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Asthma

Asthma is a chronic or longstanding condition of the airways. The condition is also known as reactive airway disease because of the way the airways “react” in an adverse manner to certain triggers. The diagnosis is usually reserved for children over the age of 1 year who have had at least 3 separate episodes of wheezing. A child who wheezes once at the age of 8 months does not have asthma.

People who have asthma may suffer asthmatic “attacks” or “exacerbations” when exposed to these triggers, but have normal breathing in between the attacks. Some physicians recognize variants of asthma such as “exercise induced asthma” and “cough variant asthma”. While these terms are useful, asthma should be viewed as a vast spectrum of illness widely affecting each person differently. To one individual, asthma may be a debilitating illness requiring frequent hospitalization, reliance on constant medication usage, and perhaps even with bouts requiring assisted breathing by machine in an ICU setting. To another, asthma may mean no more than a nagging cough following a “cold” once a year. Asthma may be so severe as to be life threatening and to make school and career pursuit difficult, or so mild as to allow Olympic caliber sports participation.

Asthma exacerbations or attacks occur when an individual is exposed to a “trigger”. Different people react to different triggers, but common triggers include viral upper respiratory illnesses (“colds”), sinusitis, cold air, exercise, chemical irritants such as smoke, aerosols, and hairsprays, and allergens such as dusts and animal danders. Signs and symptoms include; wheezing (high-pitched whistling sound usually heard during expiration), coughing, chest tightness, and usually without fever (or low-grade associated with a cold). Diagnosis should be made by a physician.

Prevention of an exacerbation starts with targeting control of these triggers. In particular, smoke and allergens can be controlled in the environment. If there are any smokers in the house, they should be encouraged to smoke outside. In terms of allergens, there are many things that can be done. Firstly, an air filter will remove pollen, smoke, and animal dander from the air, though, they are not good for mold spores or dust mites. For a child with asthma, his bedroom should be made hypoallergenic in the following ways: plastic covers for the mattress and pillows, remove down comforters, the bedding should be washed in hot water, use area rugs instead of wall-to-wall carpeting, and remove stuffed animals. All of these attract dust mites. If it is difficult to remove the stuffed animals from your child’s room, you can wash them in the washing machine once a week or place them in the freezer for a couple of hours once a week to kill the dust mites. Dust mites like high humidity, and therefore the humidity in your house should be kept to less than 50%.

During an attack, there are three main adverse (negative) effects on the airway: inflammation, excess mucus production, and airway spasm. All three adversely affect breathing by reducing the size of the space within the airway for airflow. These effects are reversible over time and helped by various medications known as bronchodilators and by steroid anti-inflammatory agents. These classes of medications used in the treatmentof asthma exacerbations are discussed in full below.

Bronchodilators are medications that do just as the name implies; they dilate or open up the airways. Albuterol is the most common bronchodilator used in the treatment of wheezing. It is given as a syrup, aerosol (metered dose inhaler or MDI), or mist (nebulized solution). The syrup is most commonly used in infants, although you may also use an MDI with a spacer and mask in an infant. The mist and aerosol forms are used in older children and adults.

How to use an inhaler: (also called metered dose inhaler or MDI)

  1. shake the canister
  2. hold the MDI 2 inches from your mouth
  3. breathe out and release the spray (i.e. actuate the pump)at the beginning of the next breath in
  4. hold your breath for 10 seconds
  5. repeat this in 2-5 minutes
  6. children under the age of 6-8 will need to use their MDI with a spacer

In a child who is known to have asthma, it is important to start using his MDI or “puffer” at the first signs of wheezing. The treatments should be given every 4-6 hours for 7-10 days. Most children wheeze with colds and the natural history of a cold is to last 7-10 days. Thus, giving the broncodilator during this time will help to control the wheezing and in many cases help to prevent the episode from worsening. If your child seems to be needing the treatments more often than every 4 hours or if your child is having trouble breathing–breathing very deeply or quickly, you should see his physician immediately.

Normal respiratory rates:

Age up to 1 month  - less than 60 breaths per minute

Age 1-12 months -  less than 40 breaths per minute

Age 1-3 years   - less than 30 breaths per minute

Age 3-12 years  - less than 25 breaths per minute

Age 13 and older  - less than 20 breaths per minute

For many episodes, the bronchodilator will be the only treatment your child will need. In some instances, for children who are not responding to the bronchodilator therapy, your health care provider will add a steroid to the regimen. Steroids are anti-inflammatory agents. They are important in asthma therapy because an important part of the pathogenesis of asthma involves inflammation. Steroids, when used for asthma, can be given by liquid, a pill, or by IV (intravenous-given only in the hospital setting). Steroids are given in short courses of 3-5 days, usually 1-2 times per day. When used in short courses such as this, you will not see the side effects usually associated with steroids—these occur with long term use–months to years of steroid use. If your child seems to be needing frequent bronchodilator or short steroid use, your health care provider will probably opt to start him on some form of preventive medication.

Preventive medications for use in asthma include:

  • cromolyn sodium (inhaler, nebulizer, nasal spray, eye drops)
  • steroids (inhaler, nasal spray, ointments)
  • leukotriene receptor antagonist (pill) *the newest

Cromolyn sodium (Intal, Nasalcrom, Crolom) is a mast cell stabilizer. Mast cells in the body contain chemicals, one of which is histamine, a mediator of allergic reactions and wheezing. When a mast cell is disturbed by either pollen, smoke, animal dander, etc., it will open up and release the histamine. Cromolyn sodium will keep the cell membrane intact, and, therefore, when pollen comes in contact with these cells, they will not open up. So the wheezing and allergy symptoms of sneezing, watery eyes, and runny nose are prevented. It is important to remember that preventive medications must be used on a daily basis to be effective.

Inhaled steroids (Beclovent, Aerobid, Azmacort, Pulmicort, Flovent) work locally in the lungs to help prevent the inflammatory response in asthma. They are used for asthma as inhalers (MDIs) and are used the same way that bronchodilator inhalers are used (see above). These medications, until recently, have not been used in younger children because of the fear of stunted growth. Recent studies, though, show that budesonide or Pulmicort (at 400 micrograms per day) and fluticasone or Flovent (200 micrograms per day) do not suppress growth in the majority of children. And it is important to remember that poorly controlled asthma can affect growth. There may be side effects if these medications are used in high doses, and therefore their use should be monitored by a physician.

Leukotriene inhibitors (Accolate, Zyflo, Singulair) are reserved for older children and adults (Accolate and Zyflo 12 years and older, Singulair 6 years and older). These medications are given in pill form, and work by preventing the bronchospasm that is caused by cold air, exercise, and allergens. These are not to be used alone. They are meant to be supplemental therapy, and their use should be discussed with your physician.

In addition to medications and the control of triggers, the use of a peak flow meter is an integral part of asthma treatment. A peak flow meter is used in children older than 6 years (4-6 years in very cooperative children) and helps parents and health care providers monitor need for therapy. There are 3 zones–green, yellow and red (similar to a stop light). These meters measure how fast you child can move air out of his/her lungs. There are baseline numbers that correspond to you child’s age and height. When the number drops to 50-80 % of baseline, your child should start bronchodilator therapy, and if it drops below 50% of baseline, you should see by a physician immediately.