Doctors’ Notes

Asthma

Asthma is a common, and often frightening, disease.

At Kids Plus, we think about it every day. We’re fortunate to have powerful medicines available to prevent and treat asthma, as well as diagnostic and treatment tools we can use in the office to keep kids with asthma healthy and safe.

Asthma symptoms tend to come and go. Sometimes they change quickly. They can look and feel frightening. Often patients with asthma are prescribed several different kinds of medications, each with different instructions. For all of these reasons, it’s helpful when parents (and patients) understand a bit about how the disease works and why we prescribe the medicines the way we do.

What is Asthma?

To understand asthma, think about what it’s like to get hay fever (seasonal allergies) when there’s pollen in the air. If you’re lucky enough not to get hay fever, imagine getting a stuffy nose from a cold.

When a person gets hay fever, a TRIGGER (such as pollen, cat dander, or grass) causes the inside of the nose to get swollen and make mucous. It gets congested. Congestion can make it tricky for air to pass through the nose, but it’s not a big problem: We simply breathe through our mouths instead.

When someone has asthma, the process is similar, only it all happens down in the lungs. In other words, a TRIGGER (pollen, cat dander, etc.) causes the air-carrying tubes in the lungs to get swollen and make mucous. The tubes are called bronchioles. The bronchioles get congested.

Congestion in the lungs makes it tricky for air to move through them — and, since the lungs are swollen, there’s no alternate route for the air to move. So this congestion makes you cough and wheeze. And it may create a life-threatening situation.

Asthma triggers are often the same as allergy triggers — pollens, molds, animals — but there are other common ones. The same viruses that cause a head cold can also trigger asthma. Cigarette smoke is a very potent, very common asthma trigger for many people. Other chemical smells, like strong perfumes, can be triggers. Cold air and exercise, or the combination of the two, can also be triggers for some people with asthma.

When your child has asthma, the first step is to AVOID TRIGGERS. Parents generally learn what their child’s triggers are over time, based on when they get symptoms. Some triggers (like exercise, cold air, and viruses) can’t normally be avoided, but others (animals, molds, cigarette smoke) can be.

When it first happens, an asthma attack may look dramatic and scary. Over time, repeated swelling in the bronchioles causes scarring inside the lungs. For both reasons, it’s well worth the effort to avoid triggers.

Asthma Medicines

Fortunately, we have some terrific medications for asthma these days. If used properly, they can keep asthma attacks from being life-threatening. If you or your child has asthma, you’re probably familiar with some of these.

ALBUTEROL (brand names are Pro-Air, Ventolin, or Proventil) is our first-line medicine against asthma. Albuterol works quickly to make bronchioles wider. It doesn’t decrease swelling, but it does make it easier for air to pass through the swollen tubes into the lungs. Because it works so quickly, albuterol is sometimes labeled in red and called the “emergency medicine.”

Albuterol is given by INHALER or NEBULIZER (a noisy machine that aerosolizes the medicine into a mist). We tend to use nebulized albuterol (“nebs”) in babies and young children because it’s easier — but it’s the same medicine an older child might take from an inhaler. Sometimes an inhaler comes with a spacer (a plastic tube about the size of a toilet-paper tube), which makes the inhaler easier to use.

Xopenex is a brand-name variety of albuterol that is more expensive, but may be needed for some patients.

ORAL STEROIDS (Prednisone, prednisolone, Ora-pred) are powerful medicines that make swelling go away. These medicines are used when asthma symptoms are significant. When children have a bad asthma attack, they’re typically prescribed a 3-5 day course of oral steroids. Oral steroids work relatively slowly to get rid of the swelling, and they can cause some side effects. We only use them when we need to.

INHALED STEROIDS (Flovent, Q-Var, Pulmicort) are similar to the powerful oral steroids, but they are given in very, very small doses through an inhaler (or sometimes a nebulizer, diskus, or other device). The tiny doses cut down on side effects. In fact, the doses are so small that they don’t really take away any swelling, but they can prevent it from happening. Most kids with persistent asthma use inhaled steroids every day when they DON’T have symptoms, to keep an asthma attack from happening if they’re exposed to a trigger.

Many other medicines are prescribed for asthma in various situations. Please talk to your doctor if you have questions, or if you’re not sure when to use each medicine. And, of course there is lots of other information you should know about all of the medicines mentioned above before you start using them. Your child’s doctor and your pharmacist are good resources for questions about the medications.

The Asthma Action Plan

Okay, the medicines are very effective, but only if they’re used properly. So how can you keep them straight?

Patients with asthma are often given an ASTHMA ACTION PLAN — a sheet of paper with three color-coded sets of instructions:

GREEN, for when everything is good;

YELLOW, for when symptoms start to ramp up a bit;

RED, for when symptoms are becoming significant.

When things are “green,” patients should have no symptoms; in other words, they have no difficulty breathing, they don’t have a cough, and they don’t cough when they sleep at night.

When kids have persistent asthma, they stay “green” by taking an every-day preventative medicine — usually an inhaled steroid. We recognize that it’s hard to give your children medicine every day when they seem healthy. But persistent asthma is a serious, chronic disease, so if they’ve been prescribed an every-day medicine, stopping it could put them at risk for worsening symptoms.

“Yellow” symptoms may be a cough, mild tightness in the chest, and difficulty breathing with exercise. Often, asthma patients in the “yellow” zone cough at night during sleep.

“Red” is when things are getting worse. Patients in the “red” zone have difficulty breathing and may not be able to speak a full sentence in one breath. They may breathe quickly and feel frightened.

The Asthma Action Plan, or other instructions from your child’s doctor, should tell you what to do if your child has “yellow” or “red” symptoms. Of course, if you’re not sure, call immediately for advice. Asthma symptoms can change quickly, especially in children, and difficulty breathing is ALWAYS a legitimate emergency.

Is There a Test for Asthma?

Asthma is usually diagnosed on a physical exam, after hearing about the patient’s medical and family history during an office visit. The diagnosis is confirmed when the patient’s symptoms respond well to the medications and show improvement after appropriate treatment.

Technically, yes, there are tests that can be done to confirm a diagnosis of asthma. Spirometry (or pulmonary function testing) can be done in the office, and it works well for older kids (over about 7 years old) who are experiencing symptoms.

Allergy testing can be helpful in some cases, and may be undertaken with help from an Allergist. Pulmonologists have other, more specific (and more invasive) testing that can be done, but this is usually reserved for complicated cases. Most of the time, specialist visits and extra testing are not necessary and a diagnosis is made during an office visit.

Don’t feel badly asking questions about asthma. If your child has asthma, it’s important for you to know how to manage her symptoms. Make sure the instructions you’ve been given are clear. If they aren’t clear, or if you’re not sure, please call and have them explained.

And, of course, if your children ever have difficulty breathing — whether or not they have asthma — don’t attempt to treat them at home. Always seek emergency care.

Dr. Kerry McGee is a former Kids Plus provider.