Episode 12 - Surviving Pollen Season with Allergic Asthma: Expert Advice

Dr. Meagan Shepherd: Do your allergies sometimes make it hard to breathe? You experience wheezing or shortness of breath during allergy season? It's like your immune system mistakes harmless pollen for some type of invader that sets off a chain reaction in your airways. And what we are going to do today is chat about that in ways that you can keep it from happening and keeping you down whenever your asthma flares during allergy season.

Welcome to Allergy Actually.

The Allergy-Asthma Connection: Why It Happens

Dr. Meagan Shepherd: All right, everybody. So am I the only asthma sufferer among us? Oh. 

Dr. Kara Wada: Remember, do you remember when we were in Ed O'Hare?

Dr. Meagan Shepherd: Yes, yes. So, quick, quick, quick little detour. We're gonna talk about this, but so.

Dr. Kara Wada: That was when realized it was a bigger problem than I thought.

Dr. Meagan Shepherd: Yeah, so everybody knows how big O'Hare airport was, and Kara and I and oh one of our other allergist friends were there for we had done this little conference and we were all leaving at the same time. And as Amber knows, I really love time in airports too. That's a whole other story. But

Dr. Kara's Real-Life Airport Asthma Attack Story

Dr. Amber Patterson: Oh, me too. Send me to DTW. Pick me up next week.

Dr. Meagan Shepherd: But I know with carrier flight got changed and so you had to do this race.

Dr. Kara Wada: Well, I mean, I wish I could blame it on the gate being changed, but really it was me like totally spacing out and just being at the wrong gate and realizing I had to be halfway across.

Dr. Meagan Shepherd: Got it.

Dr. Kara Wada: I, I don't even remember if it was in the same terminal and I'm getting hot, like thinking about it. But I had all of my stuff and it was over, only an overnight, but I was still pumping, and so I not only had like my suitcase, but I had all my pump gear and my pumped milk

Dr. Meagan Shepherd: And you had dinner.

Dr. Kara Wada: And my laptop and all that stuff.

Dr. Meagan Shepherd: You had dinner, remember? You had gotten

Dr. Kara Wada: That's right. I also had dinner because there's a restaurant 

Dr. Amber Patterson: carrying your dinner?

Dr. Meagan Shepherd: With the whole family, not just the husband.

Dr. Kara Wada: Was bringing dinner home for the family. You're right 'cause I do that. Because it's only an hour flight and it's delicious tortas. But that running in that dry airport air with all of that, had me breathing a very heavily and very you know, fast, lots of airflow, and it triggered some pretty profound coughing. We, you know, not, I, I have more cough variant asthma. So it was cough, cough, cough, cough, cough, cough, cough. And you could tell there was a bit of a mucusy component to it. And I had only really ever had that happen, maybe one other time maybe a year before.

And so I didn't have an albuterol inhaler because I didn't really, you know, like the other time was like a one off. I was like, oh, you know, I don't know. And so, Megan, I, I texted her, "I'm like, I'm at the gate. I got rebooked, but I can't stop coughing. I think I'm having an asthma attack." And so, you graciously came over and had me take six puffs of your albuterol so that I could like breathe and stopped coughing. And I was so jittery from all of it, the adrenaline, the albuterol. But I was able to breathe and they let me back on the plane 'cause I thought that they may not let me on the plane if I was cough, cough, cough, cough, cough, coughing.

Dr. Amber Patterson: Oh my God.

Dr. Meagan Shepherd: Yeah. No,

Dr. Kara Wada: It's funny now. It wasn't so funny then. 

Dr. Meagan Shepherd: No, it was, it was kind of intense because, and, and especially because it wasn't something you were used to like, if I would've been there I would've accepted that I was going to cough a lot. You know, and it would get better with my albuterol inhaler, but still, I, you know, if you run spur the moment.

So, but yeah, so I'm also an asthmatic and I was diagnosed with exercise-induced asthma back in medical school and it's progressed into fairly severe asthma. Now I'm on two different types of a combo inhaler and then another type of inhaler that works for a different like a different medication and then also a biologic medication. And all that together helps so that I am pretty okay. I went from, before I started the biologic, I had been on steroids like the entire month of February. There were several years where I was like that. And so, and it was a slow recognition that that was asthma. 'Cause I also have cough-variant asthma, I don't very, I wheeze very much.

Dr. Meagan's Journey with Severe, Cough-Variant Asthma

Dr. Meagan Shepherd: Um, I do sometimes get short of breath, but mostly it's a manifest as a cough. So one of the things, and so we're gonna talk about pollens more, we're just kind of more talking about asthma itself. But for me, I don't have allergies. You know, the, when we do allergy testing and when we read it, I can like, muck around in it. And, you know, I, I mean, I obviously wash my hands and whatnot afterward, but it, it doesn't bother me at all. And I've been tested, you know, we learned to test on each other. You know, I've no allergies, anything like that.

And so I do get worse when allergy season happens though, because I always tell people, even if you don't make the allergic protein on a molecular level, you, it's still an irritant. It's still stuff in the air. And so what do you guys tell your patients about whenever this is happening to them? Like when pollen season is coming and you know that typical asthma is going to flare up for people who are triggered by pollen or irritants? 

Dr. Kara Wada: Often I'll talk about the the air, kinda this idea of the one airway hypothesis, but like our nose all the way down to the basis of our lungs, it's all interconnected. And so, often, and, and I, I've seen this most profoundly in my patients who have nasal polyps, which is a topic for another episode, but when their nasal inflammation is well controlled, very often the lung inflammation stays pretty quiet too, not the case for everyone.

And, and I think, you know, one little extra thing I'll throw in there that I was talking about quite a bit yesterday was when I went through med school, which was not quite 20 years ago I learned that there were two types of asthma, allergic asthma, and non-allergic asthma. And what we've realized over the course of our training and our career is that that's, that's not the case. It's a gross oversimplification that we actually have over a dozen different types of asthma.

And although all of them are united by, you know, periodic airway narrowing and inflammation there are nuances, like yours, developed in adulthood has been fairly fast in its, in its worsening and, and its severity and needing more medications. And and, you know, some of the other like demographic type things will factor in the fact that you're a woman and, you know, and, and at that age, we kind of now have some ideas of how that may affect you a little differently than a kiddo who has who has wheezing. And so often I'm talking about that too, and kind of what we've learned and how that applies in their specific situation.

Dr. Amber Patterson: I think a lot of times patients who have really bad allergies and asthma, they end up on our doorstep first because they've either landed in the hospital or like you experienced, Megan, have a month where they've been on steroids and they can't get off because pollen season's so bad. So they land on our doorstep and then we first have to do the work to help them figure out what are your triggers, how can we reduce exposures and try to make a plan so that this doesn't happen again. I don't want you in the hospital ever again because of asthma, because this is preventable. treatable, something we can do something about. And part of that plan that I've started implementing with my patients is remote home monitoring of their lung, lung function.

Proactive Management & At-Home Lung Monitoring

Dr. Amber Patterson: There are a couple different devices that we use. One can measure FEV1, which is that, you know, when, when you go get a pulmonary function test or a breathing test, there's one number of all those numbers that's so important to us in diagnosing and tracking your asthma, and that's that forced expiratory volume in the first second, when you breathe out really hard and fast, how much air can you breathe out?

So one of these devices can check that. Um, the other one checks kind of the reverse of that, but still gives you kind of similar information and, and also can help you with adhering to your daily medication regimen. But when you use these devices, essentially recording on an app, your lung function in real time every day. So you're building this database you know, your personal information that you can track over time that you can see on your app that your doctor can see in real time. And so you start to see these patterns then. And you can sometimes see when lung function starts to dip before the clinical symptoms even start. So it helps you get ahead of it. And, excuse me, whole of maintenance, prevention I think is a really important thing for our asthma patients.

Dr. Meagan Shepherd: Yeah, I would agree that. And as an asthma sufferer, what, and what I tell my patients basically is, you know, triggers are overall different yet similar for a lot of asthma patients. A lot of patients get worse whenever we get a cold. A lot of us get worse when there is stuff in the air, whether it's pollen and whether you're truly or like I'll have patients say when they have allergy testing, "But I don't understand. I get so bad during grass season," and I'll say, "but I'm not allergic." And I'll say, well, grass can be very irritating. Again, it's a particle, not only is it, a, a pollen in the air, but we're also like mucking in it all the time with mowing and throwing it everywhere.

So, you know, whenever you have one of you know is coming up that's going to aggravate your asthma, make sure you do what you can to control it. And if that means doing a controller medication prior to any exposure or, you know, something like, or preventative medication prior to any exposure like albuterol, something like that, increasing your prophylactic medications. Some of those are done on a daily chronic basis. Some of those are done on an as needed basis. I have families especially with little children, I ask, one of the main things I ask is, do, you have, when your child has a cold or something happens, anytime they get snotty nose, does it always go to their chest? And they say, yes. I say, don't, don't wait on coughing then, because I'll say, when do you start albuterol? And they'll say, oh, when they're having trouble breathing and you know, I can hear wheezing and they're coughing really, really hard. And I'm like, don't wait on any of that. They have, at this age at least proven that right now that is their MO. That's what they do whenever they get sick. So as soon as they get snotty, go ahead and start it because you know it's going to happen. 

Overlooked Asthma Symptoms: Cough, "Bronchitis" & "Asthmmonia"

Dr. Amber Patterson: What do you guys think for all those people out there that are, after listening to this thinking, "Oh my gosh, do I have asthma?" What are some of the symptoms or signs that people should look for besides just trouble breathing, which I think is kind of the main thing people think about?

Dr. Meagan Shepherd: Cough in your sleep, cough in the morning, cough whenever you run and play hard. Cough is a huge one that's overlooked. And I also think that's interesting because when you look at the data, cough and asthma, not a lot of data for that in adults and even with children, and they, you know, it, it's, it's not necessarily a high percentage, but I feel like that is the main symptom of asthma that I see not actually wheezing. A lot of the wheezing that patients hear as well is actually from the upper airway. It's not coming from here down, so cough is huge.

Dr. Kara Wada: I would say the other key word or word that gets my ears, you know, turned on is hear or asking, hearing if someone has bronchitis that's diagnosed by the urgent care, the primary care related to infections. In my mind, bronchitis equals asthma exacerbation until proven otherwise. 

Dr. Meagan Shepherd: And I I have a lot of younger children who are you know, even admitted to the hospital frequently and they're diagnosed with pneumonia over and over and they get sent to me for and this has happened in several adults too, but they get sent to me for an immune workup, wondering if they have a primary immune deficiency. And when I start getting into their symptoms and what's going on and sort of what happens on a daily basis, I end up thinking that they actually have uncontrolled asthma. And that is literally like 90% of the time when I get these patients for that workup, and I'm going to use the word because I love it and I still use it all the time. Dr. Mustillo used the asthmmonia and so.

Dr. Kara Wada: Yes, yes.

Dr. Meagan Shepherd: It's the best descriptor of whenever you have kids or even adults who get re currently admitted to the hospital for what is an asthma flare, but it, it, you know, you're often treated as you have that you have pneumonia. You may have pneumonia in addition to the asthma flare. It might be what's causing it. On x-ray, whenever we look at some of the changes seen whenever you have an asthma flare, you can have Atelectasis where your little small air sacks collapse a little bit, and sometimes that's hard to tell from pneumonia on chest x-ray well, so. There are plenty of reasons why that all kind of gets together, but when I have people sent to me for recurrent pneumonia, my first thought is always this is, there's a high likelihood that this is asthmmonia and we need to work out the asthma component before I really get concerned about your immune system. 

Dr. Amber Patterson: Totally agree.

Dr. Meagan Shepherd: This has been an awesome talk today. If anybody has any questions about asthma or comments, I would love to hear, I think we would all love to hear what your triggers are. Anything odd that triggers your asthma would be interesting for us to talk about and learn about. So, go ahead and leave us comments. Hit like, and subscribe. We would love to keep talking about this and other things with you. And thank you for listening to us today on 

Kara: Allergy, Actually.

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