In my last post, I wrote about what asthma is and how it’s diagnosed. I wanted to continue the theme by discussing how asthma is managed (or at least, how it should be managed) after the diagnosis is made. It’s important to remember that, while asthma is very common, it’s also a serious and potentially life-threatening disease. In many cases, asthma may not require a daily medication, but it’s important for all parents of children with asthma to keep a rescue inhaler with them for use in emergencies. You never know when you may need it.
Basic Principles of Asthma Management:
Our primary goal for asthma therapy is to allow children with asthma to live normal lives. They should be able to keep up with their peers on the soccer field. They should be able to sleep at night without waking up coughing. A simple cold shouldn’t land them in the hospital, and they shouldn’t be missing a significant number of school days. In short, kids with asthma should just be kids.
It’s crucial to note that asthma management isn’t limited only to medications. The current guidelines for treating asthma in children make this pretty clear. They divide asthma management into four categories:
- Assessment and Monitoring: This refers to regular visits with the healthcare provider who manages your child’s asthma. Depending on your situation, this may be a pediatrician or family doctor, a physician assistant or nurse practitioner employed by their practice, or a specialist such as a pulmonologist or allergist. Whatever the case may be, it’s important to schedule frequent visits (at least every three months; more often if things aren’t going well). Asthma symptoms frequently change over time, and these visits allow us to monitor your child’s symptoms, increase medications when needed, and–even better–decrease or stop them when symptoms improve.
- Education: This is what we’re doing right now, but it’s also what your doctor should be doing at every visit. It’s crucial for parents of children with asthma to understand the disease and how it’s treated. We review how to properly administer medications, which inhalers to use and when to use them, and how to recognize worsening symptoms. This education may be provided by the doctor, a nurse, a respiratory therapist, or an asthma educator–but it’s crucial that somebody does it. Another key part of education is a written Asthma Action Plan, which gives parents a road-map to treating asthma whether it’s a good day or a bad one.
- Controlling Environmental Factors and Comorbid Conditions: I touched on “comorbid conditions” (other conditions that tend to be found in children with asthma) in my last post. Properly addressing these conditions as well as removing potential triggers from the child’s environment play a huge role in improving asthma symptoms. In fact, it’s not uncommon for children to go from needing one or more daily medications to being medication-free just by making a few changes.
- Medications: This is what most people jump to when they think about asthma treatment. But I don’t think it’s by accident that medications are listed last. One of the points I try to make to parents (and readers) is that every treatment we provide comes with potential risks as well. This goes for conventional medications and alternative treatments alike. This is why environmental controls are so important; while there may be some financial or emotional tradeoffs to replacing carpets, getting rid of stuffed animals, or finding a new home for the family pet, none of these interventions place your child’s health at risk. By starting with the non-medication aspects of asthma management, we can improve symptoms while reducing the need for asthma medications. Not a bad deal.
You may have noticed that alternative treatments didn’t make the list. The reason for that is that we don’t have sufficient evidence to show that they are safe or effective treatments for asthma. I’ve written before about using alternative treatments in lieu of proven medications for serious diseases such as asthma; in short, it’s dangerous and I don’t advise it.
A word about honesty (for everyone except you):
Please, when your child’s doctor asks if you are giving medications as prescribed, be honest. We know you’re human; most of the families we care for are. You forget. You get tired. You get busy. You lose things. I promise, you’re not the only one.
We don’t ask because we’re judging your parenting; we ask because we use the information to make medical decisions. Say I see two identical kids on the same medications, both of whom have been coughing for the past month. One is using his medication faithfully while the other hasn’t touched an inhaler for weeks. My management will be very different.
Here’s a little secret: doctors aren’t stupid. We can call the pharmacy and ask when you last picked up your child’s medication. If it’s been 4 months since you filled a prescription for an inhaler that should last 30 days, we know you’re not really using it. It’s also pretty obvious when your teenager “never forgets” to use her inhaler, but “can’t remember” what color her it is.
We don’t usually confront parents about these things; it can be awkward, so sometimes we just play along. But the most common reason that asthma medications don’t work is that children don’t actually get them.
If this doesn’t apply to you (and I’m sure it doesn’t), that’s fantastic. And if it does, no need to apologize–just level with us from now on. It works better that way.
Common triggers for asthma:
Many children have asthma symptoms that are worsened by physical activity, exposure to tobacco smoke, or fragrances. Most children with asthma have worsened symptoms in the setting of a viral infection. Those with allergies frequently struggle with asthma symptoms when exposed to allergens such as pet dander, pollen, dust mites, or other specific triggers.
Often, asthma symptoms can be greatly reduced by taking simple measures to decrease exposure to these triggers. The most important thing is to identify specific triggers for your child and eliminate them whenever possible. (How far you go depends on the severity of your child’s symptoms and the financial or emotional cost of making these changes.) Allergy testing can sometimes be helpful in identifying specific triggers, but isn’t always necessary. Here are some general suggestions:
- Keep your home and car smoke-free. If you smoke, stop. (Easy for me to say, right?)
- If possible, remove carpet from the home and replace it with hard flooring.
- Inspect your home for signs of mold and address any issues you find.
- Change household air filters frequently, and vacuum regularly.
- Remove drapes, stuffed animals, and other dust-collectors from the bedroom.
- Use allergy covers for your child’s mattress and pillow.
- If pets worsen your child’s symptoms, consider finding them a new home, moving them outside, or—at the very least—keeping them out of your child’s bedroom. (To be clear, I’m talking about the pets, not the children.)
Activities that kids with asthma should avoid:
There aren’t any. Many children have asthma symptoms that are worsened with physical activity, but that shouldn’t keep them from participating. Obviously, children with uncontrolled, active asthma symptoms shouldn’t participate in activities that make them worse. But once these symptoms are identified, the goal of asthma management is to allow kids to be kids. They should be able to keep up with other children on the playground, run track in high school, and participate in any other physical activities to the limits of their abilities. Chances are, your child won’t be a professional athlete–but it shouldn’t be because of asthma. If the only barrier to a child’s physical activity is asthma, we’re not doing our job.
Medications used for asthma:
In general, asthma medications are designed to address the two basic causes of asthma symptoms: bronchoconstriction (when the small airway muscles tighten), and airway obstruction (caused by swelling of the airway walls and increased mucus production). We’ve come a long way in our understanding of asthma, and there is a lot of evidence surrounding effective treatments.
Current recommendations for asthma medications involve the following steps:
- Classifying the child’s symptoms by frequency, severity, and risk. Kids who have symptoms daily need different medications than those who have problems once a year. Those who end up in the ICU should be managed differently from those with a mild cough.
- Starting medications that typically work for children of a similar age and with similar symptoms.
- Reassessing frequently and “stepping up” or “stepping down” therapy as required. Stepping up may involve changing doses or adding new medications. While the guidelines provide recommendations for treatment, they also allow some wiggle room to tailor the plan to a particular child.
Children with mild and infrequent symptoms are typically treated with a medication to be used only when needed. The most common medication used in this way is albuterol. This medication can be given with a nebulizer or with an inhaler. (It is also available in an oral form, which increases a child’s heart rate but does little to relieve asthma symptoms. I’m not sure why this is still on the market.) Albuterol works by causing the muscles in the airway walls to relax, which makes the airway larger and allows more air to flow.
Many parents believe that nebulizers work better than inhalers, but the evidence is clear that–if used appropriately and with the correct dose–inhalers are just as effective. They’re also easier to carry with you and more likely to be available when you need them. All inhalers should be used with a spacer to help the medicine get down inside the lungs. With a mask attached to the spacer, they can even be used on screaming infants and toddlers. It feels like you’re suffocating your kid, but they will eventually breathe, and the medication gets where it needs to go.
Just to make it more confusing, albuterol inhalers have several brand names (Ventolin, Proventil, ProAir), each of which looks slightly different. They all do the same thing. Xopenex (levalbuterol) is a very similar medication that works in the same way, but may cause fewer side effects (irritability, shakiness, rapid heart rate). It also costs several times as much, so it’s typically only used when children don’t tolerate its less-expensive counterpart.
When children have asthma attacks, or exacerbations, they are typically treated with albuterol (sometimes, a whole bunch of it) and a short course of oral steroids like prednisone/prednisolone (Orapred) or dexamethasone (Decadron). These start working within a few hours to decrease the inflammation in the airways and improve asthma symptoms.
Steroids are awesome, and they work for almost everything…except that they have terrible side effects when used long-term. Long-term use of steroids is associated with weight gain, thinning bones, high blood pressure, growth suppression, and a host of other serious complications. Don’t let that discourage you from using them when your child needs them; just recognize that this is why we try to avoid using them more than we have to. Children who need multiple courses of oral steroids in a short period of time should be placed on a daily medication to limit the need for oral steroids.
“But wait, you said steroids had bad side effects…” Exactly–but they are also a fantastic treatment for asthma. Which is why we use them in very tiny doses delivered right where we need them. Inhaled steroids are medications like fluticasone (Flovent), beclomethasone (Qvar), or budesonide (Pulmacort), among others. These medications are used on a daily basis (usually twice a day) to prevent asthma symptoms.
Even when used every day for a year, the combined dose is quite low in comparison to a few days of oral steroids. We minimize the side effects while maximizing the benefit. But, while the side effects are much less serious, there are still a couple that we see pretty frequently. One is thrush (an overgrowth of yeast in the mouth and throat). This can typically be prevented by rinsing the child’s mouth or brushing her teeth after giving the medication. The other is growth suppression. This effect is typically small (on average, less than 1/4 inch per year, with some studies showing no difference in final adult height).
One problem with these daily medications is that, when they work, you child doesn’t have symptoms. And when your child doesn’t have symptoms, it’s a lot harder to remember to give him medication. For parents who have a difficult time remembering daily medications, setting phone alarms, making a weekly checklist, or placing the medications in a visible place like the kitchen counter or beside the toothbrush (assuming you’re better at remembering oral hygiene) can be helpful. Remember to keep them out of reach of young children.
For children with more severe symptoms, we will sometimes use inhalers that combine an inhaled steroid with a long-acting bronchodilator (similar to albuterol). These are medications like fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort).
Montelukast (Singulair) is a medication taken by mouth that can improve both allergy and asthma symptoms. It can be quite helpful, especially for children who struggle with both of these conditions, and it sometimes reduces the need for steroid medications. There are a handful of other medications that are used less frequently as well, but I’ve covered the main ones.
Does asthma last forever?
One of the most common questions that parents have when a child is diagnosed with asthma is whether asthma medications will be a lifelong necessity. The simple answer is that we don’t know. Some kids are at higher risk for lifelong symptoms, but there’s no way to know for certain which ones will outgrow their symptoms–at least to the point of not requiring daily medication.
The goal of asthma therapy is to give the minimum amount of medication required to achieve control of symptoms. This is the reason why it’s important to follow up frequently and reassess your child’s asthma control. If she struggles only during a certain time of year, it may be possible to give a daily medication only during that time of year. If her symptoms are well-controlled, it may be worth decreasing or stopping her medications to assess whether she still needs them. And if she does well without a daily medicine, the frequent visits can be spaced out.
Do children that “outgrow” asthma still have the disease? Honestly, I’m not sure that it matters. They’re certainly at risk to develop symptoms again in the future, but until that happens, just enjoy living asthma-free.
Hopefully, I’ve clarified some of the confusion about this common disease. Thanks for reading (especially to those of you who made it this far). If you have comments, please leave them below or on my Facebook page. If you found this article helpful, please be sure to follow me on Facebook or Twitter for future posts, and share with your friends on social media (or even in real life).