The Flare That Didn’t Look Like One

After decades of asthma, more than 50 intubations, and years of managing my disease like a part-time job—I’ve developed a sixth sense for when things are going south. But this last flare? This one rewrote the rulebook.

When Subtlety Spelled Trouble:
It started deceptively quiet. Four days before things blew up, I was breathing at my baseline. That morning I cleared a couple of small mucus plugs—usually a good sign, something that usually makes breathing a bit easier in the days ahead, as its often an indicator that my blocked smaller airways are open a bit more with less trapped air.

But instead of feeling clearer, I started noticing creeping shortness of breath. Even mild exertion left me winded. I forced myself to keep up with my fitness walks, but I had to slow down and stop multiple times just to catch my breath. That’s not typical for me.

By day three, just walking from room to room in my house left me SOB (short of breath). My O2 sats were dropping, and my peak flows weren’t looking great either. Still no wheeze, no sense of air trapping. Just this unnerving sensation of not getting enough air. I messaged my doctors and preemptively bolused myself with prednisone, just in case this was indeed an asthma flare brewing.

Then came the evening of June 26th.

I walked from my living room to the kitchen—just a few steps. I made it, but after a short catch up period, sudden shortness of breath hit me like a ton of bricks. It was so intense I thought I might pass out. Checked my sat: 86%. Peak flow down to 200. After a few minutes of recovery, my sats crept back to 94%. This happened again. And again.

That’s when I knew it was time. We made a plan head to the hospital. Just the walk from the patient drop-off point to the ER check-in felt like a marathon. I nearly blacked out at the front desk. A triage nurse got me into a resus room immediately. Within moments, I was surrounded—respiratory, nurses, doctors, leads, IVs. Thankfully, some of the ER staff knew me and what I live with, and things moved quickly from there.

ED Note –
Dr. Namrata Garg (June 26, 2025): “Chief complaint: Severe shortness of breath. Vitals on arrival: BP 200/113, SpO 85%. Physical exam: Diminished breath sounds, audible wheeze, no stridor. Interventions included continuous nebs, IV magnesium and steroids. Transitioned to BiPAP due to increased work of breathing. ICU consult requested.”

The interventions were swift and familiar—but the underlying cause? Still unclear. I wasn’t following any of my usual patterns.

Clinical Puzzle Pieces
The team launched into full workup mode:

CT chest: No PE. No pneumonia.

Labs: Normal cardiac markers

Lungs: Clear on imaging, not so much in real life

Primary Care Note:
Stephen has a complicated asthma history for which he follows with both pulmonary and allergy. He has required many intubations, with the complication of posterior glottic stenosis, last dilated 2 years ago.

In terms of his recent exacerbation, he describes managing many severe episodes at home prior to this. He will sometimes dose his own steroids, often 80-60 mg of prednisone and reports courses longer than two weeks. He has done this twice in the last six months. He describes that what made this episode different is that he did not have his typical wheezing/chest tightness, but instead experienced profound desaturations with minimal exertion (walking from the parking lot to the ED for example) that rendered him dizzy/near syncopal. While is not clear what triggered this exacerbation he does describe some URI symptoms with sore throat/frequent throat clearing. He describes coughing up plugs which normally makes him feel better, but in this case he did not feel his usual relief. He describes the onset as slower than his usual exacerbations without the usual response to his home treatments, but does describe a change in peak flows that are consistent with his asthma flares (though this was notably after his symptoms started which is atypical). When his stenosis has given him trouble in the past, he has felt stridor without significant effort (he feels stridorous if he inhales forcefully persistently). He does not feel that is at play now. He wonders if tapering of azithromycin may have been holding something at bay that is now flaring.

Even with all their tools and training, they couldn’t peg exactly what triggered this. But they didn’t second-guess me. They let me drive, even while they steered.

Pulmonary Consult –
Dr. Shum & Elizabeth Gay, PA (June 27, 2025): “Atypical flare in patient with history of severe asthma and posterior glottic stenosis. Negative workup for acute infection or PE. Possible contributors include recent azithromycin taper and potential tracheobronchomalacia. Plan: resume home asthma protocol; obtain TTE with bubble contrast to evaluate for right heart involvement.”

ICU Note –
Dr. Kathleen Liu (June 28, 2025): “Treated with BiPAP and continuous albuterol at 20mhs per hour, weaned to nasal cannula with q2h treatments. No evidence of infection; antibiotics stopped. Patient was able to ambulate well while in ICU, but remained tight on exertion. Code status clarified—intubation acceptable, no CPR or defibrillation. Plan: continue steroids, observe one more day before discharge.”

Discharge Summary:
Pulmonary Consult Note – Dr. Anthony Shum & Elizabeth Gay, PA (June 27, 2025): “Stephen Gaudet is a 70 y.o. male with PMH of HTN (hospitalization for hypertensive emergency on 1/29/25), severe asthma requiring >50 intubations (last time about 18 months ago) complicated by posterior glottic stenosis s/p dilations, CAD, R ICA occlusion, and former respiratory therapist presenting with 3 days of shortness of breath requiring ICU admission for NIV, likely asthma exacerbation.

Mr. Gaudet has a complicated asthma/bronchiolitis obliterans history and has developed a care plan that optimally manages his condition. We advise continued adherence to that plan, as he appears to be improving with it.

This exacerbation is atypical from his prior episodes, with pronounced desaturations on exertion, and its exact etiology remains unclear. CT is without pneumonia or PE. Troponin and BNP are reassuring; he is not fluid overloaded. A 1/25 echo showed no RH strain, but ED POCUS suggested a possibly large RV—consider repeat TTE with bubble study.
Simultaneous tracheal stenosis and TBM is rare, but TBM is possible given his history. Given his use of self-directed steroid bursts (e.g., >50 mg for >2 weeks or multiple rapid bursts), we recommend he initiate PJP prophylaxis with his outpatient team if this continues.

Recommendations:

Continue home asthma protocol

Consider repeat TTE with bubble contrast

Discuss PJP prophylaxis if high-dose steroid use recurs

Thank you for this consult; we’ve communicated our recommendations to the primary team. Patient seen and discussed with Dr. Anthony Shum.”

Here’s the hospital breakdown. Not bad, only 4 days this time.

6 hours in the ED
2 days in the ICU
2 days on the CV stepdown unit
Kuddos to the lovely Respiratory Therapists, Nurses and Doctors you know who are.

I was discharged on June 30th. I’m home now, recovering, walking slowly—but walking. Im still short of breath, but I’m stable. And thats what counts.

This may not be the end of the book, but it closes a difficult chapter on this oddity of a flare. Thinking back this was probably just another asthma flare disguised as something else. Sneaky little devils.
For a deeper look at what ICU survival really feels like, read my most personal asthma story: 70 Years of Breathlessness.

But Still here. Still stubborn. Still breathing—on my own terms.