have the energy to fight it too much.  I start to experience altered consciousness, starting with forgetting what I was about to say and repeating myself. My vision goes wonky. Eventually, I pass out.

—

The previous post in this series is here.
The next post in this series is here.

Asthma treatment, part one: First aid

So, at this point I’ve provided a big load of theoretical information in the previous posts (I will probably get a master list up tonight, hopefully). You know how asthma works, what it’s symptoms are, and how we classify it. In spite of my inclination toward theoretical and mechanistic knowledge, I’m going to take a break from the wheres and whys and hows and provide a bit of practical first-aid knowledge.

Note that I am not a doctor. Nothing I write here is medical advice, I am relaying currently-recommended guidelines for first aid. I will reference articles written by medical professionals. I strongly recommend that everyone get first aid and CPR qualified if finances allow it so you have a more nuanced how-to than being pointed to articles online can give you.

There are two major classes of situation you might find yourself in when dealing with someone who is having asthma symptoms: when the person does have their inhaler, and when they don’t. If you are not a medical professional, you don’t have the expertise (or the instrumentation) to tell the difference between mild, moderate, severe, potentially life-threatening, and live threatening flareups, so I won’t talk about those differences in this post.

If an inhaler is present, that makes things easier. Saint John Ambulance provides the following steps:

1. Keep the person calm. I will add here, from experience as a patient: If you want to keep the person having an attack calm, you have to act calm yourself. This means: Try to keep your voice quiet. Do not hover. Keep motions slow and steady. Make sure the person wants to be touched if you want to touch them to reassure them. Try not to let your voice shake. Do not lie: Don’t say “you’ll be just fine!” if you’re not sure of it. Socially savvy people will be able to feel your uncertainty and get more scared. Instead focus on things you know are true, like the fact that help is on the way.
2. Encourage them to use their inhaler. I will add:  They should know how to use it, but you might have to help them get and maybe use it depending on how bad the attack is. A rescue inhaler is usually (not always) a blue metered-dose inhaler. If the person can’t talk or move much, you might have to look through their things to find it. Ask first. “Do you need your inhaler?” “Do you want me to get it for you?” If the person can answer in words, then ask, “Where is it?” If they can’t answer in words, it’s 20 questions time. Common places for inhalers are purses, coat pockets, sweater pockets, gym bags, back packs, night stands, and bathroom drawers. If they have a spacer device (a tube about 7-10 cm (3-4″) long, with a mouthpiece on one end and a rubber rear end with a hole to put the inhaler mouthpiece in on the other end), get them to use that as spacers are better at delivering medicine. At this point, if you can, ask them if they have an asthma action plan, and if they do, ask what they’re supposed to do in yellow zone if they can answer.
3. Tell the person having an attack to breathe slowly and deeply. You might have to breathe with them so they have a breathing pace to follow (“Breathe slow and deep” becomes meaningless when you’re having a bad one because your whole world is need air need air need air, I say from experience). Get the person sitting down if possible. If they’re having a bad attack, they might want to stand or even pace. If you can convince them to sit, do so, but don’t fight with them over it.
4. Have them continue to take their inhaler as instructed by their doctor until their breathing improves or until they’ve taken a total of 10 puffs or followed their yellow zone instructions. If their breathing improves significantly then congratulations! You’re done! If it doesn’t, progress to step 5.
5. Call emergency services. Tell EMS that you have a person who is having an asthma attack and their inhaler isn’t helping. Tell them how many doses of inhaler the person has had, and some basic things about the person who is having the attack – how old are they? Do you know if they have a history of severe asthma? Are they wheezing or coughing a lot? Are they able to talk at all right now? If yes, do they speak normally or *breathe* do *breathe* they *breathe* talk *breathe* like *breathe* this? If they took medicine other than their inhaler, what did they take? What control meds are they on, if you know? And so on. Tell EMS where you are, how to find you if you’re in a large building (in a house, “We’re in the dining room!” is fine, but “I’m in apartment 437” doesn’t help people who don’t know where on your floor room 437 is. It will save them time if they don’t have to ask the building manager for directions.

 

If at any point, the person passes out or starts to seem confused or drunk or disoriented, call EMS immediately, and if you know it, start rescue breathing. If you don’t know it, get the operator to talk you through. If the attack is getting worse but you haven’t gotten to 10 doses of inhaler yet, call EMS immediately. If you or they think the attack is severe, call EMS immediately. If you are scared and don’t think you can handle it, call EMS. Always err on the side of calling EMS. They would rather you call unnecessarily than not call in an emergency.

If the person does not have an inhaler, see if someone around has one you can borrow. In some areas, they put inhalers in emergency kits, so check the emergency kit, too. If you can get an inhaler, follow the steps above. If you can’t, try to keep the person calm and help them breathe slowly. If the person is a child or is elderly or has other medical conditions that might make breathing harder, call EMS immediately. Able adults can tolerate asthma attacks much better than kids, elderly people, and those with other disabilities. If air quality in the room is bad (like say if someone burned something in the kitchen), move them to a room with better air. Do not move them somewhere with cold air. It is a myth that cold fresh air helps asthma. In reality, cold air triggers asthma. You could make the attack worse if you get them to sit right in front of the air conditioner or go outside in winter.

Try to help them to stay calm and comfortable until the attack passes or help gets there if you’ve already called for help. If the attack seems severe (they can’t talk in full sentences, or they’re wheezing very loudly or they were wheezing but aren’t anymore but seem more distressed, or if they’re coughing so badly they can’t speak much or if they seem to be working hard to breathe), you or they are getting scared, or it just seems to be getting worse, call EMS. As above, it is always better to err on the side of calling EMS than not.

Finally, something which holds true for all cases: unless you’re in a place with no ambulance service, do not attempt to take the person to the hospital yourself. Do not do this. Call EMS instead. You do not have the medical equipment or the expertise to deal with it if the person passes out on you. You can’t help prevent them from passing out by providing oxygen. You don’t have equipment for emergency airway management or the strong medicine for opening airways that EMS has access to in most areas. Don’t try to meet the ambulance – they might drive past you in the confusion. The person is better off waiting for an ambulance wherever they are. Waiting might feel like you’re doing nothing, but if you’ve called EMS, it’s the best thing you can do.

The previous post in this series is here.
The next post in this series is here.

Asthma classifications: Severity model

So, now that we’ve discussed a bit about what asthma is, how it works, and what it looks like, why don’t I explain how asthma is classified? You’ve seen me toss around terms like “mild intermittent” “moderate” and “severe” here, but what do those terms mean? How do we classify asthma?

Well, there’s two ways: a severity model, which I’ll discuss today, and a phenotype + severity model, which I will discuss in a later post. The severity model has been used for decades, although how we classify people into each category has been refined as technology – and especially treatment – improves. There are four main categories of asthma severity:

• Mild intermittent
• Mild persistent
• Moderate
• Severe

And some more recent classification schemes include a fifth category either below or above the current severe category as “severe” encompasses too wide a range of severity to really be useful now that treatment has improved, so the fifth category was introduced to provide a more useful classification. The Canadian guidelines use “very severe,” which as it sounds is more severe than severe asthma. Under these recent Canadian guidelines, I’m classified as a severe asthmatic, but internationally, I’d be more likely to be classified as a moderate asthmatic, so that’s what I tend to use on the blog, lest I give people the wrong impression.

With the severity model, it is important to remember that doctors pick the most severe category you fit at least one criterion of. This is to prevent under-estimating a person’s severity and under-treating them (something that happened to me back when my asthma was starting to get bad again). So when you’re reading the descriptions of severity categories, remember that any one of the things I list put you in the next category up. Or, as my doctor says, “You take the worst of pulmonary function, symptoms, and medication needs, and that’s your severity.” Another important thing is that symptoms listed are what your symptoms are like without any treatment. So if you were off meds entirely, this is how bad your asthma would be. For simplicity, I’ll use the common international classifications in this post, but you can look up your country’s classification scheme if you’re curious – most countries I’ve searched post them online.

Mild intermittent asthma is defined as asthma where people experience symptoms no more than twice a week, wake up no more than twice a month, need their quick-relief puffer no more than twice a week, don’t have asthma interfere with daily activities at all peak flow and pulmonary function are normal between attacks, and asthma flares only rarely (<1/yr) require oral steroids. People with mild intermittent asthma can go weeks, months, or even years between significant flareups. Mild intermittent asthmatics need only a rescue inhaler to achieve good control.

Mild persistent asthma happens when people experience symptoms more than twice a week but not daily, or wake up 3-4 times a month, or use their quick-relief inhaler more than twice a week but not daily, or have minor limitations of daily activities without treatment or have peak flow readings of 80-100% between fares, or need oral steroids 2+ times a year. Mild persistent asthmatics are able to achieve good control, but need daily maintenance therapy, usually with low- to moderate-doses of inhaled corticosteroids.

Moderate persistent asthma happens when someone has daily symptoms, or wakes up more than once a week, or needs their quick relief puffer daily, or has some limitations of daily activity, or has peak flow of 60-80%, or peak flow variability of 15-30%, or asthma flares need oral steroids twice a year. Moderate persistent asthmatics are able to achieve good control, and are treated with high-dose corticosteroids, with or without other treatment.

Severe persistent asthma happens when someone has symptoms all day, or wake up every night, or need their inhaler several times a day, or limits activities daily, or have peak flow of <60%, or have peak flow variability of >30%, or need steroids for asthma several times a year. Severe asthmatics may or may not be able to achieve good control, always need other treatment in addition to high-dose corticosteroids. Many severe asthmatics need daily oral steroids.

Because it’s dangerous to take someone off their meds to see how bad their asthma is, in Canada, we’ve started categorizing severity based on how much meds you need to achieve control and whether or not you’re able to achieve textbook control.

The previous post in this series may be found here.
The next post in this series may be found here.

Asthma: The symptoms

So, as you’ve learned from my previous post, asthma is a lung disorder characterized by chronic, reversible airway obstruction due to lung inflammation and bronchospasm. But what does that mean in terms of how it looks on the outside? What does it make a person do or feel?

That’s what I’m going to talk about today: Asthma symptoms.

Asthma symptoms are wide and varied, and depend to some degree on how severe your asthma is and what type of asthma you have (I’ll talk about types and classifications of asthma in later posts). Some of the most common symptoms include:

• Wheezing is what happens when your lungs are tight enough that when you breathe out it makes a whistling sound. The whistling sound may be quiet or loud. Wheezing is always a sign of airway obstruction, even if it’s not caused by asthma. Asthmatics vary greatly in how much we wheeze, and sometimes we don’t wheeze much at all. Some asthmatics I’ve met describe wheezing as feeling like a rubbing feeling in their chest, whereas for me it feels more like a deep vibration. Others say they don’t really notice what wheezing feels like.
• Coughing is, well, coughing. It happens when your cough reflex is triggered. It may or may not be a sign of airway obstruction, but it’s a sign of airway inflammation. Asthmatic people – particularly those with cough-variant asthma – tend to cough a lot. You may or may not cough up gunk (the medical term for this gunk is sputum) when you have asthma. Sputum is often clear between and during attacks and may look pus-like afterwards. An asthma cough is a deep, chesty cough that often but not always is loud. It’s not the little “ahem-ahem” they sometimes show on TV. Asthma coughs rock your whole body and can cause things like pulled muscles because you’re coughing so hard. Think less “I have a mild cold” and more “bronchitis”. In fact, asthma is often misdiagnosed as recurring episodes of acute bronchitis, especially in mild intermittent asthmatics, who may go months or years between symptoms.
• Shortness of breath is a thing that I prefer the alternative name of: air hunger. Air hunger is far more descriptive and accurate than the shortness of breath name. It’s that feeling that you can’t get enough air, and to me it’s the single most unpleasant asthma symptom out there. It is a fundamentally different feeling from that normal people get when they work out too hard, and one that’s hard to describe. It’s one of those things that if you’re not sure whether or not you’ve ever experienced it, you haven’t. When you’re air hungry you know. Everything in your body screams, “must get air” and you can’t, like the proverbial person stuck on a life raft in the middle of the ocean. Air, air, everywhere, so why can’t I breathe?
• Chest tightness is a catch-all term for dull chest pain, chest discomfort, and chest pressure. It is a general term for discomfort in the general chest area without another explanation and that doesn’t fall under some other category like a pulled muscle or the crushing pain of a heart attack. I pretty much always have some degree of chest tightness. I’m kind of used to it. For me, chest tightness feels like that burning chest feeling you get if you’ve spent too long at the bottom of the pool. Others describe it as feeling like an iron band is around their chest. I couldn’t find a good description link for chest tightness because it is a rather vague and ill-defined term.

The above four symptoms are the classical asthma symptoms, and the most common. Almost all asthmatics will have at least one and often more than one of those symptoms. Less common symptoms of asthma include prolonged exhalations, feeling as if you have to work to exhale, and feeling as if you can’t get all of your air out when you breathe out, all of which are signs of air trapping, with which I’m very familiar (in fact, as I write this, my I:E ratio is 1:5, where normal is 1:2. And, no, I’m not wheezing. I almost never wheeze). My doctor has told me that small-airway inflammation can cause air-trapping without wheezing, and this is backed up by my lung function tests, which indicate a more obstruction in my small airways than my large ones (more on lung function tests in a later post). Additionally, there are symptoms that are not necessarily associated with flares but that may be signs a flare is coming. These warning signs include:

• Frequent cough
• Reduced peak flow meter readings (more on this in a later post)
• Losing your breath easily
• Shortness of breath
• Feeling tired, weak, or not with it during exercise
• Coughing or wheezing more than normal during exercise
• Being tired, irritable, grouchy, cranky, or moody
• Cold or allergy symptoms
• Difficulty sleeping because of nighttime symptoms
• Anxiety
• Dark bags under your eyes
• Rapid breathing
• Sighing
• Yawning
• Itchy neck
• and others

The above is by no means an exhaustive list. Asthma symptoms are as varied as people with asthma, and each person who has it should keep a symptom diary until they figure out what their early warning signs are.

The previous post in this series is here.
The next post is here.

Asthma: How it works

So, before we get into the meat of the posts that I’ve planned for the month, I want to lay down a foundation of knowledge that further posts will build on. To do this, I have to discuss what asthma actually is – for many people, this will be review.

Asthma is a chronic lung condition where people have episodes (called attacks or flares) of difficulty breathing. Their breathing may or may not return to normal between these attacks, but it is always better between attacks than during attacks. In asthma, lungs are often irritated. This irritation causes swelling and redness, and in medical terms is called inflammation. The problem with lung swelling is that your lungs are a series of progressively-smaller, ever-branching tubes called airways. Air goes from your trachea, to your left and right bronchi (large airways), and from there the airways branch into smaller and smaller airways, eventually becoming the small airways, or bronchioles. When the bronchioles are so tiny that they’re microscopic, they stop at little sacs called alveoli. At the alveoli is where all your air exchange occurs, with carbon dioxide leaving your blood and oxygen entering.

In order for your lungs to work, you need to be able to get air from outside of your body all the way down to your alveoli and back again. You do this every time you breathe: Your diaphragm contracts, creating a slight vacuum in your chest cavity, which makes your lungs inflate and suck air into them. That’s inhaling. When you breathe out, called exhaling, your diaphragm just relaxes and the air flows out of your lungs passively.

Or, at least, that’s how it should happen.

In asthma, things sometimes work a bit differently. Remember when I mentioned about the inflammation? Well, the problem with swelling inside your lungs is that it blocks the airways a bit. In medical terms, this is called airway obstruction. This can make it hard to move air. As well, your airways are coated in a type of muscle called smooth muscle. If your airways get inflamed, the smooth muscle gets twitchy and sometimes can go into a spasm. This is called a bronchospasm. It’s like a muscle spasm in your hand, except when your airways spasm, it clamps your airways shut even more. So now you have obstruction because of the inflammation and more obstruction because of the bronchospasm, and this is an asthma flare or an attack. Airway obstruction makes it hard to breathe, and is the direct cause of all the asthma symptoms I’ll discuss in later posts. In asthma, airway obstruction is reversible, meaning that between attacks, your airways are not as blocked up as they are during attacks. The obstruction can be fully reversible, where people breathe normally between attacks, or only partially reversible, where people always have at least a little breathing trouble, depending on how bad a person’s asthma is.

So, the point of this post was to explain a bit about what asthma is and how it works. If I’ve done my job right, you should now know that asthma is a condition of reversible airway obstruction, the names of different types of airways, and the role of inflammation and bronchospasm in asthmatic airway obstruction. Tomorrow, I will talk about asthma symptoms.

The previous post in this series is here.
The next post is here.