Everyone’s asthma or COPD flare ups manifests differently. Along with the background breathlessness that’s always present to some degree because of my low baseline FEV1, for me there are 3 distinct types of flare ups that I experience on a regular basis. The mild flare, the severe flare and the one in the middle that I probably hate the most, is the moderate or “Pesky” flare.

When I say pesky, Im not referring to those sudden, but mild chest tightening occurrences that quickly reverse with a hit off the old inhaler. Those milder symptoms or hiccups if you will, can be disconcerting for sure, but are usually more of a nuisance than a real concern. A few adjustments to your treatment plan can usually fix that. Pesky flares on the other hand, tend to be more insidious in nature and once the symptoms emerge they dont let up. There’s a slow but constant feeling of breathlessness, wheeziness or maybe the constant urge to cough that just drags on and on, sometimes for days, even weeks. Unlike a mild flare, this type of flare telling you that something is going on inside your airways and it can’t be knocked down by simply inhaling a couple puffs off something.

The only way to really treat one of these Pesky moderate flare ups and hopefully turn it around, is to hit it hard with steroids and lots of neb treatments with the hope that the medications will have an effect and improve the situation, or at least stabilize. Either way, you’re gonna have to tough it out and until things turn around, whether it be a few days or a few weeks. It’s difficult to carry on with your life and do even the simplest physical activities when you feel like this. I sometimes refer to these as the “purgatory” flare, because while you might feel absolutely miserable, you’re not quite sick enough to hit up the ER with any confidence that the trip would be worth it. You’re stuck in a sort of asthma flare limbo with nothing to do but wait, suffer and tough it out until it hopefully it gets better, and hopefully without hospital intervention.

To me, a moderate exacerbation is essentially the same as a severe exacerbation, but without the hospitalization. You’re really sick, but you’re dealing with it the best you can at home. That said, there’s a fine line between a moderate pesky flare and a severe one, so be careful. Sometimes it hard to tell when you’re starting to loose the battle, so you have to really be in tune with your body and know when enough is enough. I think as long as your PFs and SP02s remain in an acceptable range and you’re not getting too fatigued from all the extra work of breathing, you probably wont gain much by going to the ER, accept maybe a hefty bill and more of the same medications.

If after a while though you find that you’ve hit your tolerance threshold for the flare, don’t procrastinate and get to a hospital. Just know that when the dust settles from the life-threatening portion of the attack ( if you were critical), your asthma will have probably revert back into the pesky flare mode, from which you will still have to ride it out either in the hospital or at home. On top of that, you’ll probably also be dealing with some level of post hospital trauma. Things like sore and bruised arms from all the IVs and ABG sticks, a maybe sore throat from being intubated, and just feeling fatigued and battered from all the drugs and stress. All this stuff adds up so it going to take time to complete recover. I can’t think of a single time in over 150 hospitalizations, where I went home after a bad exacerbation and everything was back to normal within a day or two. It just doesn’t happen.

I think the thing I hate most about these pesky moderate flares, is the uncertainty and anxiety they bring. You never know how long it’s going to last. Whether you were hospitalized or not, will you wake up one morning and suddenly be able to breath better? And if youre breathing better, is it because the steroids are doing their job and reducing the inflammation inside your airways? If that’s the case, then wouldn’t that just be a medication induced band aide stinting open your airways? Though you’re breathing a little better, wouldn’t you still be technically sick. I guess the only way to really know, is by weaning off the steroids and see what happens. If you reduce the dosage and your breathing starts getting difficult again, then there’s your answer. If the effort to breath stays about the same, then Id say you’re probably not sick anymore and getting better. I know it sounds confusing, but Im sure some of you who have been through this can relate.

Of course once you start on steroids, particularly prednisone, there’s nothing more irritating (literally) and more frustrating than trying to wean off them. It’s not a one-size-fits all process as some doctors would have you believe. Weaning is a game that requires some strategy, usually learnt from previous weans. That, plus a keen sense of how your body is reacting to everything that’s going on. You’ve got to get it just right or you could actually prolong the healing process. Prednisone side effects is a whole nuther story that we’ll skip for now, but I think its important to remember that when weaning off steroids, to not let the goal of PERFECT breathing be your only guide on how fast to wean. As a person with severe chronic asthma , you’re breathing is probably never going to be PERFECT, so expect some difficult breathing days during the weaning process and resist the urge to immediately up the dose if you’re breathing is only slightly worse. Better to maintain the current dose for a while and then resume weaning when you’re more comfortable. It can take a long time for the airways to adjust after withdrawing from the roids.
In general I find it takes at least a week to 10 days to get completely through one of these pesky exacerbations. That is, if you don’t rebound and your symptoms don’t get worse. If they do , all bets are off.

Statically I experience about 4 of these pesky type flares up per year, with about 50% of them escalating to hospital status. Not sure why, but it could be due to the type of triggers involved. If you have some kind of secondary infection that’s aggravating your asthma, its going to be more difficult to deal with. Of the times that I’ve managed to avoid hospitalization, it could be due to starting steroids earlier on. As far as the “mild” flares, those are pretty much daily and the severe ones, maybe 2 times per year, which is an improvement over a few years ago.

I actually wrote this post on day 4 of a pesky flare. As mentioned above, I hit it pretty hard with prednisone and tons of nebs right off the bat and it seems to be helping. If I dont backslide, I should ne able to stave off a hospitalization this time. I really hope so, because I need to recover from this quickly so that I can resume my training for the 400 km hike I hope to do this Fall in Europe.

Anyways, here’s hoping everyone out there suffering from a pesky asthma flare at this very moment, will wake up tomorrow breathing much better.

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4 thoughts on “Those pesky asthma flares

  1. Juan Enrique says:

    Stephen! This is exactly what happened to me 3 weeks ago. A pesky flare. I end up in the ER. The throw me a tons 4 therapies of albuterol with ipatropium bromide, the did arterial gas, put me on solumedrol IV 125MG, later 40 MG more of solumedrol IV and Magnesium sulfate IV. From there my lung started open. The doctor send me home with a Medrol Pak, Azitromicin 500 mg for three days and albuterol every 4 hours. Tomorrow I will be calling my pulmonologist. I am using symbicort 160 mcg 4.5, Singulair 10 MG.

    I am still going through it and hopefully I will recover soon. Thanks for sharing that knowledge and for educating us in thins topic.



    1. Oh, so sorry to hear that. I hope your are feeling a little better now.

  2. Kat says:

    Much like Juan, I came to this post at the tail end of a 3-week-long pesky flare up – the first I’ve ever had which appears to be strictly environmental, most likely the result of intermittent haze that’s been coming down to the Midwest from the Canadian wildfires. In the past I’ve had lingering breathing issues after a bad bout of bronchitis or a nasty flu bug, but overall my asthma/COPD had been so mild (when not triggered by cats or a virus) that after my single cardio stress test they couldn’t even quite decide if it is asthma or COPD. Though, I also had cervical spinal surgery at the end of March, so there’s a possibility that my system is still being weakened by that recovery and that’s why things got quite so bad this time.

    But, while I ended up on here while trying to figure out if its normal for a cheap compressor nebulizer to vibrate so much that it makes my hands numb to hold the mouthpiece/tubing, I can’t tell you how much I appreciate you explaining the nature and progress of a “pesky” flareup. 3 weeks ago I had a mild cough before I went to sleep in the early AM, woke up the next afternoon so short of breath that evening that I tried calling the Immediate Care clinic within 20 minutes, only to realize it was too late in the day to get into any of them. That’s when I called my sister and said I needed to go to the ER, because I was genuinely scared that if I didn’t, I’d end up calling for an ambulance within the hour. I had bought this cheapy nebulizer a few months ago to deal with a sinus congestion problem I was having, but the only vials I had were saline – and I left the ER after 3 breathing treatments, with my first ever prescription for albuterol vials. When that box ran out after about a week, the GP upped me to Duoneb vials – and I grudgingly took a 2nd week of prednisone, which I hated, because the weight gain is such a PITA. And a week after that, when I was still on multiple treatments a day, as well as needing guaifen-codeine cough syrup to keep my throat from going unbearably raw, he added a round of azithromycin. I was only barely able to resume my post-surgical physical therapy this week, and just now had my first breathing treatment in 2 days.

    I admit, in all the adjustments and recovery issues I’ve had after the surgery, this 3-week asthma stint spooked me a lot. As a 48-year-old whose spinal stenosis was only finally diagnosed in the last 8 months, I feel like I’m constantly bouncing back and forth between the prospect of being healthier than my chronic pained/fatigued butt has been in decades and an awareness that the ravages of aging are taking a toll. And I really worried this was the beginning of a new phase for my breathing problems. But hearing this days-to-weeks process broken down by a veteran in this area, helped settle my mind – even if I am going to experience more frequent environmental flares, I am less worried that a weeks-long stint is indicative of a much bigger problem.

    So, thanks so much for sharing your experiences. As someone else who knows what it’s like to be chronic, even if its not normally my lungs that are the most chronic bits, I am very grateful for the insights you have given me to this new problem in my body. 🙂

    1. Hi Kat. No, it’s not normal for a nebulizer to vibrate so much that it’s difficult to hold the mouth piece. I might suggest you try a mesh neb. There are several on the market. You have to do research to find a good one, but they are generally affordable. They’re small, do not vibrate and are completely silent. I use my mesh neb at night, as to not wake up the entire house. My favorite is the Phillps Innospire Go. Unfortunately, the company stopped making them.

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