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.
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.
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.
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.
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.
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.