October 3, 2009

Cough #1: Breathing vs. Sleeping

flood4 Our government, which is to say taxpayers, offers insurance that commercial insurers would never come near. It’s flood insurance, for people who live on one of America’s great flood plains. According to the website, “30% of all flood insurance claims come from areas with minimal flood risk.” I’m flood3good at math…so 70% of the claims come from areas with major flood risk. You know the 3 most important things in real estate: location, location, location. So we may not be able to predict the timing of a crisis, but we know for sure that one will come.

A working mother called. She said that her son, 10, has been coughing for a week, and it’s been getting worse. He’s been missing school, and that’s just not working for her job or for his dad’s. Would I prescribe some cough medicine for him, since none of the stuff they bought at the pharmacy seems to be helping.

I’ve known this boy for about 10 of his 11 years. He’s had asthma for most of that time, and—to be blunt—his parents just have not pushed him to keep up with his daily medicine. Every time I see him it’s a crisis, and he often misses important follow up appointments.

Here’s what happens. He’s having a hard time breathing. Finally, his parents take him to the doctor, who prescribes the right medicine. He takes it, feels better. Nobody in the family sees any need to continue taking medicine when he’s not sick [please see The Medication Paradox] so he stops. They don’t show up for the follow up appointment in which I had planned to reduce but not eliminate his medication and to fine-tune what he gets to prevent subsequent crises. But this doesn’t happen, so the predictable crisis recurs.

I told her that I had to see him, and reluctantly, she brought him to the office.

The thin boy I saw before me was breathing a little fast, but not coughing much. I asked him if he minded missing school. He said, ‘Yes,’ and started coughing. A few minutes later, when I asked him to take a deep breath, that set him off again. He couldn’t speak more than a word or two without erupting in coughing. He was solidly in an asthma attack, and I told him and his mother this. I prescribed the appropriate regimen and told his mother as I handed her the prescription, ‘Get this filled right away and give him the full dose immediately. It won’t start helping for hours, and he needs to be better before tonight.’

I called that evening to follow up. I could hear him coughing in the background. I was told that he wasn’t better, but he was in good spirits and didn’t complain of difficulty breathing. I was in their living room in about 30 minutes. He looked about the same as when he was in the office, about 8 hours earlier. I couldn’t figure out why the steroids hadn’t helped—indeed this was an ominous sign that had hospital admission written all over it. I asked what time he took the medicine.

“Oh, he didn’t take it.” I admit to expressing more than passing curiosity about this, given my careful instructions to get it in him as soon as possible. “The pharmacist said not to give it tonight because it might keep him up. So we should give it to him tomorrow morning.”

Now, at this point in this completely true story, I hasten to interject that I adore pharmacists. My father was a pharmacist. Pharmacists have caught my errors and helped my patients.

This was not one of those times. Luckily for this child, I was standing there in his living room at 9:30 at night watching him take the medicine that might indeed keep him up all night, but breathing.

In asthma, the airways, those tubes carrying air into the deepest reaches of our lungs, get inflamed and irritated. When they are inflamed—just like other places in our bodies—they swell. But there’s a problem when the walls of a tube swell. The inside diameter of the tube gets smaller. It feels like breathing through a straw.

What we try to do medically is first, get the tubes to relax so they get a little bigger, making it easier to breathe. But as soon as this medicine wears off, the problem starts over since everything is still inflamed. So we also use anti-inflammatory medicine to reduce the swelling.

For the record, the medicines that we use with asthma can indeed have an insomniac effect. The steroids (not the kind that build muscle) can even cause some distressing behavior, especially in children. Albuterol and medicines like it (often dispensed in inhaler devices) can make your heart beat faster and make your hands shake. It might be true that these can cause a person to have trouble falling asleep. But people who are several days into an asthma exacerbation (the non-PC term used to be asthma attack) have not slept in days because they’re up all night coughing and trying to get a breath. When this primal hunger for breathing is relieved, no matter how stimulating the medication, they are often so relieved that they fall asleep restfully without a problem.

He was better within hours, and went to school the next day. We set up a follow-up appointment for Saturday. He missed it.


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