Thanks for your consult at DoctorSpring.com.
An asthmatic on and off medications could have increased sputum and interstitial inflammation, which will be visible as interstitial infiltrates. So, I would advise to adhere to the inhaled corticosteroids that have been prescribed, to suppress the inflammation, even if you feel asymptomatic.
A better way can also be like doing a FeNO test that tells you about airway inflammation, and specifically decide whether you can taper the medicines.
I don't think the burning pain can be attributed to anything specific in lungs. It might be GERD per se rather or something to do with nerves. However, it doesn't seem to warrant any investigation.
I won't be bothered about minor increase in infiltrates in cxr, provided PFT remains stable. I can't comment on the values per se. i would like to know the percentage of the same which varies according to height, sex and race.
At the same time, i would advise you to be regular on inhaled medicines to prevent permanent inflammation and scarring, and also do a serum IgE, serum eosinophil count- just to rule out an silent exacerbation.
Hope this helps, please feel free to discuss further.
Patient replied :
I was negative for infiltrates on the xray, I only had the mild interstitial changes. What does silent exacerbation mean?
The asthma specialist has set me up for a ct scan. Do you think it is warranted? I'm scared of ILD, do you think that's a possibility?
I have uploaded my chest xray and PFT test to the doctor only access if you would please review them.
Thanks for the follow-up, x ray report and PFT report. X ray has a bad reputation to vary on inter personal interpretation, and I would rely on my interpretation of the film, rather than someone else's.
I now got why you wanted a clarification on the infiltrates, and I do agree that your concerns are totally justified. By infiltrates they meant Focal infiltrates which might have suggested a pneumonia. Mild interstitial changes is a vague term, and is synonymous to interstitial infiltrates. Both will mean absolutely nothing for the time being.
I had a look through your PFT. You seem to fare well regarding the Fev1, FVC, and FeV%1 with respect to a corresponding female of same age, and race. I am not that happy at your FEF 25 - 75, which shows a mild decrease, that may suggest an early small air way disease, which can progress. To comment about use of bronchodilators, this PFT alone cannot be used. I would like to know the technique of PFT, personally witness the effort, and also know whether you had taken any anti-asthma medicines in prior 6 hours (or oral medicines in 24 hours).
If you see, you have taken a bit more time on the second attempt than the first. This plus the fact that i don't know your medicine timing, incapacitates me to make a comment om continuing of medications. As for now, because you are already diagnosed of asthma, I will definitely advice you to continue the same medicines.
The PFT shows no evidence of any ILD. and my previous statement that you need not press the panic button stands true. Hope this helps, please feel free to discuss further.
Wish you a good recovery
Dr. Jacob George P
Patient replied :
What are examples of small airway disease? Can it be asthma? I had not taken any asthma medicines before the PFT. On the 2nd attempt, after giving me the breathing treatment, they only gave me 1 minute of time instead of the normal 15-30 minutes because I was in a hurry to leave. could that be the cause of no improvement? As I said before, these numbers have remained the same since 2011. At that time I was told I had no asthma and I should discontinue the inhaler, but the new dr put me on qvar inhaler.
Personally I believe acid reflux may irritate my small airways. If I forget my reflux medicine I have severe aspiration (that has happened about 5 times over my life), but I believe the acid irritates them daily. Could that be correct? Is it reversible? What kind of treatment?
The classical small airway diseases mentioned are COPD, Bronchiolitis and Asthma. Of these I fear asthma - which might be becoming irreversible- because of irregular treatment. Post Bronchodialtor PFT is done after a patient skips medicines for atleast 12 hrs, and then 20 mins post of inhaled bronchodilator (like ventorlin) 4 puffs. 1 minute is unacceptable.
Asthma has many triggers, one of which you have correctly identified as GERD / reflux. I would strongly suggest anti - reflux therapy along with asthma control.
Qvar is beclomethasone, a inhaled corticosteroid, in dose of micrograms. The side effects are less compared to oral steroids and are useful for asthma control. I concur with your present doc that it needs to be continued till i get solid evidence that you don't have asthma.
Acid reflux occurs daily and microaspirations(Of which you may not even be aware of) happen even more frequently. so kindly use your reflux medicines regularly, stick on to qvar, probably one puff in night and have a symptom free, disease free life.
I strongly suggest you to do sputum eosinophil counts, blood eosinophil count, Serum IgE and an exhaled nitric oxide test. If they come to be normal, then you can continue your reflux medicines alone and asthma can be stopped confidently.
Asthma is a reversible disease, many a times reverses by itself only. So a positive PFT will be obtained only if test is done properly, that too when medicines are stopped for adequate time and if you have disease. If the test is done when you are totally asymptomatic, test results may be normal, especially in mild intermittent or controlled asthma.
So till i get a documented evidence that you are disease free ( Not symptom free), I would advice you to continue asthma medicines, along with reflux medicines. I too concur with your present physician that qvar is essential, probably at the lowest possible dose.
Wish you good health,
Dr. Jacob George P