just diagnosed with asthma at age 58
Last August in Mont Tremblant I noticed during the marathon that I was coughing after each breath. Leading up to race I had terrible allergy-type symptoms (I've never taken meds- over the counter or otherwise- for allergies).Since then I noticed that when I get into Z4 range I consistently feel the need to clear my throat and cough. I've never really experienced any chest tightness or shortness of breathe (outside of the "normal" range of exercise effort). This prompted me to see an allergist this week.
Well, this week after pulmonary function testing before and after treadmill running and an inhaler trial the allergist/immunologist told me I have bronchial asthma with a fixed (mild) restrictive component. When I told him I don't really get short of breathe nor have ever had chest tightness he said I've compensated very well because of all the exercise I do (I'm 58 and have been racing for 20 + years).
So here I am, an "old time" athlete sitting with the diagnosis of asthma for the first time in my life. I've been given an Rx for advair to take twice a day and told to take an inhaler (brochodilator) every time before I exercise. I'm taking the advair but not the inhaler - I have done the FTP/VO2 advanced OS workouts this week since the diagnosis without any big issues except the need to clear my throat and cough a bit when I'm up in the Z4-Z5 range.
My question to the team is where do I go from here? I'm worried about progressive fixed restrictive damage in my lungs if I don't address the chronic inflammation from the asthma (I guess I need to take the advair) but I don't want to take the inhaler if I don't have unusual (not related to the effort) shortness of breathe. I certainly DO NOT want to take meds for a performance edge but seeing some of my PFT parameters fall below what they should be for someone who is lean and fit is scary. I don't want to develop a chronic lung condition that will progress to the point where it interferes with living normally. Has all the exercise,racing, ironmans taken a toll (promoted the asthma) or been my rescue to date from a condition that could have been worse?
I'm sorry for the long post. There are worse problems to deal with but for someone who is looking at 60, doesn't take meds and continues to believe he can get better as an athlete and enjoys racing and has a desire to improve this is a blow to the ego. Where do I go from here?
Comments
1. You already have a chronic condition. It doesn't make you any more or less of an athlete. It is no different than hypertension, diabetes, etc.
2. Given the restriction (presumably you are not obese), the asthma has already caused issues and will continue if left untreated so good for you to use the Advair.
3. Why don' t you try the inhaler before you work out and see if there is any difference. Given the coughing at z4, this may be related to your underlying asthma. If you have some obstruction then you should look at it from the point of view that you are already limiting your performance by not treating your asthma as opposed to taking a PED.
I would be curious to see your pre- and post- treadmill PFTs if you want to post it or send it to me via email. Specifically I am looking at the following things:
a. FEV1 (% predicted)
b. FVC (% predicted)
c. FEV1/FVC
d. TLC
e. RV
f. FEF 25-75
g. DLCO
My training was, reactive airways disease-RAD- (asthma is a clinical diagnosis signifying that RAD has reoccured at least 3 times, anybody can have a bout of RAD once after a bad viral infection or exposure to allergen)-can be cough, and/or shortness of breath and/or wheeze. The cough alone can be indicative of the condition. To have the diagnosis of intermittent RAD, it signifies that you completely clear up with no symptoms in between episodes. Chronic RAD means you have symptoms all the time. During an acute attack, the beta agonist inhaler (albuterol) should last four hours. If it doesn't, then you need to add steroids.
With all that background (from my training, maybe others do it differently) I would take the advair until I completely cleared up then stop. You need to resolve the inflamation. Once you feel that you are comletely clear, no clearing throat or whatever your symptoms are, just use the albuterol as needed, remembering if it doesn't last at least four hours without cough, you need the advair.
I have this problem intermittently, usually once every 3 years with a really bad URI. I got sick 12/31 with fever that broke 1/2 then the nasal congestion and cough started. I started my albuterol on 1/3 then realized by 1/5 I needed the advair. I only had to use it for about 4 days then cleared. I did my JOS Vdot test at the end of this and I didn't push as hard as I usually would for fear of a coughing attack-I really don't wheeze of get short of breath either.
One of our other team mates developed something similar and was sicker than me and progressed from advair to a stronger combo drug, symbicort, and is finally clearing. We are all in our late 50s-so you are not alone! And you are right-your fitness and also your athlete attitude has gotten you as far as you are despite this problem. Also, asthma is one of the most common diseases
@ Betsy's symptoms are entirely consistent with RAD post-URI and will occasionally require the ICS/LABA tx but it sounds as though @ David has something a little different.
Finally I have a concern in regards to the restriction seen on your PFTs. It is not clear to me what the significance of this is. Depending on the severity, it could be borderline mild and simply a reflection of the test or it could be something else. Furthermore, a reduction in TLC would make classification of the severity of his asthma problematic. In other words, if you have a restrictive lung disease (think of it as having a belt cinched around your chest preventing you from taking a full breath), then it follows that the FEV1 and FVC have to be low as they are dependent on the volume of air that you inspire. Therefore if you had significant restrictive lung disease then your FEV1 and FVC will likely appear to be moderate or worse. I probably made many of the peeps' heads spin reading this but I didn't stay at a Holiday Inn Select, I promise ;-) I have some other thoughts re: your coughing at Z4 and above but I will hold for now.
Betsy-thank-you for taking the time to respond to my cry for help and giving me some good advice
Kar Ming- Wow -what can I say other than I feel fortunate to be part of a team that has access to someone like you. Clearly you are a WSM (wicked smart member). As a physician myself (I know- the worse kind of patient) everything you say resonates with me and you hit the nail on the head - I'm most concerned about a fixed restrictive component that reflects long standing untreated asthma. I will e-mail you my PFTs and I'd love to hear your thoughts about my cough in Z4.
I guess my big questions are whether or not I need the inhaler immediately before exercise if I'm not experiencing SOB (or will the inhaler before exercise help prevent long term damage?) and is the inhaled steroid/B agonist treatment something I need to commit to for life?
Again, I can't thank-you enough for trying to help me.
It is not entirely clear to me whether or not you need albuterol prior to exercise. The cough you are experiencing could be one of two things. Firstly it could represent underlying bronchospasm. As such it would be reasonable to experiment on yourself to see if it goes away with the use of albuterol. Also being on an ICS/LABA may improve the underlying inflammation such that you might not experience any further issues at Z4. Only time and a little experimentation will tell. Secondly, another option which is a little more interesting from a less common point of view is that as we approach our maximal exertion there can occur a flow limitation based simply on our airways. Typically this does not affect the vast majority of people but since you are exercising at such a high level this may be happening. I have not seen it in my 11 years of clinical practice (the average pt is frail with COPD) but actually saw it in my own exercise PFTs when I was a pulmonary fellow. If you have a restrictive defect then this flow limitation (coupled with declining lung function of getting older) may be occurring earlier than in the past. Of course, this is just speculation as it is not entirely clear to me if this results in any clinical symptoms (I will look more into it and ask my more experienced partners). A third possibility is exercise induced pulmonary hypertension or other cardiac factors.
Was your DLCO abnormal?
BTW my email is: pinoetnani@gmail.com
I am also on Advair. It took a few months for it to see the full benefit, and I would often have coughing or wheezing during a workout if I didn't take the bronchodilator before. You might want to try taking it before workouts for the short term, and see if it improves the symptoms that you do have. Keep a record, that is something that has been very helpful to me. My symptoms have significantly improved, and I recently entertained the thought of trying to come off the medications. But today, out of the blue I had a pretty significant episode of wheezing and coughing during a swim, and needed albuterol. I'll stay on the Advair, much as I don't like paying for it.
I have a question for Kar-Ming Lo. As David's test results show a fixed restrictive defect, is that fixed in the sense that this is permanent, or fixed in the sense that it is not reversible with bronchodilator, and is maybe due to inflammation? As his inflammation resolves, could this improve on future tests? Also, I've never had a physician tell me that I could permanently damage my lungs by not treating the inflammation; that is very good information to know.
http://members.endurancenation.us/Forums/tabid/57/aft/10634/Default.aspx
As for coming off the meds, the goal nowadays is to taper as far as possible as long as the patient is clinically stable as well as stable from spirometry perspective (if available). I have folks that take Advair in the spring , fall or both but is off during the winter/summer. As in most things in medicine, it all depends.
Sarah,Kim- Thank-you for your help and encouragement.
Kar-Ming- The PFT at the allergist/immunologist did not include a DLCO. I've sent you my PFT data via EN messaging but will resend to the e-mail address you provided. Again, your help is MUCH appreciated!
Just making sure you got my email.
Thanks Kar-Ming- I got your e-mail and responded
David,
I just came to the forum to ask if anyone could help me when I read your reports. I am 50 and was finally diagnosed on Monday with asthma. My problems began over the Christmas break. My primary care physician started me on albuteral inhalers that initially helped. I had a bout a few years ago and after a month or so, the symptoms resolved. I started using them before runs, then before and after exercize. If I forgot, I was walking home trying to suck air through a straw. Finally got to the pulminologist who did a breathing test then an albuteral nubulizer, then a retest. I was breathing 77% and the albuterol did not make much difference. I can verify that when I used it for running, it was getting less and less effective. He said I should be 110 to 120% based on my long term fitness level, and this meant a diagnosis of asthma. Since my dad just passed away with end stage lung disease and my sister suffers from severe asthma, I was depressed. Mad because I'm a non smoker and I exercize.
The plan is to use an inhaled steroid/combo product (Advair) for 2 months and use the albuteral inhaler 30 min before exercize and every 4 hours if needed. I immediately feel better. I was able to do a 3 hour ride and a 1 hour brick run yesterday with no symptoms...except a little when I began to cool down.
I'm still mad and slightly depressed, but have more concern about long term inhaled steroid use. What is this going to do to me? I am an allergy sufferer and it is full blown spring here with clouds of yellow pollen blowing everywhere. I hate being dependent on meds.
I'm hoping the others who answered your reports will jump in on htis.
Jodi (in Georgia)
Jodi,
Sorry to hear about your troubles. I've also been started on Advair. Although I was given an inhaler to take before exercise I do not take it. I also did not get a "significant" improvement in my PFT parameters after taking a bronco dilator.
My problem has not been the perception of any unusual shortness of breath with exercise but rather the recent tendency to cough frequently when doing hard efforts (Z4 range). I've seen both an allergist and a pulmonologist and was told I have a "mild fixed bronchial obstruction" which I suspect reflects long standing untreated seasonal allergies. I still don't know if by strict standards I have "asthma" since I did not seem to have any particular response to bronco dilators.
In terms of therapy I have been taking the Advair (the only "prescribed" medication I've ever taken in 58 years) and also fish oil in an attempt to reduce inflammation (? if it works). Training has been fine but a broken fibula 4 weeks ago derailed my running for a bit but still OK with the bike (Jan advanced OS) and other odds and ends to fill in for the run. I can't quite tell yet if the Advair has helped my symptoms (cough) but I want to believe it has,
In terms of pulmonary knowledge within EN- Kar-Ming Lo is the man. He is a pulmonologist and very smart.
Do not get discouraged - there is a way. As they say- we do not improve despite our difficulties but precisely because of them. Hope this is of some help. Best of luck
@ David, you are too kind. I am sorry to hear about the busted fibula. Thank goodness it is not a weight bearing bone (I think)
@ Jodi, I am not certain how they diagnosed you with asthma if you did not exhibit reversibility ie change in your FEV1 of 12% and 200 mL. If there was no reversibility then it might explain why you don't benefit from the albuterol. I am not aware of any data that suggest that long term athletes should have FEV1 >110-120% but I will review when I get a chance. These numbers are based on population norms and reflect how we stand as a male/female of certain height/race etc. Some people will be higher and some lower based on where they are statistically on the bell curve. If you did not have bronchoreactivity previously on your test then the final definitive test would be a methacholine/histamine challenge test that would "bring on" an asthma attack. Sorry re: your dad. What kind of end stage lung disease did your father have? pulmonary fibrosis, COPD? Get a copy of your PFTs and you can send to me if you wish.
Good Luck
Dr. Kar-Ming Lo,
Thanks so much for your response. I will get my PFTs to you. What you are saying is making sense. I was just following Dr's suggestion of Advair bid and albuterol inhaler before exercize. Of course the steroid helped. I would rather not be on it if not needed. As for my dad, he had COPD diagnosed around age 70. Prior to that he had multiple bouts of myocardial infarctions starting in his early 40's resulting in at least 4 stents and 2 bypass surgeries. In the end he was on O2 for 3 plus years and it seemed the lung disease was the final straw.Death ruled end stage lung and heart disease, or so the family was told.
David, Thanks so much for your support and for hooking me up.
Jodi
@ Jodi, it is interesting and good that you are feeling better with the Advair. Perhaps the steroid component may be helping any allergic component that may be resulting in your reduced lung fxn. Difficult to tell at this time. I have many asthmatics that go on their steroid inhalers during the spring/fall and come off in winter/summer. Maybe that will be your case as well. Look forward to your PFTs.
@ Leah, EIB tends to occur 5-15 minutes after initiation of exercise. After it peaks, you should feel a refractory period for several hours. If you are concerned then PFTs before and after initiation of exercise is the way to diagnose it.