A Unique Asthma Presentation: Not All Asthmatics Wheeze

What if there is no wheeze? It still might be asthma. 

So, we are taught the standard presentation of asthma. We are taught auscultate and listen for wheezing. If wheezing is present we determine the symptoms are caused by asthma. The treatment is a breathing treatment with albuterol.

But, when no wheezes are heard, we often diagnose the patient as having anxiety or some other disorder. Here, no breathing treatment is indicated. Still, we often give one for the psychosomatic effect.

Here, I would like to contend that not all asthmatics wheeze. This is a view that not many health experts have expressed. I have discussed this with many of my coworkers. They have lectured me about if airways are narrow, you will hear a wheeze.

But, I spend lots of time in asthma communities. Many of my asthmatic friends contend that they don't wheeze. Some say they were poorly treated because their healthcare teams heard no wheezing. So, when this happens, and the person truly does have asthma, it can lead to poorly controlled asthma. It can lead to death.

So, let's go with the notion that not all asthmatics wheeze. I can tell you for a fact that I rarely wheeze. I did as a kid, but rarely does this happen as an adult.

I said this to a friend of mine. He said, "Well, if that's the case, then your doctor should do a PFT. If your lung function is diminished you have asthma. Or, if you did a peak flow, your peak flows should go down. That would prove that you have asthma."

I said, "In 1997 I ended up in the hospital for 10 days for severe asthma. My peak flows were 750 on the day I was admitted. If your theory holds true, then why did my peak flows not drop?"

He had no answer.

And I didn't mean to put him on the spot. I was just trying to make the point that not all asthmatics present the same. And that means that some asthmatics don't wheeze. And some asthmatics do not have drops in peak flows. Their FEV1 may be normal even during their worse asthma attacks.

And why would this be? A doctor did explain this to me once. She said that it's because my asthma is occurring in my smallest airways. Peak flows and spirometry measure flow through your larger airways. They do not measure flow in your deepest airways. So, if this is where your asthma is occurring, you will not wheeze. Your peak flows will probably be normal. Yet you are still having asthma.

To add to this, most inhalers do not get that deep. For instance, I was taking Advair for the longest time I had pretty good asthma control. But, it wasn't as controlled as I liked. When I sprinted, for example, my chest would get tight. I was still able to do it, but the chest tightness irritated me.

So, I did some research. I learned that HFA inhalers got deeper into airways than CFC inhalers. Likewise, HFA inhalers get deeper into airways than DPI inhalers. By deeper I mean better airway distribution. HFA particles seem to get into the smallest airways, or deeper down than the other types of inhalers.

I discussed with with my doctor. He changed by prescription to Symbicort. Since then I have not experienced this tightness when running. I have had better asthma control. So, I think this is because Symbicort gets deeper into my lungs.

Now, my control still isn't perfect. But, it's far better than if I would be if I didn't do my own research. It's far better than if I wasn't my own best advocate. It's way better than, say, if I didn't present with these symptoms until adulthood, and my doctor said I didn't have asthma because I don't present like a typical asthmatic.

So, some asthmatics do not present as typical asthmatics. Some of us have unique asthma presentations. When this happens, it's best to not brush us off as having anxiety. Sure, it could be anxiety. But, if a patient says they have asthma, it's best to listen to your patient. What you were taught should be heeded. But, what your patient says should be heeded as well.