On vacation & forgot your meds: what can you do? How long do drugs last in the med cabinet?

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: I forgot my nebulizer at home i dont have any of my asthma meds what can i do im felling very tight. I normally carry a resuce inhaler with Albuteral and use it in my nebulizer as well but i left everything at home

My humble answer:
First of all, know that you are not the first nor the last asthmatic to do something like this. I've done it, and so do many other asthmatic vacationers I see in the ER.

I have a couple options for you.

1. Most pharmacies allow prescriptions to be transferred. If you go to a Walgreens back home, for example, you can go to the Walgreens wherever you are vacationing and just have them transfer over your scripts. You won't be able to get a new nebulizer this way, but at least they should be able to get you a rescue inhaler. Other pharmacies that will do this are Rite Aid, Walmart, Kmart, etc.

2. In fact, I'm pretty sure any pharmacist would understand your predicament and help you out. I've gone to random pharmacies before and have never had a problem having my prescriptions transferred.

3. Don't be afraid to go to the nearest emergency room. The people that work there will understand your predicament, give you a quick breathing treatment in the ER, and send you home with a rescue inhaler. If you need it, they can also contact the local home health care company and have them supply you with a machine to use until you go home. The doctor there can also write prescriptions for any other medicines you might have forgotten. Since you should never wait too long to treat your asthma symptoms, this might be the best option for you.

4. You might be able to go to whatever home health care company in the area you are vacationing and see if they can hook you up with a nebulizer and vials of meds to last you until you get back home. I'm not positive exactly if they would be able to help you, but you could try.

Good luck!

Question: What is the shelf life of Theodur

My humble answer: Here is a neat article I found concerning the shelf life of medicines.

Basically, most new drugs like Theodur (theophylline) are good for 2-3 years from the date of manufacture. However, once the "original container is opened for use or dispensing, the expiration date on the container no longer applies." When the product is repackaged for you -- the consumer, it is "usually" dated by the pharmacist to expire within one year.

The expiration date of a medicine is the predicted date at which the drug will lose10% of its potency, according to this ABC News post.

The expiration date also assumes you are storing the medicine at the recommended temperature and humidity. According to our own site, theophylline should be "stored between 59-86 degrees F (15-30 degrees C) and away from light and moisture." This means that it should not be stored in the bathroom where it will be exposed to high humidities during and after showers.

While most drugs like Theodur are not hazardous if used after their expiration dates, the efficacy of the medicine after that date can no longer be guaranteed. Thus, if you are using an expired medicine you may not be getting the expected results.

Question: Is breathing-in more difficult for Asthma patient or breathing-out ?

My humble answer: Believe it or not, asthma is a disease of air trapping. What happens is air comes in, the airways constrict and swell, and air gets trapped in the lungs. While it may feel as though you can't get air in, the reality is you can't get air out. In fact, this air trapping is one of the reasons that during an asthma attack it often feels like you can only take in half a breath, or a quarter of a breath.

Those in the medical field may think of this air trapping as intrinsic PEEP. PEEP is air that is left in your lungs after you exhale. Normally PEEP is 2-3 CWP. During an asthma attack, this PEEP increases, thus causing hyperinflation of the lungs (which can be seen on an x-ray). If this intrinsic PEEP gets severe enough, it can lead to a severe asthma attack, and (possible although rare) even death.

This air trapping is also one of the reasons that diaphragmatic breathing is a technique often taught to asthma and COPD patients. The idea is if you give your lungs more time to exhale some more air might escape your clamped down air passages. Of course you probably know your rescue inhaler also works to relax your air passages to, thus letting out this trapped air.

Question: Intal versus Advair for asthma: have problems with asthma (wheezing sometimes) and respiratory allergies. Age 62M. I heard that Advair is a "ramp up" medication for sicker people and has more side effects and causes weight gain. Is Intal less problematic and am I better off with it if it helps or will I create more long term problems by not using Advair right away? Thanks

My humble answer:
You are wise to ask this question. Intal was a popular controller med for asthma in the past, (in fact I was on it in the 1980s) but it is less commonly used today due to much better medicines. It is a anti-inflammatory medicine, but I rarely ever see it used anymore, especially with adults.

The most common asthma controller medicines used today for asthma are inhaled corticosteroids such as Flovent (a ramp up from Intal). Flovent is much more effective for treating inflammation than Intal (at least most asthma experts conclude this).

If you continue to have trouble with your asthma despite inhaled corticosteroid use alone, your doctor might prescribe Advair (or Symbicort). Advair (a ramp up from Flovent) is a combination drug with both Flovent and a long acting bronchodilator called Serevent in it. Advair has been very effective in controlling asthma for many asthmatics, including myself.

There used to be a fear that inhaled corticosteroids had the same side effects as oral corticosteroids (prednisone), but many studies have been done to prove this is not true. If you take your Flovent or Advair properly, and you rinse really well after each use, side effects from these meds should be rare.

In my opinion, if Intal is working for you great. Your doctor may have been wise to have you try it before resorting to inhaled corticosteroids.

If, as you describe, Intal is not working, you might want to talk with your doctor about other options, such as the Advair you mention. Either way, it's always a good idea to keep in touch with you physician as I'm sure you are doing.

Good luck getting your asthma under control.

If you have any further questions you can contact me by clicking the "contact me" icon above.

Alternative therapies for status asthmaticus

So you have a really bad asthmatic in the emergency room, and you already have him on a continuous bronchodilator breathing treatment, and the nurse has already given intravenous epinephrine and solumedrol.

Now you, the RN and the doctor are willing to grasp at straws to prevent that person from needing to be intubated. What are some choices you might be able to recommend to the ER physician?

A book called Fatal Asthma and CMAJ list some of the most common "alternative therapies."

1. CPAP: This can be started to help the patient overcome his increased work of breathing. Adding CPAP is also a great technique of overcoming instinsic PEEP that causes hyperinflation. The problem with this is that asthmatics already feel as though they are suffocating, and this might make matters worse.

However, with good equipment, good coaching, and a doctor willing to apply to the patient some sedatives, this might be worth a shot if you have a compliant patient.

2. BiPAP: All the principles of CPAP apply here, except this also applies pressure with inspiraton to help the patient take in a deeper breath, thus allowing the patient to blow off some CO2. This may be of particular use if you suspect impending respiratory failure associated with a rising CO2.

I have seen BiPAP work on at least five asthmatics in the past couple years. Usually if a patient is bad enough to require noninvasive ventilation, we skip CPAP and go right to BiPAP.

3. Heliox: This is a helium/ oxygen mixture that consists of 80% helium and 20% oxygen. With the exception of hydrogen, helium is the lowest density of gas. And, according to medscape.com, since asthma is a disease associated with narrowed passages that result in turbulent flow and increased airway resistance, heliox can help create a more laminar flow, and thus decrease the work of breathing

According to studies, some patients benefit from this and others do not. So, while this is used in some hospitals, the jury is still out on whether it is a cost worthy investment for hospitals.

So now you have a patient in status asthamticus intubated in your emergency room. You have tried all the conventional therapies, and you once again are grasping at straws. What are some options?

4. Bronchiolar lavage: Also known as lung lavage. This is done with a fiberoptic bronchoscope and washing the bronchioles out with normal saline with the intent of clearing the lungs of mucus plugs. This is still not commonly done in a crisis, but remains an option.

5. Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation."

Ketamine is a smooth muscle relaxant and antihistamine, and is given intravenously. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here.

Isoflurane is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."

6. Permissive Hypercapnia: This is something I'd wish doctors where I worked would consider more often. We had an asthmatic a few years back who was admitted to CCU, and the doctor ordered a tidal volume of 750. Since I was bagging the patient, and her lungs were stiff, like ventilating a brick. When I finally got her hooked up to the vent the highest tidal volume I could get was 150. The doctor was irate. But I was right. He finally admitted as much.

So, the point with permissive hypercapnia is that you allow a high CO2 and low pH at the expense of low pressures and a lower tidal volume and an appropriate respiratory rate to allow time for the patient to fully exhale to prevent air trapping. You do this while continuously trying to get the patient's airways to open up. In this patient's case, it took two days for this to happen.

As the author's of Fatal Asthma state, "Prolonged severe hypoxemia can cause devastating neurological injury and death, prolonged hypercapnia per se is thought to have no long-term adverse consequences. Use of permissive hypercapnia has become standard practice in many intensive care units and in general has rendered unnecessary other 'heroic' measures in the critically ill asthmatic patient."

Well, those are some of the options available to today's physicians for the treatment of status asthmaticus unresponsive to conventional therapies. Where I work we've used BiPAP and Bronchiolar lavage, although rarely.

I've known about heliox and permissive hypercapnia, but the anaesthetics used to treat status asthmaticus is something new to me. If these medicines were ever used at my facility I'm unaware of it.

If any of my readers know of any other alternative therapies for asthma please share them in the comments below.