Wheeze, wheeze. Do I need an allergist or a pulmonologist?

March 1, 2011 11:59 PM

Should I see a pulmonologist or an allergist? My asthma has become much worse recently, and I don't have a primary care doctor. Specific questions inside.

I'll preface this by saying I know you're probably not a doctor, and you're definitely not my doctor, and that whatever you say here isn't medical advice.

I was diagnosed with moderate persistent asthma when I was 11 and was seen by a pediatric allergist until I moved away from the city in which he practices. I was treated with a variety of inhaled corticosteroids, most recently Advair, which was pretty much a miracle for me, and occasional prednisone bursts when needed.

Anyway, I moved away, and now I don't have an allergist. Due in part to a brief stint without insurance, I had been getting by with just an albuterol rescue inhaler, but in the past six months or so, my asthma seems much, much worse, and I'm beginning to be concerned. I need the rescue inhaler multiple times daily and wake up at least twice every night to use it.

Obviously, I need to be seen by someone as soon as possible, ideally before I end up hospitalized, but I'm not sure what kind of doctor I need. I also don't have a primary care physician here. Please forgive my ignorance of basic life skills, but I've never made a specialist appointment for myself, so I don't know if I need to find a primary care doctor and then ask for a referral, or what.

1. Should I be seen by a pulmonologist or an allergist? Does it really matter?

2. Do I need to find a primary care doctor first?

3. Do you have any recommendations for a pulmonologist or allergist in Philadelphia, preferably at the Hospital of the University of Pennsylvania main campus or Penn Presbyterian?

4. Have you experienced a worsening of asthma symptoms as an adult? Should I be worried about this? As a child, I was always told to "suck it up", and now it's very hard for me to determine when to seek medical attention.

posted by easy, lucky, free to Health & Fitness (11 answers total)

Whether or not you need a referral, or need to have a primary care doc first, is determined by your insurance. (You mentioned that you didn't have insurance for a stint there, but I'm unclear on whether or not you have it now.)

I'm not personally familiar with Philadelphia, but it looks like the Perelman Center at Penn has a Lung Center that would cover all your bases at once-- they have all kinds of lung specialists there and treat asthma, thus relieving you of the guesswork about which specialist to see.

You'll need to call your insurance provider to figure out how to proceed with getting seen-- either you're in an HMO and need a primary care doc and a referral, you're in a PPO and can just pick a specialist in your network, or something else has to happen. Once you're clear on how to proceed, you can either ask the phone guy at the insurance company to find you a primary-care doc at Penn, or you can ask them if the Lung Center at Perelman is covered for you. From there, you can call your new PCP and schedule a checkup and ask them to refer you to the Lung Center or to their favorite asthma specialist (HMO version), or you can just call Perelman up and make an appointment (PPO version).

I do not believe this is a thing you should be sucking up. It's your breathing, and you need the reassurance of knowing that it will reliably work when called upon.
posted by fairytale of los angeles at 12:14 AM on March 2, 2011

A clueful GP or physician's assistant can diagnose you and, if necessary, put you on a steroid inhaler which, in this mildly asthmatic's opinion, is one likely avenue for treating your moderate persistent asthma / breathing problems.

So, re 1 and 2, see whomever you can get to first, GP or specialist. I'd see the GP.

And re 4: yes, it happens. And no, don't suck it up. I sucked it up for years and would get pneumonia from complications every other year. Not sucking it up has made me much healthier and happier.
posted by zippy at 12:15 AM on March 2, 2011 [2 favorites]

I also have a hard time knowing when to seek medical attention. It helps to have my own peak flow meter at home. Additionally, your doctor (once you follow fairytale's advice above as to how to get one) should be able to give you a metric like "if you use your rescue inhaler more than x times in y period, you should come in".
posted by nat at 12:58 AM on March 2, 2011

It sounds like Advair was really helpful, but it sounds like you're not still taking it? I think asthma is associated with two potential mechanisms --- inflammation and constriction, and Advair addresses both. Rescue inhalers only address one of those sources.

I suggest seeing a primary care physician first, for three reasons 1) you'll likely get an appt sooner, 2) it'll be cheaper--even if we're only talking copay, and 3) you already know that advair may help.

Btw --- when my mild chronic asthma got worse, I worried that it was a sign off something degenerative. It wasn't. My asthma is better --- I use medication much less often than I used to....so improvement is possible too.

Call some primary care offices and ask if they're accepting new patients, and tell them your asthma has worsened and you'd like to see someone asap.
posted by vitabellosi at 2:32 AM on March 2, 2011

Allergists can help with asthma. You don't need to see a pulmonologist.
posted by dfriedman at 5:46 AM on March 2, 2011

Here's what I would do in your situation (I also suffer from asthma, but it's severe and directly tied to allergies): get an appointment with a primary care physician first. It'll be quicker and you can get relief faster. Since Advair worked so well in the past, mention that to the doctor, and don't forget to tell him/her that you're using your rescue inhaler so much (too much! I worry!). Once you've got the flare-ups under control, I would see an allergist to find out what, if any, specific triggers you have (your primary care physician can refer you to one when it's time). I, for example, have serious trouble with dust, which made us decide to rip up all the wall-to-wall carpeting in the house. It helped tremendously and I also take a daily anti-histamine.

To answer your last question, yes, my asthma worsened as I got older. I didn't have any problems when I was a kid but when puberty hit, I started having issues. It's only become worse as I age, and Advair truly has been a miracle for me, too. Don't suck it up, ever, when it comes to asthma. This is one of those things you do not want to mess around with.
posted by cooker girl at 6:37 AM on March 2, 2011

Your problem is no more Advair. I went off mine for a short while a few years back, and it was living agony. It doesn't make your asthma worse, it's just that you had forgotten how bad things really were before Advair, and it's a slow, agonizing slide back down.

A general practitioner can prescribe Advair. It's hella-expensive without a drug plan, but it's pretty much the cost of living for asthmatics... online pharmacies can help with that, but make sure you find a reputable one. (I know, I know, but not all grey-market pharmacies are the same. Make sure you find one that won't sell you counterfeits.)

Also, Zyrtec and Claritin are available over the counter now, and they're pretty big guns in terms of allergy control - no scrip needed. If you really, really need Allegra, your GP can get some of that, too.
posted by Slap*Happy at 6:48 AM on March 2, 2011

For my asthma treatment, I've seen over the past 30 years 3 allergists and 3 pulmonologists. I vastly prefer the allergists to the pulmonologists, and I do not plan to see a pulmonologist again for asthma treatment.

I could write thousands of words about this, but I'll skip to the tl;dr: Pulmonologists as a rule seem concerned mainly with lung function and optimizing only lung function. Allergists seem mainly concerned with quality of life, and optimizing lung function within that frame. Put more simply, pulmonologists tended to treat my lungs and only my lungs, while allergists would treat me as a whole person.

Also, in my experience pulmonologists are much more expensive, so if cost is a consideration.
posted by u2604ab at 7:01 AM on March 2, 2011

I developed allergy-induced asthma in my early 20s. I'm lucky enough to have a very mild case, but when I was having some bronchitis issues that were making my breathing kind of wheezy late last year, my NP put me on inhaled steroids. They told me that I should start on the steroids once I hit the point where I was using the rescue inhaler every day.

So that's just my anecdotal experience, but at least from my (non-doctor) perspective, this definitely sounds like something to take very seriously. I agree with everyone else who said that a PCP or NP is the best place to start, and that they can prescribe inhaled steroids right away (mine did!).

I have very similar feelings of needing to "suck it up" and not bother doctors. What has really helped for me is asking my doctors (a) if what I'm coming in for is a reasonable thing to come in for, and (b) what my standard should be for asking for help for similar issues in the future. As far as (a) goes, I have never had a doctor tell me I came in too soon or should have waited. And for (b), my doctors have been good about giving me specific points at which I should come in -- "doing Y for X days without relief", that sort of thing. And then when I start feeling like I should suck it up, I can remind myself that I have done Y for X days and therefore it's time to go in.
posted by pie ninja at 7:02 AM on March 2, 2011

Asthma attacks can kill -- I've seen it personally. Rescue meds should be needed no more than twice a week! Asthma care has evolved incredibly in the past 15 years, and is now all about prevention, to which you testify when you talk about how helpful Advair was. See your primary care physician ASAP.
posted by citygirl at 7:15 AM on March 2, 2011

I will just nth that you need to see SOMEONE. I recently lost a friend when asthma segued into pneumonia which segued into Acute Respiratory Distress Syndrome within several weeks and then he died.

So just see someone about it ASAP, OK?
posted by Danf at 8:00 AM on March 2, 2011