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When to go to the hospital?

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I have asthma and it has been very out of control lately. Yesterday, I tried to go jogging but could only walk and after about 50 yards, it was incredibly hard to breath. I stopped and went home but my asthma was still acting up all night.


Finally I went to bed (this is the only "clean" room in our house- the one I can breath best in) and was just laying there but I still could not breath well. I took my rescue inhaler 4 times with no relief for about 20-30 minutes. I was about to go to the hospital (I could breath but it was straining to do so and I could only say a few words before I had to stop to take another breath) but took my rescue inhaler one more time. After about 5-10 minutes, I started to feel relief. I have never been hospitalized for my asthma before- however, I have just learned that asthma attacks leave permanent scars on your lungs and scarred lungs are more susceptible to lung cancer so now I am scared.


For those of you who have asthma, how long do you wait before you go to the hospital? How bad are your symptoms when you go? I don't want to harm my lungs anymore than they already are...

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Are you on any type of "maintenance" medications for your asthma? Like Advair?


Before I went on "maintenance medications" I usually went to the doctors if my peak flows fell below 300. Do you use a peak flow meter at home to measure your peak flows (take a short deep breath and blow into peak flow meter to measure)?


I have been hospitalized before for asthma related issues, but this usually came after I was sick with bronchitis and it worsened into pneumonia.

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I am on singulair and take zyrtec for allergies. I am going to be put on Flovent but have to wait until after my lung function test. I do take my peak flow but have not yet been informed of my "red zone" areas. I did not do the peak flow last night- I actually never thought of it.


I am starting to worry that I may have bronchitis- my chest has hurt all day (in the middle, near the bottom) and I have been slightly wheezing but not bad enough to have to take my rescue inhaler. What did it feel like when you had bronchitis? I just don't want to go to the doctor or hospital if I don't have to- it wastes time and money!

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I work in a school clinic...(as you may have heard me say in other posts) I deal with kids with asthma...if I had treated a child who was not responding the way you weren't...I would have called the parents after less than two treatments and reccomended they take the child in to the ER. There are lots of allergens in the air this time of the year...etc. Do you have a nebulizer?

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No. I want to look into getting one but don't know how to go about it yet. When I was younger, that's what my parents had me do when I had attacks like the one last night and it would help big time. I live in a farming community and when I went running (walking, actually), the wind was blowing really hard- I'm sure that's what caused the attack.


So after two attempts with my rescue inhaler with no avail, I should go to the ER? How long do you give the rescue inhaler to work?

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When I had bronchitis, it felt like every breath I took, it hurt like hell. I could only take small, shallow breaths. I was wheezing and could hardly talk. I got to the point that I was nearly hunched over and hobbling around and could take small, shallow breaths. This happened to me when I was in college. It started off as a cold, then went to bronchitis. I went to the health center and they gave me some cold meds. I was in the middle of midterm week so couldn't do anything about it. Finally when I got to the point that I could hardly breathe or walk much, I hobbled over to the health center and they were alarmed and called an AMBULANCE for me to go to the hospital. I was hospitalized for THREE days.


As the other poster suggested, having a nebulizer on hand is also something you should look into since taking your meds that way makes it easier to go into the lungs.

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In our school, (elementary) If there is no improvement within 15 to 20 minutes of the initial treatment (inhaler) we are supposed to call 911 if a parent cannot be reached. Or any of these symptoms are present....


Chest and neck are pulled in with breathing (retractions)

Person is hunched over

Difficulty carrying on a conversation due to breathing

Difficulty walking due to breathing

Shallow, rapid breaths

Blueness of fingernails and lips

Deacreasing consciousness

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See, I don't ever feel that my symptoms are that bad. It's more frustrating than anything to be taking what feels like huge, deep breaths but hardly getting anything from it. I was hot and sweaty from the strain of trying to breath and I had shallow, rapid breaths and I could only say a few words before I had to stop to breath again but it didn't feel like I was dying or anything. I was starting to think better safe than sorry but my attack subsided- it always does. It just sucks because I can't run and I really want to.

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If you see a doctor and get on "maintenance" medications, you will be able to do more things like run, walk for longer distances, etc., without getting out of breath or having an asthma attack. Talk to your doctor about it. Advair is a GREAT maintenance medication. I take it once a day, in the morning, every day, and I am good to go (it comes in a diskus of 60 inhalations, you just take one inhalation a day).

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I used to be fine on just singulair but it's not enough anymore. Did you get diagnosed with asthma as a child or an adult? I was diagnosed when I was 8 and it's only gotten worse but I've heard some people say it gets better and even goes into "hiding" when you get older. I wish....


I think I might try to run again tonight.. or is that just a bad idea? If it is, maybe just a walk. I hate not being able to exercise.

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I was diagnosed with asthma as a child and had periodic bouts of it where I would get wheezy and stuff like that and have to go to the doctors and get a shot.


When I got older, like in my teenage years, the asthma disappeared for about 4 years. My third year of college (I was about 21 years old) was when I got my asthma back, and it came back because I got really sick with a cold, that turned into bronchitis and then to pneumonia. After that bout with pneumonia, my asthma came back full force and I got sick a lot and was hospitalized a few times. The specialist that I saw, finally put me on maintenance medications since taking prenidsone for severe asthma attacks is not good for you in other ways (prednisone is a steriod medication).


Right now my asthma is ok. I haven't had a major flareup in years, and I also have guinea pigs as pets (which I am highly allergic to)

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chickidee... the immune system in general can fluctuate in response to allergens or other factors... so something that bothers you a little at one time, might bother you a lot at others.


things that can make the response stronger are things like stress, allergies to things in the air, food allergies, having a virus or bacterial infection etc. all can make asthma worse while you are being affected by them.


some people's asthma can also worsen from too much exercise or overexertion. you may also be getting spring pollen from trees right now if this gets worse from jogging outside, and your body is reacting to that, especially if the wind is kicking up dust and other pollen, and possibly stuff in the dirt such as mold.


so really, you need to be VERY careful if your body is trying to tell you something and this is worsening. it is probably not good to jog at all right now if you are having trouble from this, due to pollen or some other worsening of your asthma. it could be a temporary worsening, or mean that you are not responding well to some medication you are taking.


please do not take chances with this since asthma can be fatal, especially if you are out alone jogging where no one else can assist you if you pass out. you should go to a doctor very soon to tell him these worsening symptoms, and if you start to have another episode where you can't breathe before you have a chance to see the doctor, you need to go to the emergency room.


it is just not worth the risk if you don't take a worsening condition seriously. if you are getting pain and not responding well to the inhaler, that attack should be taken seriously and a visit to the ER is called for. your doctor can also answer your questions as to when you should and should not go to the emergency room, since people on this board are not doctors and can't judge your particular health history, other than in general terms.

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Well, I have a doctor's appointment Thursday to get a nebulizer and "re-evaluate" my asthma. In the meantime, I guess I'll just get busy cleaning or something instead of jogging.


I'm sure it was a mix of overexertion and allergens in the air, bestong. Also, I wasn't asking for a diagnosis, just wanted to see how other people with asthma dealt with attacks that severe. I didn't want to go see the doctor again so that's why I asked people here first but it seems it was inevitable seeing as how I need a nebulizer.


Thank you everyone, especially rw101, for all your input and concern!

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If you see a doctor and get on "maintenance" medications, you will be able to do more things like run, walk for longer distances, etc., without getting out of breath or having an asthma attack. Talk to your doctor about it. Advair is a GREAT maintenance medication. I take it once a day, in the morning, every day, and I am good to go (it comes in a diskus of 60 inhalations, you just take one inhalation a day).


what genius doctor told you to use advair once a day?? and what pharmacist actually let it be dispensed that way? You're not getting the full benefit out of it, just thought id let you know...it should be inhaled twice a day. And thats one puff, twice a day, EVERY DAY. I will discuss the whole mouth washing thing in the next post

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Ok, I have seen a lot of questions and concerns about the management and treatment of asthma here in this post and im glad because I actually love asthma, since it is one of those disease states that if managed properly, usually has good outcomes, however most general practitioners dont know how to manage it properly. Not discouraging any physicians out there, but its just what I happen to see in practice from how my patients reiterate their knowledge and education from their physician about the disease state.


In references to to all the steroid questions (corticosteroid is the actual word) in inhalers, yes that is what most maintenance therapies of asthma consist of. Steroids in a medical sense mean to reduce swelling and inflammation, the key symptoms of asthma.


However before i go into maintenance, i want to discuss albuterol inhalers and their role. Albuterol inhalers are meant to be used in very mild intermittent asthma as a first line agent, and thereafter as only a rescue medication, if you feel shortness of breath or wheezing. Typically the effects of a single puff should take place within less than 5-10 minutes, typically almost within seconds - minutes. If a second puff is necessary, wait a minute in between inhalations. Usually it shouldn't have to be more than 2 puffs every 4 to 6 hours, and thats only if necessary. It may also be advisable to consider using a spacer such as AeroChamber to allow for optimal flow of the inhaled medication (through pumps) into your lungs. If you are using your albuterol inhaler most than twice a week, you should be placed on some type of maintenance therapy. The problem with albuterol is that your body develops a tolerance to it and the most often you use it, the less effective it becomes, and then when a real emergency arises, you have no rescue medication, and you HAVE TO be rushed to an ER. Kinda like the boy who cried wolf story.


Stages of asthma are critical in developing a plan for the treatment, and these are usually based on how often you get ashthma symptoms (day vs night) as well as the length and severity of an attack, along with the results of an LFT (lung function test).


At stage 1, typically only a short acting, as needed, albuterol inhaler is necessary.


At stage 2, a low dose inhaled corticosteroid inhaler (such as flovent) can be given, along with an albuterol inhaler for rescue purposes in the case of an attack or symptoms. Singulair may also given in place of a steroid inhaler, especially with patients that have allergies as a main trigger for their asthma


At stage 3, either a medium dose inhaled corticosteroid inhaler or combination corticosteroid inhaler + long acting beta agonist (Advair = combination of flovent and salmeterol), plus the albuterol inhaler for rescue purposes. An agent like singulair may also be added in these cases if goals are not reached with advair alone, however advair should be given several months to reach full effect. Singulair may also be given at stage 1 or 3 as well even before an inhaled steroid inhaler, especially in aspirin sensitive patients as well as in patients that have allergies as a mainstay cause or trigger of ashthmatic attacks. Singulair is a great maintenance drug and is convenient at once a day dosing. Although theophylline (an old pill drug, which is structurally similar to caffiene) may be prescribed, its use has declined in the last 5-10 years due to many adverse effects and a narrow therapeutic index (meaning the benefits only slightly outweigh the risks)


Stage 4 consists are high dose combination steroids/beta agonist inhalers, in addition to a drug such as singulair, albuterol as rescue (either via oral inhaler pump or via nebulizer), and may even need to add on oral steroids such as prednisone in severe non-responsive cases.


You will not see an immediate effect from any maintenance inhaled steroid medication, and this is a reason people are sometimes non-compliant with the drug. It may take several months to see the desired effects, however these effects and goal points are critical in the long term management of one's ashthma and to prevent hospitalization and ER visits as well as morbidity and mortality. Inhaled steroid inhalers are only what they say - inhaled...meaning a good portion of the medication stays in your lungs and very little is absorbed into your bloodstream. A portion of this is absorbed through your stomach when inhaled, however these long term effects are minimal compared to oral (pill form) steroids such as prednisone over a long time. Using the inhaled steroids prevents the long term effects of taking daily oral (pill form) steroids such as prednisone. The reason for washing out your mouth after the inhaled steroids, is that the powder can sometimes stick inside your mouth, initially just causing a dry mouth feeling, however if consistently done, can lead to oral thrush in some cases. Not a big deal, not too common, shouldnt be something to worry about. Having your asthma under control is much more important than worrying about thrush. Thrush is a fungal infection with white patches in the oral cavity. Although prednisone is a great drug to use in case of an acute ashthma attack, where almost every ER will discharge a patient with a 5 day course of prednisone. Prednisone and oral steroids in the long run, will slow down the function of your adrenal glands. I wont go into detail about the complications of that, however we try to prevent patients from having to go on long term oral (pill form) steroids, and reserve that as pretty much last line therapy.


There are other ways asthma can be managed, and other agents, and other things that have to be taken into consideration however i only kept this sorta an overview right now. If anyone has any questions, they can ask me personally about any health related topic.


When to go an ER...usually when a second attempt from your rescue albuterol inhaler fails to control symptoms within about 10-15 minutes. This is usually the case with individuals who have "abused" their albuterol inhalers over the years and lost the full effectiveness of them. It normally only typically takes several minutes for the effects of albuterol to reach an effective potential, and a maximal potential within 15 minutes or so. These symptoms are typically severe shortness of breath/wheezing, chest pain, pain upon inhalation/exhalation, dizziness, lightheadedness, palpitations, slowing down of the heart rate, headaches, blurred vision, cyanosis (face turns blue), or with any type of trauma that may cause the lungs to have to work harder. Bronchitis is an infectious state that it literally means swollen bronchioles, and in an asthmatic patient, has be treated accordingly, or else in most cases will develop into pneumonia. Having consistent, gradual onset over several days of consistent shallow breaths, coughing (usually with green/brown phlegm) and chest pain/tightness is typically signs of possible bronchitis.In an ER you will most likely receive nebulized treatment of albuterol/alupent. thereforeeee as stated previously, a nebulizer is a good investment, as it will work better in the case of an acute attack since it provides better direct and consistent drug to the lung as compared to an inhaler. Remember, drugs such as advair, flovent, singulair, will NOT help in the event of an acute asthma attack (acute is the opposite of chronic and just means a short term event). These medications are meant to be maintenance drugs to improve longterm symptoms, improve the quality of life of the patient and prevent future hospitalizations. From what you wrote, you might either just have allergies that bring on a inflammatory response and tightness in your chest, or if it is only when you are undergoing physical activity, it might be just exercise induced asthma. I believe with the right treatment, you can be running again, however if you do go out running, take it slow at first, let your body warm up, your lungs and heart warm up, and maybe breath through a scarf to bring in warm air as this will be less irritating to your lungs, and also carry an albuterol inhaler with you when you go out running, and if you feel these symptoms every time you run, you can take a puff each time BEFORE you start running or any type of strenuous activity. This is how we usually manage exercise induced asthma.


Best of luck with everything, and let me know if you any questions or concerns.


- RB, PharmD

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Thanks for all the info tmf. I've had asthma for 15 years so I am aware of what meds do what and what causes my asthma attacks. I do take an inhaler before I run, it just doesn't always help. My asthma was under control for a long time but since I have moved into a new environment, it's suffered quite a bit so now I need to change my meds or add more to get me back in control. Knowing that if I don't respond to my inhaler after the second try is when I should go to the hospital helps a lot! However, if they only administer a nebulizer treatment, a hopsital visit won't be necessary because I am going to get one of my own. Hopefully my doctor and I with the help of the asthma program I am in will be able to get me back in control soon! I will definitely ask if I have anymore questions. Thanks again everyone.

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