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Asthma Exacerbation

What is Asthma Exacerbation

Asthma is also known as “reactive airway disease” because the larger breathing tubes in the lungs (the bronchi) react to things that make them squeeze down to a smaller diameter. They also become inflamed, which makes them produce more mucous, and causes their lining to swell. The swelling also makes them smaller in diameter. When the bronchi get smaller, it is harder for air to move through them. A child with asthma has faster, shallower breathing and must work much harder to breathe than normal. Doctors say that a child who is having trouble breathing has “air hunger,” which is a good way to think about how it feels.

When air is trying to move through the smaller tubes, it often makes a noise called “wheezing.” Wheezing is often described as a whistling or a “musical” sound. Wheezing is often the most noticeable thing about a child with asthma, but it is not the most important. Many children with very loud wheezing are not in very much distress. Many children who are having really bad trouble breathing are hardly wheezing at all.

Asthma generally runs in families, but not every member of a family always has asthma. For a number of reasons, more and more children get asthma each year. That means there are plenty of children with asthma now who don’t have any history of it in their families.

People who have asthma don’t usually wheeze all of the time. Almost always, there is something that “triggers” an asthma attack. Common triggers are cigarette smoke, animal hair or dander, pollen, and air pollution. Dust from household vermin such as roaches, mites, and mice or rats can also be a trigger. Some children’s asthma is triggered by weather changes. Most children with asthma will develop some wheezing with every cold or respiratory infection.

Asthma is a chronic condition, which means that the person has it for a long time, even if they don’t always have symptoms of the disease. The good news is that most children with asthma do outgrow it. Even better news is that these days, there are many very effective ways to cope with asthma. The most important part for parents and children is to learn about what triggers your child’s asthma. Learn how your child’s body tells him or her (and you) that it is starting to develop an attack. You can also learn how to head off (or even entirely prevent) the attack. Children with asthma can be athletes, dancers, singers, or anything else they want to be – they just have to learn how to understand their asthma.

Biggest Asthma Exacerbation Concerns

Because an asthma attack makes it hard to breathe, getting air in and out of the lungs is our biggest concern. Untreated, asthma can be fatal – sadly, several hundred children die of asthma in the United States each year. Doctors believe that all of these deaths are preventable. Preventing these serious outcomes means taking asthma seriously, and treating it as early as possible with the right medications.

When people with asthma have trouble breathing, they don’t get enough oxygen into their blood, and they also don’t get rid of carbon dioxide fast enough. Together, these effects can make a child fussy or irritable. They can also make the child sleepy or lethargic. Children with asthma may spend so much effort trying to breathe that they cannot concentrate on other things like play, schoolwork, or other activities. They may limit their own physical activity because it is hard to breathe.

Children also do not usually eat and drink as much as they should when they are having trouble breathing. This can mean that they get dehydrated, which in turn can actually make the asthma worse. Both asthma and some of the medications we use to treat it can cause abdominal pain and vomiting.

Asthma Exacerbation Treatment

Doctors and patients with asthma have learned to think about treating the condition in three different phases: rescue therapy, maintenance therapy, and prevention.

Rescue Medications

Since your child has just had an asthma attack, you have probably become familiar with rescue therapy, even if this was the first attack. We call it “rescue therapy” because it is meant to be used only when an attack has already developed. These drugs work by fighting thebronchospasm, making the bronchial breathing tubes relax and get larger, so more air can move through them. The most common medicines we use in rescue therapy are called albuterol or salbutamol (trade names Alupent®, Ventolin®, and others). These medications all come in a form so that children can inhale them, either as multi-dose inhalers that are pocket-sized, or as solutions to use in a nebulizer machine. A newer form of albuterol called levalbuterol (Xopenex®) may have fewer side effects, but is only available as a nebulizer solution. Albuterol syrup and tablets are still available, although most doctors have stopped prescribing these because they cause more side effects than the inhaled forms of the medicine. Some doctors also prescribe inhaled medications such as atropine, ipratropium (Atrovent®), or combination medications such as Combivent®. These are usually for children with more severe asthma.

In doctors’ offices and hospitals many of these medications are often given by a nebulizer – a machine that produces a fine mist of the medicine for your child to breathe. Some parents use nebulizers instead of inhalers at home. Please discuss the pros and cons of nebulizers versus inhalers with your doctor, to decide which method is best for you.

Regardless of whether you use an inhaler or nebulizers, it is important to give the rescue medication as prescribed. This usually means giving it several times a day for a certain number of days (for example, every six hours (four times a day) for five days). Doing it this way keeps the bronchospasm under control. Do not give rescue medication only “as needed.” Doing so means your child is always getting the medicine afters/he has started to wheeze.

After this current asthma attack is over, learn to recognize the signs of an upcoming attack. Start the rescue medicine as soon as your child develops a cough, a cold, or a runny nose. Once you and your child recognize the things that trigger his or her asthma, you will both become experts at predicting an attack and heading it off with rescue medication.

After the main part of the asthma attack is over, your child was probably given a dose of a steroid either by mouth or by a shot or and IV. Steroids such as prednisone (Pediapred®, Prelone®, Ora-Pred®, and others) are very helpful in stopping the inflammation of the bronchi. Most children only need to take the steroid medicine by mouth for 4-5 days after an attack. The well-known side effects of long-term steroids such as weight gain, stretch marks, and bone changes do not occur with this short-term dosing. Children on any dose of steroid should avoid people with contagious diseases like chicken pox. Although you can start the inhaled rescue medication on your own, it is best to check with your doctor before starting the oral steroid medicine.

Maintenance Medications

Medicines used in rescue therapy are effective at treating an attack, but they have many side effects. They are also not very useful at preventing an asthma attack. The medicines that are used to keep your child’s bronchi from reacting to triggers are called the maintenance medications. They all work by preventing inflammation. Your doctor follows current guidelines that stress the use of anti-inflammatory medicines in keeping asthma under control. Use the maintenance medicine every day exactly as prescribed by your doctor, in order to get the best results.Maintenance medicines do not help to make a new asthma attack better – they can only work by preventing the attack. If the dosing schedule your doctor prescribed is hard for you to manage, please ask your doctor about changing it. There are so many different medicines these days that a convenient pattern is almost always possible, no matter how hectic your day is. Children who do not use their maintenance medicines regularly need to use the emergency room or urgent care center much more often than children who do.

The best and most commonly used maintenance medication is a steroid given by an inhaler (Flo-Vent®, Vanceril®, and others) or by nebulizer (Pulmicort®). Have your child use the inhaler or nebulizer as directed at about the same time or times every day if possible.

Another category of anti-inflammatory medications is called leukotriene (“loo-koh-try-een”) modifiers (Singulair® and others). These can be given by mouth, and usually only once or twice a day. They have no significant side effects. Many doctors believe that the leukotriene modifiers are among the best forms of maintenance therapy available for milder forms of asthma.

Cromolyn sodium (Intal®) is a maintenance medication that works by preventing inflammation. Your doctor might choose to use it alone or in combination with some of the other medications.

Among the most recent maintenance medications is one called Omalizumab (“oh-mah-liz-oo-mab”) (Xolair®). Children get this medication by an injection once every two to four weeks. At present it is used only in children with fairly severe asthma, and only in combination with other treatments. It appears to be safe and well-tolerated.




There are many newer drugs and combinations of drugs that are intended for use as maintenance medications. Be sure you understand which of the medicines for your child are meant for maintenance and which are for rescue. Busy doctors sometimes forget to explain the difference, so don’t feel bad about asking! You can help your child stay healthy and out of the hospital by using maintenance medications properly.


Even though we discuss it last, prevention is one of the best ways to control asthma. The most important step in preventing asthma attacks is to believe that you can! You and your child can learn the early warning signs of an attack, and then take the right steps to head it off. You and your child can think of yourselves as “detectives,” seeking clues that might predict an attack, and recognizing triggers that could cause an attack. Once you have gathered enough evidence that an attack is coming, you can call in your rescue team to fight it off!

Your child’s body gives clues long before s/he begins to wheeze. These clues might include feeling short of breath, breathing fast, or coughing. Some children recognize a feeling they call “tightness” in their chests. Your doctor may recommend that your child use a device called a “peak flow” meter to measure daily lung performance. If you and your child keep an “asthma diary,” you can both learn to match the way s/he feels with the peak flow measurements. Use the diary to write down how your child feels just before an attack. Over time you and your child will learn to understand the language that his or her body is using to tell you about important clues that predict an attack.

An asthma diary can also help you learn about the triggers for your child. Triggers are outside influences that set off an attack. Learning what the triggers are and how to avoid them is one of the most important steps in preventing an asthma attack. Just like the clues to an attack, it will take some time for you and your child to learn to recognize what kinds of things trigger his or her attacks. Your child can learn to get away from some kinds of triggers, like cigarette smoke or animals. Other triggers are harder to avoid, like pollen or air pollution, but going into an air-conditioned building can help. Some triggers, like a cold or viral infection, are very hard to avoid, but by recognizing them you and your child can be ready to start rescue therapy the minute you recognize a clue to an attack.

Dangerous Asthma Symptoms

Once you and your child learn to predict an attack, you will be able to control it most of the time. Sometimes, though, the attack will come on too quickly, or important clues might be missed (it happens to everyone). Signs of a severe asthma attack that requires an urgent visit to the doctor or emergency room are:

  • A feeling that the child cannot catch his or her breath
  • A child who cannot speak more than a few words at a time without pausing for breath
  • A child who refuses to talk at all because of difficult breathing
  • A child who sits up and leans forward, often holding on to the seat of the chair or edge of the bed
  • Bluish color around the lips, eyes, or fingernails
  • An anxious or frightened-looking child
  • “Grunting” to push air out with each breath
  • Flaring of the nostrils and/or retractions (pulling in of the skin) between the ribs
  • In a child who is too young to talk, extreme fussiness or irritability,or lethargy or sleepiness
  • Needing to use a rescue inhaler or nebulizers more than every four hours

Other points of concern

  • Many parents, especially those whose children have newly-diagnosed asthma, feel unsure of when to call the doctor or go to the emergency room. Parents often feel torn between calling early to try to head off an attack, and waiting to see if their own treatment will help. They don’t want to seem like “worry-warts” but they also don’t want to wait too long and have the attack get worse. These are normal feelings – asthma is a very hard disease to deal with when you are new at it! Remember that your doctor works for you, and wants you and your child to learn how to identify an oncoming attack. Please do not be afraid to call your doctor, or if in doubt, go to the emergency room. If you have a few “false alarms,” you will learn how to tell a serious attack from one you can manage at home.
  • Many parents and some teenagers worry about the side effects of steroids. Oral steroids given for 4-5 days at a time and not more often than a few times a year do not cause weight gain, stretch marks, softening of the bones, or any of the other side effects that people often read about. People taking steroids should try to stay out of close contact with those who have contagious diseases like chicken pox, because even the low doses cause a small drop in the immune system function. Teenagers who are worried about their body image sometimes stop taking their steroids too early. Have a talk with your teen at the beginning of treatment with steroids, and try to be sure s/he will tell you if s/he plans to stop taking the medicine. Often a discussion with the doctor can help you reach a compromise. Suddenly stopping a steroid medicine can be very dangerous, and a few teenagers die each year when they do it.
  • A very small number (less than 1%) of children develop oral thrush (yeast infection) with long-term use of inhaled steroids. You can read more about it on our article on thrush.
  • Teenagers occasionally overuse their rescue medicine inhalers. They may do this either because they don’t want to have to go to the hospital or because they want to avoid steroid use. Overusing rescue medications can produce dizziness, fast heart rate, dry mouth, and a number of other unpleasant and occasionally dangerous side effects. Help your teen to understand that if s/he is using the rescue medicine more often than prescribed (usually not more often that four or at most six times per day), s/he is probably having a more severe attack than usual.
  • Parents and doctors used to recommend limiting athletic activity in children with asthma. While it is true that some children and teens have “exercise-induced” asthma, most can learn to manage it in a way that lets them still participate in sports and other activities.

Other Conditions that Might Be Present With Asthma

Children who have wheezing on more than one occasion, and who have clues and triggers to their wheezing, usually do have asthma. Doctors used to be hesitant about diagnosing asthma in younger children or in children whose wheezing was only mild, because they did not want to “label” the child. Today we know that early identification of asthma is one of the most important steps in preventing attacks. Nevertheless, both parents and doctors should know about a few of the things that can cause wheezing that are not asthma.

  • Infants and toddlers may wheeze if they get a condition called “bronchiolitis.” A number of different viruses cause bronchiolitis, though by far the most common is “RSV.” Bronchiolitis happens during late fall through early spring, and always starts with a runny nose and a cough. Many children who get bronchiolitis turn out later to have asthma, but most do not. There is no good treatment for bronchiolitis, but the good news is that it almost always clears up without problems. Unlike asthma, bronchiolitis does not recur.
  • Older infants and toddlers (and occasionally older children) may accidentally inhale a small object like a peanut, a crumb, or a small part from a toy. This so-called “foreign body aspiration,” usually causes a sudden attack of severe coughing. After the coughing attack goes away, however, the child may appear nearly normal for a few days until a new cough and sometimes fever set in. This happens because an infection is developing behind the object in one area of the lung. These objects always have to be removed in a hospital by a trained specialist.
  • Certain kinds of heart disease can cause wheezing, especially in younger children when the heart condition has not yet been diagnosed. Children who wheeze for this reason usually get worse, not better, with rescue medicine in the hospital, which is often the first clue that the problem is in the heart, not the lungs.