Did you know you can have asthma without any symptoms? – Asthma Poor Perceivers

What is a ‘poor perceiver?’  It’s when you have asthma without having any symptoms!

And it’s common.  This article will go through the “poor perceivers” of asthma and how to control your asthma!

Asthma poor perceivers are difficult to treat
If you are a ‘poor perceiver’ of asthma — this article is for you!

Let me start with a simple question for everyone:

Do you know why your doctor’s office will check your blood pressure on every visit? Or do your “annual labs?”

The reason is that there are certain diseases that can have a significant, negative impact on your life but often show no daily symptoms.  The top three are:

  • High blood pressure (also known as the ‘silent killer’)
  • High cholesterol
  • High blood sugar

In these cases, your blood pressure measurements or your annual lab results identify the problem and allow you to get them fixed.  They are also the only way to know if the treatment is working and to adjust your medication doses.

I know many people hate these medical problems.

I understand.  I mean, you felt no symptoms!  And now a blood test tells you to change your diet or adjust your very comfortable lifestyle.  How frustrating.

But frustration aside, the morbidity and mortality benefits of treating these silent problems is not debatable (unless you value conspiracy theory over science.  And if you do that’s cool.  I’m accepting.  But you’re probably on the wrong webpage).

What is frustrating is asthma can also fall into this category of a ‘silent disease.’

Yet this part of asthma gets no medical coverage, no media PR, and no advocates to defend your health.

Well, today that changes.  For all my ‘poor perceivers’ of asthma – here is YOUR day of reckoning!

Basic overview of asthma symptoms

Let me try another experiment:  close your eyes (ok, read this first THEN close your eyes) and imagine the symptoms you associate with asthma.

My guess is that you thought of a person:

  • Wheezing or gasping for breath
  • Clutching their chest with shortness of breath or chest pains
  • Using an inhaler (which is not a symptom but a common mental association)
  • Getting short of breath with exercise

If you know someone with asthma, you may have thought one of these more ‘advanced’ symptoms:

  • Coughing with cold air exposure or exercise
  • Nighttime awakening with wheezing
  • Shortness of breath with colds/infections
  • Coughing after laughing (or coughing after yelling/crying)
  • Wheezing when exposed to cats or other allergens
  • Chest tightness around strong smells, perfumes, smoke, odors
  • Recurrent bronchitis (a common sign of asthma)

I bring this up because these are SOME of the ways asthma presents… but not all of them.  Worse, these are not just your perceptions.

Most medical providers learn very similar associations, whether through school or public perception, and believe these are the only ways asthma can present… which might explain why when a primary care provider will tell you your asthma is under control… 55% of the time IT ACUTALLY ISN’T!
(source: REACT asthma trial 2007)

Who should read this article?

adults and kids are treated similarly with poor perceiver asthma
This article works for both adult and child asthmatic ‘poor perceivers’

This article is an important read for anyone with asthma.  Overall I think you should read this article if:

  1. If you have asthma (even if it’s controlled) you should read this
  2. If you have allergies (seasonal or year round) then a quick skim is a good idea
  3. If you have a child with asthma—you should also read this article
  4. If you have asthma and have kids who don’t… this will be a good article for you
  5. If your children have allergies, eczema, or food allergies…. please read the section on who is at risk for asthma and the section on having asthma and not knowing it (your child is at an increased risk for asthma and this will give you an overview of what to look for)

If you don’t fall into this category, then this article might not be for you.  But for this article, I ask that you take a minute and share it with any/all the social media platforms you use.

Why?  Because asthma affects 6-8% of the population and they NEED to know their 55% of “controlled asthma” is really not well controlled (even if their doctor thinks it is!)

Can you REALLY have asthma and not know it?

Yes (#stopclickbait).

It is common to have asthma without a lot of symptoms OR to have a low breathing test but not recognize asthma unless there are special circumstances (such as colds/flus, bad allergies, smoke exposure).  I’ve tried to address this group in a prior article on asthma control.

It is also common to have asthma with no recognized symptoms… a group we call ‘poor perceivers.’

THIS is the group I want to focus on today because it is a very under-served group of people.

To begin, I will explain the 3 types of asthma patients I see regarding asthma control.

3 types of asthma control

As a general rule, I see 3 types of people/parents regarding their/their child’s asthma control:

  1. Well controlled asthmatic—this asthma control is ideal
    • You monitor your asthma control test results (monthly is appropriate)
    • You know your baseline control and your triggers
    • You get spirometry at least twice a year
    • Your provider adjusts medications for both symptom and spirometry results
  2. Don’t know what control means—this asthma control is most common
    • You know what control means FOR YOURSELF… but don’t know what control means
    • You DON’T regularly do the asthma control test
    • You DON’T regularly get spirometry
  3. You want good control… and do your best… but can’t tell if your asthma is controlled
    • You are what we call a ‘poor perceiver’
    • You monitor your asthma control test… and think you have well controlled  asthma
    • But your doctor finds you have a bad spirometry
    • As a result, you never know when you have good asthma control and when you don’t

The bulk of this article will address #3 – my ‘poor perceivers’ in the group.  But I would be a bad allergist if I didn’t at least help group #2 first.

Group 2 read this: If you don’t know what control means, here’s a quick section for you.

If this sounded like you… don’t feel embarrassed.  You’re not alone.  In fact, the majority of people fall into this category.  But don’t get too comfortable either… this is NOT the category where you want to belong.

  1. I have written a post previously on asthma control I think you should read first.  It will give you an overview of what it means to have well controlled asthma.
  2. After that, take the asthma control test for adults (or asthma control test for kids) quiz and see your results.  It only takes 3-5 minutes and could improve your life!
  3. Finally, review this post on asthma action plans and how to create a personalized approach to helping your specific asthma triggers
treat asthma poor perceivers to help them feel their best
If you are a poor perceiver — it’s time to get you feeling your best!

Asthma ‘poor perceivers’ – it’s your time to shine!

The rest of this article focuses on my ‘poor perceivers’ of asthma.

‘Poor perceivers’ – you’ve been dealt a difficult hand:  you honestly cannot tell if you have good asthma control or not!

If you are a ‘poor perceiver’ then you fall into one of these 3 groups:

  1. You feel you have controlled  asthma because you don’t know what good control actually feels like
  2. You feel you have controlled asthma because your brain/lungs register your current state as controlled… but you can ’retrain’ your brain/lungs to better recognize control
  3. You feel you have controlled asthma because your brain/lungs do not register your asthma state as controlled… but you will never be able to rely on your brain/lungs to recognize your asthma control

Let me go through each of these in more detail.

1.  You feel you have controlled asthma because you don’t know what good control feels like.

If you are a part of this group, you have been living with bad asthma control for a while.

Let’s say your lung measurement shows you have a 65% lung function.  If this is all you’ve ever known, then you have lived your life and done everything with a lung impairment.

  • What you know as ‘normal’ — is actually 65% lung breathing
  • What you feel is ‘normal exercise symptoms’ — is only 65% lung breathing
  • When you get your ‘normal sickness symptoms’ — they’re not normal, but due to 65% lung volume

As you can see, your entire life and what you think of as ‘normal’ is coming from a 65% lung function.  So how would you ever be able to tell that things were abnormal?

This is almost a philosophical question—the kind that every 10th grader thinks of at some point and makes them feel deep, worldly, and better than their parents (whoa, what if what you think of as green is not what I think of as green!)

If you fall into this category, your brain/lung receptors are all working well but when you get on appropriate asthma treatment you, then ‘realize’ how good life can be!

As an allergist, you are a fulfilling group of people to treat.

Story time: I still remember one patient who always had exercise intolerance and she got beet-red and near passing out when trying to do fitness.  This was her normal life.  She saw me for allergies and I found she had a lower lung value and treated her (there was resistance at first because she didn’t feel symptoms).

She was thrilled on her next visit!  Able to exercise beyond anything she ever imagined, to not feel like passing out after exercise and to burn more calories, enjoy exercise, and feel better at the same time!

2.  You feel you have controlled asthma because your brain/lungs register your current state as controlled… but you can ’retrain’ your brain/lungs to better recognize control

If you are in this group, you start very similar to the group above.  Your lungs are 65% and you have lived your entire life at 65% lung function.  Everything you know as ‘normal’ is actually 65% lung volume.

When I see you as an allergist, I will start you on proper asthma medications.

On future visits, you still feel the same.  Your lung function may be 90% (80% is the low end of normal) but you feel about the same as you did before and never get that amazing “a ha” feeling like in my patient example above.  As an allergist, I’m happy that your numbers are normal but it’s not as much fun as if you felt better.

The difference is that now when things get worse, or if you stop your medication and get back to 65%, you now register 65% as being abnormal!

If you’re in this group, your brain/lung sensors can re-calibrate to what is normal which allows you to better identify when things are wrong.  Here, even if you didn’t feel an amazing improvement at first, you now can recognize true well-controlled asthma.

3.  You feel you have controlled asthma because your brain/lungs do not register your asthma state as controlled… but you will never be able to rely on your brain/lungs to recognize your asthma control

You are my most challenging group.

Here, you begin your life feeling normal and controlled even though your lungs are 65% of normal.  You start like everyone else listed above.

Then I treat you and do a great job and your lung function improves to 100% (what a great allergist I must be!)  But you feel no different.  You’re not able to run a marathon or have endless energy.   Then you stop your medication and your lungs drop back down to 65%.  And you still feel no different.  No worse, no subtle changes, nothing.

In your case, you are a true ‘poor perceiver.’  Your asthma is the blood pressure, high cholesterol, or high blood sugar of the asthma world.

It is frustrating for you and I understand.  You’re also not alone:

Final story time:  I remember seeing someone who was a wilderness survival instructor (think huge buff guy, grizzy-adams beard, who goes to the wilderness for weeks at a time with only a knife, paperclip and pocket-lint but who hikes for 12 miles at a time, eats 3 meals a day with a campfire and can build a Marriott out of twigs and branches).  His lungs were about 47% normal and he could do more than I could do with full lung capacity.

I treated him to 90% lung function, and he felt no different (he said he had to stop less often when he was hiking, but I think he said to make me feel better).  I had to convince him to keep taking his medications and had my clinic call to remind him because he truly felt no difference!

To this day, I believe he was so full of toughness he could disassociate himself from his body’s responses and thrive with less than half his normal lung capacity.  I also think he could break his ankle and still hike for a week claiming “a small sprain” in his foot.

So if this final category sounds like you, don’t worry because there is still a plan.  And you can tell people you are so tough you have evolved to ignore what your lungs tell your brain.  Call yourself an X-men or something.

But also take asthma medications, please.

Why do we treat asthma?

If you are a ‘poor perceiver’ and don’t feel asthma symptoms yet I tell you you need to take medications anyway, then I feel I need to provide justification for my recommendation.

The obvious answer for most people is that proper asthma treatment will enable you to breathe better, easier, and do activities without limitations from your asthma.  This is a great selling point if you feel your asthma symptoms.

But there is an often ignored problem with asthma that treatment also helps do:  prevent emphysema.

Asthma and emphysema (or chronic bronchitis) are both what we call obstructive lung disorders:  problems where you can get air in you lungs just fine but can’t get it out correctly.

Most people think you are born with asthma or develop it in childhood, it is related to allergies, and is reversible.  This is true.

Most people also think of emphysema (or COPD) as a permanent lung problem associated with smoking.  This is also true.

But it’s better to look at it as a spectrum with asthma on one side and emphysema/COPD at the other (since they are SIMILAR functional lung problems).

  • If you have lungs that are 100% improved with treatment then you are on the asthma side
  • If you have lungs that are 0% improved with treatment then you are on the emphysema/COPD side
  • But most people are in the middle somewhere.  If you treat your asthma and your lungs only get to 90% normal, then it’s reasonable to think you have 90% asthma and 10% COPD.  And so on.

If you look at it this way, then the next part makes more sense:

If you have asthma that is untreated, it will become more permanent over time and less treatable.  So, if you had severe asthma and never treated it, it is likely that you would develop the same problem as emphysema… without ever smoking!

So we know if you have asthma and are treating it, you are also preventing (or slowing… the studies are still out) the progression to emphysema!

This is the main reason a ‘poor perceiver’ of asthma should still get their lungs treated to the goal treatment outcomes.

Spirometry is the key to managing asthma 'poor perceivers'
Spirometry is the key to managing asthma ‘poor perceivers’ (also, could this person BE more bored? )

Allergist’s approach to an asthma ‘poor perceiver’

The national guidelines for asthma say every asthmatic should get:

  1. A subjective measurement of symptoms (such as the asthma control test)
  2. An objective measurement of symptoms (such as spirometry)

And that treatment should fix the worse of either one.

If you are a ‘poor perceiver’ then the approach is the same… except your subjective measure of symptoms is kinda worthless.

You NEED to rely on spirometry to show your lung values and base your treatment on these numbers.  From now on, consider spirometry to be the same as a blood pressure cuff or annual labs.  This is the only way to manage your asthma.

Your treatment plan will now be:

  • Know the difference between spirometry and peak flows
  • Get treatment based on spirometry values
  • Get regular spirometry values
  • Get an asthma action plan based on peak flows

The difference between spirometry vs peak flow

I’m preparing a full spirometry vs peak flow post, but until I finish that post know a spirometry is an easy test done at an allergist or many primary care offices where you blow into a machine and it measures your lung capacity.  It is the gold standard for asthma, is reproducible and reliable.

A peak flow is a hand held device you can take home that, when you blow through it, gives you a maximum amount of air out of your lungs.  This is an OK test but is easy to get inconsistent results.  Alone, it does not manage an asthma ‘poor perceiver’.  But it is better than your symptoms for monitoring asthma control

Treatment based on spirometry values

The national guidelines are clear in how to adjust treatment based on spirometry values (again, this is 50% of what a good provider should do with every asthmatic every visit!)

As a general rule, what you should expect from your provider is:

  • If your spirometry’s FEV1 is >80% then you have well controlled asthma (and if you’ve been good for 3-6 months, consider reducing your medications).
  • If your spirometry’s FEV1 is 60-80%, then your asthma is not well controlled.  You should have your medication increased by 1 step up in the medication strength.
  • If your spirometry’s FEV1 is <60%, then you have very poorly controlled asthma.  You should have your medication increased by 2 steps up in the medication strength

If your primary care provider is not doing spirometry measurements for you, ask them to do it.  Or, if they don’t have the machine, then ask to see an allergist.  It will be well worth your time and effort!

Get regular spirometry values

This is the part that most providers don’t explain well:  you will now need regular spirometry evaluations to guide your asthma treatment.

By regular, I would recommend a plan like this:

  • Quarterly spirometry evaluations for the first few years (until stable dosing/spirometry patterns)
  • Then at least twice a year every year
  • Consider adding spirometry with colds/flus lasting for > 1 week or if you need antibiotic treatment

Consider the spirometry your blood pressure machine.  It’s now your guide for asthma treatment.

Get an asthma action plan based on peak flows

Wait… didn’t I say peak flows are inferior to spirometry?

Yes.  Yes I did.  And if you had home-based spirometry that would be ideal.  But we don’t have that option right now and so peak flow is the best we have.

The key point to this section:

  • Most asthma action plans based on symptoms (i.e. if you’re having specific symptoms, increase your medications, call your provider, etc.)
  • In your case, you need a peak flow based asthma action plan (i.e. if your peak flow drops to XXX value then increase your medications, call your provider, etc.)

If you have not received a peak flow based asthma action plan and would like one, please contact me and I will put one together for you (note:  I will need a copy of your latest spirometry so make sure you have this first!)

Summary

Asthma is a very common problem affecting 1 in 12 people and has a higher risk in people with allergies, eczema, food allergies or a family history of asthma.  Asthma can also present having no symptoms… a group of people called ‘poor perceivers’ of asthma.

If you are a poor perceiver, the only way to diagnose and treat asthma is through a spirometry breathing test.  This is a common test available in many primary care offices and in every allergist’s office.

If you are a poor perceiver, then you need to shift your asthma control plan to an objective spirometry based plan in this manner:

  • Recognize the difference between spirometry vs peak flows
  • Get treatment based on spirometry values
  • Get regular spirometry values
  • Get an asthma action plan based on peak flows

Treating ‘poor perceivers’ of asthma better mirrors other silent diseases such as blood pressure, cholesterol and blood sugar and requires close monitoring from your provider and treatment based on those results.

If you think you might be an asthma ‘poor perceiver’ please consider getting these tests, seeing an allergist, or if you are unsure just email me and I will try to guide you as much as possible.

Questions?

I tried to lay out a comprehensive article on an aspect of asthma control that is not usually discussed:  the ‘poor perceiver’ of asthma.

But while every asthmatic is unique, trying to capture the entire spectrum of poor perceivers in one article is just not possible.

So if you have questions, specific or general, that you thought of while reading this article then please let me know!  I will do my best to guide you as much as possible.

Next Steps

There are only two next steps you need to do:

1.  If you are / think you might be a poor perceiver, make an appointment with your primary care or allergist to get a spirometry test done.  It will be one of the best things you can do for your health.

2.  Please click the share icon for any/all of your social networks.  This is a VERY common problem and many people don’t know about it.  Please do your part to help share this article’s advice.

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Comments

  1. I have never seen a post like this on poor perception asthma. Because I didn’t experience the traditional symptoms, I thought I had mild asthma. It was only because a friend who used to chair an asthma foundation who said I should get myself checked that I found out that I was at risk of having a “life-ending” asthma attack at any moment. Now that’s poor perception for you. I am in the category that has to rely on objective measurements- the very person your opening paragraph speaks to. So good to see an article on this vitally important side of asthma that you never hear about.

    • Helen,

      What a scary story! Thank you for sharing.

      Poor perceivers are definitely a real thing and sometimes I lay awake at night thinking about how many primary care providers are blowing off asthma because they don’t check objective measures (OK, to be honest, I’m usually awake because I had caffeine too late in the day… but the state of asthma control definitely bothers me too).

      Thanks for your comments. I’m sure they will help other people who find this article as well!

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