Wednesday, January 27, 2010

Rescue inhalers

So let's talk rescue inhalers. You know what I'm talking about: Albuterol. Well, there are other ones out there too, but for me the bronchodilator (rescue inhaler) of choice is Albuterol.

It didn't start out that way though. I was first introduced to Alupent in 1980 shortly after my 10th birthday. I remember sitting on the edge of the doctors table, and the doctor entering the room with this little white thing. "This is an inhaler," he said. "We'll see if it helps you breathe better."

He held it a finger's length from my mouth, and I inhaled (as instructed) as he squirted. As most asthmatics do on their first inhaler breath, I choked on the nasty taste, and white mist spewed from my mouth, into the room and disappeared.

"Fine," he said as I coughed and gagged, "Let's try again."

Despite the nasty taste, the procedure went fine the second time, and that was the beginning of my love affair with the bronchodilator inhaler. Soon thereafter the stuff became tasteless.

Quite frankly, I don't know how I ever got along without it before that time, nor why I wasn't introduced to it earlier. It was simply an adorable little object.

I remember thinking how would I have survived back in the days before the inhaler was invented. I bet I would have died as a kid.

Yet, in retrospect, I now wonder if it was a gift or a boon.

Now, I'll stop myself here a moment. Most of you probably read that last sentence and said to yourself, "What? How could an inhaler be a boon?" Well, that's where what you'll learn by reading my blog will differ from what you will hear about asthma anywhere else. Allow me to explain.

I read a while back that none of the asthma experts of the 19th century noted that asthma caused their patients to die. In fact, Henry Hyde Salter mentioned in his book, "On Asthma," that none of his asthmatic patients died. They had a high morbidity, but nill mortality. It wasn't until epinepherine was invented in 1903 that asthma deaths started to spike (you can read more about this by clicking on the links that follow this post).

Before 1980, before I was introduced to Alupent, whenever I had an asthma attack I told my parents (well, eventually I would), and they'd take me to see Dr. Oliver or to the emergency room, depending on how bad I was, or what time of day I revealed my secret. I say secret because few people know how to pick up on the signs of bronchospasm -- at least back then anyway. It's a skill. You have it. I have it. Most people don't have it. Many doctors have no clue either.

At the doctor's office, or the ER, I would be given a shot of susphrine (long acting epinepherine) and it worked within 5 minutes to open my lungs and make my breathing easier. Then I'd be given a shot of systemic steroids, a pack of roids for the road, and be sent on my merry way back home with mom.

Now, with the inhaler in my possession, now I have a way to treat myself. Now I can puff and puff and puff to my hearts content. Thus, once I realized I wouldn't die by taking extra puffs (which didn't take too long by the way), I would take my inhaler instead of telling my parents.

Now, do you know how many asthmatics were found dead with that old faithful clutched in their grip? Right? Neither do I. But there were many. The same philosophy holds true for the Serevent, Adviar, Symbicort, Formoterol, and those types of medications. These meds have been blamed -- linked -- blamed for many asthma deaths.

Yet, when I take extra puffs of my Alupent-Albuterol-Serevent-Advair, I don't die. If I died, I certainly wouldn't be writing this right now would I? I dont' think so. So, the fact of the matter is, those meds don't kill. So, what does kill?

What kills is the false belief that these medicines will actually make your asthma get better when what you really need to do is seek professional help. And that, my asthmatic friends, is why I think the new asthma guidelines are a gift.

While they say it's fine to use rescue inhalers, and they recommend all asthmatics have one, they highly recommend to doctors that increased use of rescue inhalers is not going to kill the patient, but is a sign of poorly controlled asthma or worsening asthma. Yet, back in 1980, or in 1981, or even in 1985 when I was at the asthma hospital, or 1990, I was not taught this.

Of course in 1985 my asthma was controlled to the point I needed my rescue inhaler less often. Yet, still, increased rescue inhaler use was not linked to worsening asthma. It was linked to noncompliance. It was linked to bad asthma. But it was not linked to worsening asthma. Or, at least I don't think it was as a general rule.

Yet, over time, when Alupent hit the dust and along came the Albuterol, which had a stronger beta 2 effect on the lungs and much less of an alpha effect on the heart, well, now we had an inhaler that we could abuse even more.

So there was another medicine like Serevent and formoterol -- perhaps it was formoterol -- that was released in the 1970s, and asthma deaths spiked. So, instead of introducing asthmatics to this medicine in 1970, long-acting bronchodilators were not made available to the public until the mid to later 1990s. Why? Because areas where this long-acting bronchodilator were trialed, asthma deaths skyrocketed. I wonder how many asthmatics were found dead with this medicine clutched in their grip.

The same was true for Serevent. There was a time a few years ago that the FDA considered taking this medicine off the market because many asthmatics were found dead with this medicine clutched in their grasp. Thankfully, someone realized something here was amiss. Thankfully a warning was put up, "Take as prescribed. Take only twice a day."

Yet, still, was it really overuse of the Serevent that killed these patients, or because these asthmatics waited too long? Did these asthmatics have too much faith that the Serevent would get them over the hump that they died waiting? That's what I think.

With exceptions of course, I think most asthmatics don't die becasue they take extra puffs of their rescue inhalers, or long-acting bronchodilators. I think they die because of poor asthma education. And, thankfully, this area has been greatly improved in recent years.

Now you see medicines like Symbicort being approved to be used as rescue inhalers in Europe, Australia and Canada as part of the SMART program. This is currently being investigated as a possible option for asthmatics here in the U.S.

However, it must be noted that I am not endorsing the overuse of beta adrenergics. What I am endorsing is a common sense approach to asthma therapy. I endorse educating doctors, researchers, scientists and patients as to how rescue inhalers really work. I endorse asthma action plans. I endorse asthma wisdom.

Too much Albuterol has been proven to be safe, yet to what extent? What patient will die from too much Albuterol (I have yet to here of a patient die from too much Ventolin). I went through an inhaler in one day once (or probably more often than that), and I'm still here. So we know Albuterol didn't kill me. Or, was I lucky?

I wouldn't take that gamble with long acting bronchodilators like Serevent and Formoterol. I do think it's safe to use them more than just twice a day, but I wouldn't go overboard. And I wouldn't do anything with these meds without permission first from my doctor. And I highly recommend you don't either, unless you're the gambling type (like I was when I first got my Alupent inhaler).

There has to be a limit somewhere. The SMART program recommends using Symbicort -- I think -- no more than 8 times a day. I think that's a good place for a patient to stop. The FDA, however, and the asthma guidelines still have not approved this medicine for any greater use than twice a day for asthma. The black box warning still exists for both Advair and Symbicort.

So while I don't think these meds at their face value kill asthmatics, I still think we asthmatics can lean too much on these meds. They, in a sense, become a clutch. Yet I most humbly, and from my own personal experience, recommend that all asthmatics not use their rescue medicine -- and especially their long acting bronchodilators -- as a clutch.

And, in that sense, I often wonder if me using my Alupent as a clutch caused me to wait too long too many times, and that's how I developed worsening asthma as I aged from 10 to 15 when I was admitted to the asthma hospital. Or, would I have gotten worse regardless what I did.

I honestly was never admitted to the hospital once before I had a rescue inhaler, and between 1980 and 1985 I was to ER God knows how many times, and admitted God knows how many times. In 1984 alone I think it was 14 trips to the ER, all because I waited too long to seek treatment.

By 1985 my parents and doctors thought I was going to die if something wasn't' done. That's how I ended up at the asthma hospital for 6 months. In fact, I know I was thinking along these lines even as a 15 year old, because I remember talking to my counselor at NJH about my rescue inhaler overuse.

So, in a strange way, I wonder if all this would have been avoided if I simply was never given that device in the first place. I wonder if I wasn't given that first Alupent, if I would have sought out help instead of staying home and letting my asthma get all that bad that many times, thus every one of those bad attacks led to worsening scarring.

I say this because we know if an asthma attack is treated swiftly and correctly that further damage can be prevented, and asthma can be treated. Yet, I also know asthma wisdom was different back then. While doctors knew that inflammation occurred during an acute attack, they didn't know there was chronic inflammation that needed to be treated DAILY with inhaled steroids. Of course, inhaled steroids were feared back then as much as systemic steroids.

So who knows. Perhaps I'm thinking too hard. What do you think?

Related posts:
  1. Modern meds may cause fatal asthma
  2. Is it possible pure asthma is not a fatal disease
  3. Advair/Symbicort: Is overuse really deadly?

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