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Normal test results?!?
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An_247337 posted:
Goo morning,
I have a question for all of you...
About 4 months ago, I started feeling my heart racing, and having trouble breathing. I felt short of breath, tight feeling in my chest, and wheezing when taking a deep breath. This has been almost 24/7 since then, with a few hours, and a few days of respite. My family doctor sent me to see a lung specialist. The spirometry came back normal. However, the specialist could hear some wheezing in my lungs, and said my symptoms sounded like asthma. I did the methacholine challenge yesterday, and although there was a small decline in lung function, it wasn't very big; the RRT offered me the ventolin, but said I didn't seem to need it, based on the results. I did feel short of breath though.

I'm super confused. Does anyone know what else this could possibly be? I have a follow-up with the actual specialist in 10 days to discuss the results, but I am at my wit's end. It's been a very uncomfortable summer, and I am scared it'll turn out to have all 'been in my head'. Frankly, I lose sleep over that possibility. The only 'saving grace' is that she did hear some wheezing when she listened. Why are all the results coming back normal then? Is it possible to do well on those tests and still have a real problem? I did have those tests done years ago, and I was off the charts good. I'm no longer off the charts good, but simply not 'in the asthma zone'.

Help please! I know I sound like I want to have asthma. I don't! But I'd rather have a definable problem so that it can be properly addressed and fixed. My test results seem to be okay, but I know myself very well, and I know that something isn't right...

If it makes a difference, I am a 29 year-old female, otherwise healthy. Thank you in advance for your answers!
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amcate responded:
I have heard of the challenge test, but have not had it done, so can't speak to that. I can speak to spirometry.

I used to work on a research team closely with statisticians. When a test is developed, they measure the values of a sample of a population. A bell curve usually results, with the most common value in the middle, and less common values at the end. When spirometry says the expected PEF of a 29 year old female that weighs such and such is (blank), they are describing the expected value based on the statistics of the sample they obtained when developing the test. However, each individual is different, and the normal value for some individuals is very high or very low. In this case, they need to use what your personal best is and then measure where you currently are, and determine the percentage. For instance, if your personal best is 600, and you now are at 400, they should say you are at 66% of your personal best, even if the expected value based on the norms the test was based on is 400.

Many doctors do not know statistics, and they will use your current number as a percentage of expected value and not a percentage of your personal best. If your normal is high, which is expected statistically that some people will be, then they need to measure your number as a percentage of what is normal for you as an individual or your personal best and not use the norms.

Related to this, sometimes a test is normed on one population, for instance, Asians, and then is applied to another population, like Africans. This is not right, because the sample was intended to measure the populations of Asians, not the population of Africans. So, you would also have to go back and see what sample was used in determining the spirometry norms and if you belong to the population that sample was trying to represent.

Bottom line-it may be more accurate in your case if they take the spirometry reading as a percentage of your personal best and not use the norms. They also should not make decisions solely based on the results of spirometry, but should look at the whole picture, including your reports.

In my case, my normal spirometry value is very high, and I actually did spirometry at a time when I was losing consciousness from asthma attacks and my rescue medicine was not rescuing me. It was very difficult to even get a spirometry reading on me, but what they got was 75% of predicted value (or 75% of the value of the norm). However, the reading they got was less than 50% of my personal best. I got on asthma meds, and moved to a low pollution area, and it responded by getting better.
 
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amcate responded:
I thought of something else-if you are between attacks when they do the tests, then you may get normal numbers whereas during the attack you would not....but it all depends on how bad you are.

"I did have those tests done years ago, and I was off the charts good. I'm no longer off the charts good, but simply not 'in the asthma zone'." I reread this, and you may want to take the spirometry readings you got years ago and then your numbers you have now and get the percentage (number you have now/number you had then). It sounds like that could be your personal best.

They could get your spirometry, then do a nebulizer treatment, wait 30 minutes, and then redo spirometry. If your numbers go up about 10%, then that supports the diagnosis of asthma even if the before and after numbers are both good when compared to the norms (or predicted value).
 
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An_247337 replied to amcate's response:
Hi, thank you for your response(s)! It was nice to see someone who went through something similar... it's very frustrating how some people can just slip through the cracks if they don't have typical symptoms...

So I am feeling very well today. I decided to use my Peak Flow Meter. I got a 558, which is 135% of my predicted value. Which also means that the value I got during my in-office spirometry was 67% of my personal best. Yet somehow, it wasn't qualified asthma because it was still 91% of the predicted value. Ahhh! Also, I did some more research. Another thing the technician might have screwed up is the fact that he gave me Ventolin, and re-took the values IMMEDIATELY after (literally, about 2 minutes after). Everywhere I've looked says to wait at least 10-40 minutes before re-measuring. No wonder my values didn't improved significantly during the test, after the Ventolin. It hadn't even had time to work... Anyway, I plan on bringing all of this up with the doc during my follow-up next week. The only unexplainable thing still is the fact that my methacholine challenge test came back 'normal'.

Lastly, another observation. I ended up using the Ventolin the doctor gave me until we got all the testing done, as I was feeling awful a few days ago. About 40 minutes later, I had a coughing it and coughed up some mucuous (gross, sorry). I felt soooo much better for hours after that.

It's too bad though, as I live in Canada. Here, we can't just 'go see another doctor for a second opinion' or to request re-testing. We're pretty much stuck with what we get : (
 
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bresky replied to An_247337's response:
Hi an_27337

I know my spirometery has always been in normal range, however I did badly fail the methacholine challenge. My respirologist is good at going with symptoms then with spirometery.
I also live in Canada and am on my 3rd specialist. I wasn't happy with my first one as he did no tests and told me it was all in my head even though i was landing in emerg every 2 weeks. My family doctor sent a referral to a respirologist and I saw that one for 6 months who realized she was unable to help me and sent me to the respirologist who specializes in asthma who I have been seeing for 2 years.
If your not happy or don't agree with your specialist you can ask your family doctor to send you to someone else, it may just take time unfortuantely which sucks when you don't feel good. You can also ask your specialist for re-testing mine redoes the pft every 6 months or if I am feeling awful when I go see her.
You are right with the ventolin where I go they wait for 15-20 minutes to do the retesting and use 4 puffs of ventolin.
And remember to take your peak flows in and show them the values you get, as it does make a difference if your normal is 558. The mucous could have been blocking your bronchioles which may have made you feel better when you coughed it up - what colour was it. If it was green or yellow you may want to mention it because you could have underlying infection.
Glad to hear you are feeling better.
Bre
 
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amcate replied to An_247337's response:
I'm glad you are feeling better. I don't know what to say about the challenge test because I've never had it done. I would think it would show asthma if you had it, but I don't know if they administered it correctly, etc.

I don't know much about Ventolin, but I know with the rescue inhalers I use, albuterol and ipratropium bromide, the doctors have always told me to wait 20 minutes before remeasuring the peak flow. I remeasure the peak flow to determine if the rescue drugs worked, or if I have to take more. Since the nebulizer forms stress the heart, the doctors normally have not wanted to unnecessarily stress the heart and so emphasize to wait 20 minutes before determining if it had an effect.

I don't know the Canadian system as I live in the USA. After wroking on the research team, I went to graduate school for licensure as a therapist in physical medicine and rehabilitation. They used a practitioner/researcher model, and we got more courses in statistics and research design. It's been too many years, so I can't recall the name of the article. I do remember reading an article which expressed concern over the lack of training in statistics that some MD schools have, and also about cooking the data (gross violations of just making the data up as opposed to more innocent inappropriate use of stastical methods) When I saw the head of the board of Allergy, Asthma, and Immunology for Texas he said the doctors should not use the predicted values or norm values in my case and should take it as a percentage of my personal best. Unfortunately, some doctors don't understand statistics, and neither does the insurance company, so when I moved to an area I could breath better in, the insurance company denies benefits based on percentage of predicted value with the doctors backing it up. They pretty much ignore what I tell them about statistics, leading into disregarding out of state consults that might help.

In my case, they gave me albuterol, waited 20 min, and then retook the spriometry with about a 10% improvement in the numbers. Additionally, they tried the shots, but I kept having an asthma attack requiring emergency meds. I also have all the itchy skin and sores from the skin with my Primary Care Physican says is asthma related disease. Also, I respond to asthma medicines and the environmental modifications for asthma. So, they say I have asthma, but due to the percentage of predicted value (as opposed to percentage of personal best) they deny certain consults/further assessment and just tell me to take a lot of prednisone.

I would try to get a second opinion if it's possible in Canada. I don't have the option right now, but am waiting to see what Obamacare does and if I can go out of state after it is put into place. Right now, I can't go out of state for a second opinion. So, National Jewish in Denver is not something I can currently do.


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