Asthma

What is asthma?

First, let's discuss what asthma is NOT:

It's not contagious. No matter how much an asthmatic sneezes or coughs when you're around, you can't catch it.
It's not curable. Unfortunately, modern medicine has not yet found a cure — but we have found good ways to keep asthma under control.
It's not something you can control on your own. Asthmatics need medications to open up their airways so they can breathe, and all asthmatics need to be under a doctor's care so the medications can be carefully managed.
It's seldom fatal. Asthma can sometimes limit the kind of physical activities that can be done, and it can make life difficult at times, but it is seldom fatal.

Now, let's look at some facts about asthma:

An estimated 15 million people in the US suffer from asthma, including 4 million children under the age of 18.
Asthma can occur at any age, to people of any race.
Asthma is a chronic, low-grade inflammation and irritation of the bronchial tubes, which carry air in and out of the lungs.
Asthma tends to run in families. If either or both of your parents had asthma — or your spouse's parents — your children are more likely to have it.
An asthmatic is always an asthmatic — even when they're not coughing or wheezing. They need to be careful to stay away from the things that could trigger an episode or "attack", as some people call it.
Treatment CAN reverse asthma symptoms.
It's important to treat even mild symptoms of asthma so you can keep the symptoms from getting worse.

What is an "asthma attack"?

(Many asthmatics prefer to call them "episodes" rather than "attacks" — so that's what we'll call them from here on out.)

During an asthma episode, you have trouble breathing because the airways in and out of the lungs have become too narrow and air can't get through. The airways become narrow because muscles around them tighten up, the inner lining swells up, and extra mucous clogs up the airways. As you try to breathe, you may make a whistling or wheezing sound, and you may cough or spit up mucous.

How do you know if your child has asthma?

Asthma episodes rarely happen without warning. Most children have warning signs that occur hours or days before symptoms appear — but the warning signs are not the same for everyone, and even the same child may have different symptoms from one episode to another. However, knowing the warning signs can help avoid a serious episode of asthma.

It's a good idea to keep a list of the symptoms that seem to happen most often with your child, so you'll be able to tell the difference between colds or flu, and an upcoming asthma episode (although colds and flu can sometimes trigger an episode as well).

Here are some things to look for:

A change in the amount of air your child is able to breathe in or out of his lungs — the peak flow
Coughing that won't go away, especially at night, early in the morning, after exercise, or during exercise
A cough that lasts more than a week
Difficulty taking a breath, or shortness of breath
Wheezing or whistling sound when he breathes
A feeling of tightness in the middle of the chest
Breathing faster than normal
Feeling tired for no particular reason
Itchy, scratchy, or sore throat
Itchy, scratchy, or watery eyes
Sneezing
Constantly stroking the chin or throat
Feeling "stopped up" — like a head cold
Headache
Fever
Restless — not able to sit still
Runny nose
Change in face color
Dark circles under the eyes

My child's three most common warning signals are:

1. ________________________________________

2. ________________________________________

3. ________________________________________

Is asthma dangerous?

Asthma episodes range from mild to severe — with very few severe episodes. Most often, medicines can open the airways within a few minutes to restore normal breathing. However, some episodes don't respond to treatment and need immediate medical attention. If the medication does not result in improved breathing within two hours, it's best to call your doctor. The good news is, by learning what you can do to help improve asthma, your child can have fewer and less severe episodes.

What causes asthma episodes?

This is the classic "good news — bad news" answer! The good news is that, if you can find the things which seem to "trigger" your child's asthma episodes, you may be able to eliminate all or some of these triggers.
The bad news is, asthma may be triggered by literally hundreds of normal particles that surround us every day — and it is nearly impossible to eliminate all of them.

Among the most common triggers are:

Pets (sorry!). Unfortunately, most animals and even birds have small flakes on their skin, hair, or feathers (called dander) that can trigger asthma in some people. And, no matter how often you give your pet a bath, some dander still remains. Other allergens are found in the saliva or urine of these pets. (And no matter what you hear, long hair or short hair doesn't make any difference — and there are no allergy-free dogs or cats of any kind!)
Smoke, such as cigarette smoke, wood smoke, or other kinds of smoke.
Scented products, such as hair spray, perfume, deodorants, talcum powder, or scented cosmetics.
Strong smells from cleaning products, bleach, furniture polish, starch, room air fresheners, fresh paint, or even cooking.
Automobile fumes or air pollution (especially if you're stuck in a traffic jam).
Dust (or, more precisely the tiny dust mites that eat the dead skin which comes off our bodies everywhere we sit, stand, or lie down). This dust is found on couches and chairs, in your bed, and on carpets and drapes.
Dust also accumulates on brooms or dusters, and in the filters of furnaces or air conditioners.
Allergies to foods such as nuts, chocolate, eggs, orange juice, fish, milk, and peanut butter.
Pollen from flowers, trees, grass, hay, ragweed.
Feather or kapok-filled pillows, down comforters.
Mold (in the shower, or anywhere indoors or out).
Insect parts, such as those from dead cockroaches
Food additives, such as sulfites or preservatives
Aspirin
Changes in the weather or temperature
Exercise (especially in cold weather)
Crying — or laughing!
Coughing
Fear, anger, or frustration
Infections, such as colds or flu, which affect the upper airways
Lying down at night, especially when very tired

There's no cure — yet — but there is help

If you think your child has asthma, first, see a doctor. Asthma is a disease you can't treat by yourself.
Your doctor can also help identify those particles that seem to trigger your asthma, and develop a plan to reduce or eliminate those triggers.
Your doctor will prescribe medicines which can help prevent asthma episodes, as well as medicines to take if an episode occurs.
Remember, you must treat the symptoms as soon as they occur. The sooner you start treatment, the shorter and milder the episode will be.
If you notice a change in your child's symptoms — such as an increase in coughing or wheezing — call your doctor. A change in medicine may be necessary.
Your doctor will tell you what to look for if an episode becomes serious — and will tell you where to call for immediate help.

Infants with asthma require special care

A baby's lungs don't work as well as an older child's or adult's lungs. As a result, asthma in babies is more serious, and parents must watch for any signs of an episode.
If the baby has symptoms or difficulty breathing, act quickly. Follow the plan your doctor has outlined — or call to ask for immediate help.
Watch closely for signs that your baby needs emergency care:
- More than 40 breaths a minute while asleep (count the number of breaths in 15 seconds and multiply by 4 to get a one-minute count).
- The baby is feeding less, or sucking less — or stops completely.
- The skin between the baby's ribs seems pulled tight.
- The chest gets bigger.
- The baby's face becomes pale or gets red.
- Fingernails turn a bluish color.
- The baby's crying changes — becomes softer or shorter.
- Nostrils are open wider — flaring.
- Noisy, grunting kind of breathing.
Before an emergency happens, be prepared. Have a plan for contacting the doctor or hospital, a way to get there, and someone to watch any other children.

Asthma medicines

Asthma is different from person to person — different triggers cause different symptoms. As a result, medications must be carefully designed to work on the symptoms of your child's specific kind of asthma — and you may have to try several medicines or a combination of medicines until you find the one that works best. Medications also come in many forms: inhalers, nebulizers, tablets, capsules, liquids, or injections.

There are two basic kinds of asthma medicines: bronchodilators and anti-inflammatory medicines.

Bronchodilators are a "quick fix" — they quickly relieve symptoms by relaxing the muscles in the airways. These are often in the form of inhalers and act within 5-20 minutes. If asthma symptoms or an asthma episode occurs less than once or twice a month, an inhaler type of bronchodilator may be all your child needs. (If exercise is something that triggers an episode, your doctor may suggest using the bronchodilator before exercise.) Bronchodilators come in many forms — metered-dose inhalers, nebulizer inhalers, powder-filled capsule (which uses a dry inhaler), or as liquid, tablets, or injections.

The metered-dose inhalers (which give a precise amount of medicine for each use) are most commonly used because they act quickly (within 5 minutes) and have fewer side effects — the medicine goes from a mouthpiece and is breathed directly into the lungs. (Children as young as 5 can use them safely, and a special device attached to the inhaler makes it possible for even younger children to use them.)
Inhalers stop symptoms of asthma episodes and prevent symptoms that are brought on by exercise. They are sometimes used in small doses (no more than 3-4 times a day) to keep daily symptoms under control.
Nebulizers deliver a liquid form of the medicine which is put into a "nebulizer" (a machine which uses compressed air to turn the medicine into a wet mist), and is then inhaled through a neck or mouthpiece. Nebulizers are good for children under 5, anyone who has trouble using an inhaler, or those with severe episodes.

Give the bronchodilator at the earliest sign of asthma symptoms, such as cough, wheezing, or shortness of breath. An episode is shorter if the medicine is given as soon as symptoms occur.

Remember: Bronchodilators are rescue medications, but they cannot reduce or prevent the swelling that caused the symptoms. If your child has to use the bronchodilator a lot, it may mean the airways are becoming more swollen, and the asthma may be getting worse. If this happens, discuss it with your doctor immediately.

Side effects are rarely serious, but may include rapid heart beat, tremors, feeling anxious, or nausea. These symptoms tend to stop once the body adjusts to the medicine. Serious side effects are rare, but may include chest pain, fast or irregular heartbeat, severe headaches, dizziness, nausea, or vomiting. Call your doctor right away if your child has any of these symptoms.

Anti-inflammatory medicines reduce the swelling in the airways — and can prevent them from swelling in the first place. If symptoms or episodes happen more than twice a month, your child needs an anti-inflammatory medicine — and this medicine should be taken EVERY DAY. Give this medicine exactly as the doctor recommends, even if your child is not having symptoms. This medicine must be taken regularly for it to work well.

If your child fears getting a "body builder" appearance from taking corticosteroids, assure him he has nothing to fear! These are not the same kind of steroids used by some athletes — corticosteroids do not damage the liver or cause long-lasting changes in the body, and they are safe for young children. They come in three forms:

Inhaled corticosteroids are taken with an inhaler that precisely measures each dose. When taken as directed, they are safe, reduce sensitivity to many of the things that can trigger asthma, and prevent swelling of the airways.
Liquid and tablet oral corticosteroids — are used during serious episodes to reduce swelling and prevent the episode from getting even worse. For people with moderate asthma, this kind of medicine is sometimes used for 3 to 7 days. People with severe asthma, however, may take this kind of medicine daily or every other day. They start working after 6 to 12 hours.
Shots of corticosteroids are sometimes used in a doctor's office or hospital emergency room for serious episodes.

Side effects are a concern with any type of steroid medicine, so these drugs require careful watching — but even if you see some side effects, don't stop giving the medicine without first talking to your doctor, because this can make asthma worse.

Yeast infections in the mouth, coughing, sore throat, and hoarseness are the most common side effects, but there are ways to keep these problems from happening: Use a special "spacer" device which attaches to the inhaler (ask your doctor about this), and have your child rinse her mouth after taking the medicine.
Liquids or tablets may have side effects that stop when you stop the medicine — but don't stop without checking with your doctor. Things to look for are: increased appetite, weight gain, a rounder look to the face, changes in mood, or sleeplessness. Side effects can become more severe when the medicine is taken for more than a few days, so doctors use these drugs only for serious asthma that can't be treated any other way. Long-term use can result in high blood pressure, thinning of the bones, cataracts, muscle weakness, and slower growth.

If you forget to give a dose, call your doctor about how to get back on track.

What is a peak flow meter — and why is it so important?

A peak flow meter is a device that measures how well air moves out of the lungs. Since people with asthma often have swollen airways (which lessen the amount of air getting in and out of the lungs), this kind of meter can tell you if the airways are becoming swollen — even before you see any symptoms. This helps you stop the episode before it ever begins, and can help avoid a serious episode. They can also help you know if your child's medicine plan is working well, and when to add or stop medicine or seek emergency care.

Children as young as three years old can use peak flow meters. Although a child may have some difficulty getting the idea of how to use a meter, many 3 to 3-1/2 year olds have mastered this. It's important to use the peak flow meter before your child has any medication. Many children cough or get some chest tightness immediately after using a metered dose inhaler that may be related to the propellant. It may last for only a few minutes, but would cause an inaccurate peak flow measurement immediately after your child receives medication.

You need to know your child's "personal best"

You need to find your child's personal best — peak flow — so you'll know when his breathing is NOT good. The higher the reading, the better — it means more air is getting into the lungs — and, the lower the reading, the less air your child is getting. To find your child's "personal best" you need to take a number of readings over a two-week period when your child is not having any symptoms and is feeling good. Each child's peak flow reading may be different, and it is important to know the peak flow for each child because the medicine plan is based on the personal best peak flow number. To determine your child's personal best:

Take a reading twice a day for two weeks (both morning and evening).
Take a reading before and after giving an inhaler or nebulizer (if you use this type of medicine).
Or take readings at other times your doctor may instruct.

Using your peak flow meter

Instructions on using the meter are listed below, but before using the meter the first time, ask your doctor or nurse to show you how to use it.

Place the indicator at the base of the numbered scale.
Have your child stand up (very important).
Have your child take a deep breath.
Place the meter in your child's mouth.
Have your child close her lips and teeth around the mouthpiece tightly to make a seal, but without putting her tongue inside the hole.)
Have your child blow out as hard and fast as he can!
Write down the number you see on the meter.
Repeat it two more times.
Write down the highest number you saw.

It's time to get into the zone!

Once you know your child's personal best peak flow, provide the information to your doctor, who will then tell you how much medicine to give and when to give it. Your doctor also will set up a Peak Flow Zone — showing you what to do, depending on the reading you get. Keeping a daily diary of the flow readings will help you know when your child's reading is good (the green zone), or if he is having some problems that may require a change in medicine (the yellow zone) or is having frequent problems which signals a medical alert (the red zone). A red alert happens when the reading falls to less than half of the normal reading, and is the "emergency zone," which means your child needs medicine immediately, and you must call your doctor or hospital right away if the medicine does not return the peak flow number back to the green or yellow zone.

This chart can be photocopied (you can enlarge it if you wish) and taped to a wall in your child's room, or kept somewhere close at hand.

Don't forget:

The most important thing about the peak flow reading is how much it has changed from the last time you took a reading, AND how much it differs from your child's personal best reading.
A decrease of 20% to 30% may mean the start of an asthma episode.
When this happens, follow your asthma control plan.

What is a spacer?

A spacer is a device that extends the end of the inhaler so it can be put directly in the mouth. It holds the medicine in the tube long enough so it can be inhaled slowly, in deep breaths. There are several kinds of spacing devices, but the two most popular are the Inspir-Ease and the Aerochamber.

The Inspir-Ease is a collapsible blue bag. Its advantages — it costs less in the beginning, and it has a higher volume, which means more medicine gets into the lungs. It's disadvantages — it's relatively fragile, the plastic bags need to be replaced every three to four months, and it cannot be used with a face mask.

The Aerochamber is a rigid tube that connects to the inhaler. The advantages — it's durable, it does not need replacement parts, and it can attach to a face mask for infants. Disadvantages — it costs more in the beginning, it's bulky and difficult to carry, and it does not hold as much medicine.

Using a spacer

Attach the inhaler to the spacer following the directions that come with it.
Shake well.
Press the button on the inhaler (this puts one puff of medicine in the holding chamber).
Place the mouthpiece of the spacer in your child's mouth and have her breathe slowly. (A face mask may be helpful for a young child.)
Have your child hold his breath for 10 seconds, then breathe out. Repeat steps 4 and 5 two more times.
If your doctor has prescribed two puffs, wait between puffs the amount of time the doctor has directed, then repeat steps 2 through 5.

Summary: Managing asthma episodes

Keep a daily record of your child's peak flow readings and symptoms, and take them with you to doctor appointments.
Know the warning signs and peak flow zones, so you can begin treatment early.
Give the correct amount of medicine at the times the doctor has prescribed. Always call your doctor if you need to give more medicine than prescribed.
Eliminate the trigger, or move the child away from the trigger, if you know what triggers the asthma episode.
Stay calm and relaxed — and other family members should, too. Anxiety can make an episode more severe.
Encourage your child to rest.
Watch for changes, such as wheezing, coughing, trouble breathing, or color.
Check peak flow readings 5 to 10 minutes after each treatment to see if the readings have improved.
Know when you need emergency help:

When the wheezing, coughing, or shortness of breath gets worse, even after the medicine has had time to work (usually within 5 to 10 minutes for inhalers, though oral medicines may take longer).
When the peak flow number goes down or does not improve after treatment with a bronchodilator, or drops to less than half of the personal best reading.
When the child is having difficulty breathing. Some signs of this difficulty are:
1. Chest and neck are pulled in or sucked in with each breath
2. Hunching over
3. Struggling to breathe
4. Trouble walking, talking, and/or crying
5. Stops playing and cannot start again
6. Bluish color to lips or fingernails. If this happens, go to the nearest hospital emergency room immediately.
Keep emergency information close at hand. Call a family member, friend or neighbor if you need more help. If no one is available, call 911 or your local emergency ambulance service.
Immediately call a hospital emergency room, doctor's office or other medical facility if you need emergency help.
Do not do any of the following:
1. During an asthma episode:
  a. Don't have your child drink a lot of water (normal sips are OK).
  b. Don't have your child breathe warm moist air from a shower.
  c. Don't have your child breathe through a paper bag held over his head.
2. Don't use over-the-counter cold remedies without first consulting your doctor.

How to eliminate or reduce potential "triggers"

Children with asthma have very sensitive airways. Their breathing is often affected by airborne particles that don't have any effect on others. These "triggers" can start an episode, or can make one worse.

It's important to find out what triggers your child's episodes, and learn ways to avoid them if possible. If you can't avoid these triggers, and if the medicine is not helping as well as you or your doctor think it should, you should discuss allergy shots (immunotherapy).
Ask your doctor about allergy testing to find out those things that trigger your child's asthma.
Ask your doctor what you can do around the house to help control these triggers.
Tell your doctor which methods seem to work — and which ones don't.
A child with asthma should never be exposed to cigarette smoke, whether it is fresh smoke or stale smoke. Parents who have previously smoked in the home must immediately stop smoking in the home, must not let anyone else smoke in the home, and should never smoke in the car. Fabric and plastic will absorb the smoke, and gradually release it later. Using activated charcoal filters in the return air duct of the air conditioner and on stand-alone air filters in the child's room can help remove stale smoke. Children with asthma should not go to pool halls, bowling alleys, or bingo halls or anywhere smoking is commonplace. The clothing of smokers also absorbs smoke, which can irritate a child's nose and chest. Other than viral infections that are difficult to avoid, cigarette smoke is the most significant trigger for asthma in children, and is avoidable.

Ways to reduce or eliminate potential triggers

Pollens and molds (outdoors)

Keep your child indoors during the middle of day and afternoon (10 am to 5 pm) when pollen counts are highest.
Use air conditioning, if possible. (Be sure to clean the filter at least once a month.)
Keep windows closed during seasons when pollen and mold are highest (usually spring and fall).
Avoid sources of molds (wet leaves, garden debris, etc.).

House dust mites

Put a zippered, airtight cover over your child's mattress and box springs.
Put a zippered cover over any pillows your child uses (or wash the pillows once a week, every week).
Avoid lying or sleeping on cloth-covered furniture, like sofas or chairs.
Wash all sheets, blankets, bedspreads or comforters at least once a week in hot water.
Wash all stuffed animal toys the child plays with at least once a week in hot water.
If possible, also do the following:
1. Reduce indoor humidity to less than 50% (use a dehumidifier, if possible).
2. Remove carpets from the child's room.
3. Use sprays or other things designed to kill mites or control them.
4. Avoid using a vacuum cleaner (no matter what the manufacturer claims, most of them spray fine particles of dust back into the air). If you must vacuum:
  - Have your child wear a dust mask (these are very inexpensive).
  - Use a vacuum cleaner that has very powerful suction (so it picks up as much dust as possible).
  - Have a central vacuum system installed which collects dust in a bag in the basement, garage, or outside the house.

Pets, pets, pets!

Skin, hair, and feathers of nearly all pets contains flakes or dander — no matter how often you wash them (and there's no such thing as an allergen-free dog or cat!). The length of a pet's hair also doesn't make a difference, because the allergens are in the dander, saliva, or urine.
If possible, remove the animal from the house or school classroom.
If you must have a pet, keep the pet out of the child's bedroom at all times.
If there is forced-air heating in a home with pets, close the air ducts in the child's bedroom (or find a special filter that fits over the duct).
Wash the pet weekly.
Avoid visits to homes with pets.
Take asthma medication before visiting homes where pets are present.
Choose a pet without fur or feathers, such as a fish or snake.
Avoid products made with feathers, such as pillows, comforters, or stuffed animals.
Avoid products made with kapok (silky fibers from the seed pods of the silk-cotton tree), such as pillows, comforters, or stuffed animals.
Use an indoor air-cleaning device (this will help with smoke, mold, and dander).

Insect parts

Use insect sprays — but only when the child is not in the home. Allow the house to air out for a few hours after spraying.
Use roach traps instead of spray.

Indoor molds

Keep bathrooms, kitchens, and basements well aired and clean away any mold that appears.
Do not use humidifiers (moist air causes mold to form).
Use dehumidifiers for damp areas, like basements, with the humidity level set for less than 50% but above 25%. Empty and clean the unit weekly.
Use an indoor air-cleaning device (this will help with smoke, mold, and dander).

Wood and kerosene smoke

Avoid using wood-burning stoves in your home. (This kind of smoke also increases respiratory problems.)
Avoid using kerosene heaters.

Strong odors and sprays

Don't let your child stay home when you're painting. Allow plenty of time for the paint to dry before the child returns.
Avoid perfume, hair spray, and perfumed cosmetics or talcum powder.
Do not use room deodorizers.
Use non-perfumed household cleaning products.
Reduce strong cooking odors (especially frying) by using a range hood fan and opening windows.

Colds and infections

Avoid being around people with colds or flu.
Stay strong and healthy: Rest, eat a good diet, and exercise regularly.
Talk to your doctor about flu shots.
Don't take over-the-counter medicines (such as cough syrup or cold remedies) without first checking with your doctor.

Exercise

Work out a medicine plan with your doctor that allows your child to exercise without symptoms, if possible.
Give inhaled bronchodilator medicine before exercising.
Warm up before exercise and cool down afterwards.
Avoid exercising outdoors in very cold weather.

Weather

Put a scarf over your child's mouth and nose in cold weather (so they won't be breathing ice-cold air).
Have the child wear a turtleneck shirt or sweater that can be pulled up over the mouth or nose in cold weather.
Dress your child warmly on cold or windy days.

Remember: Reducing or eliminating triggers is an important part of your overall medical plan. If your child has a known allergy that triggers the asthma episode, making these changes can keep an episode from starting, or make the episodes less severe.

Whether — or not — to go to school?

Your child can probably go to school:

If she has a stuffy nose, but no wheezing.
If she is able to do normal daily activities.
If no extra effort is needed to breathe.
If the peak flow number is in the Green Zone.

Your child should probably stay home if he has:

A fever above 100°F orally or 101°F rectally, with hot or flushed face.
Wheezing or coughing that still bothers him an hour after taking medicine. A child with wheezing should not go to school. He needs to be kept home and monitored with a peak flow meter, and possibly be treated every 2-3 hours with a bronchodialator.
Weakness or tiredness that makes it hard for her to go about her normal daily activities.
Breathing very fast or with difficulty.
Peak flow below 65%-70% of the personal best number, even after taking medicine.

Despite teachers' good intentions, they cannot adequately monitor a child with asthma in a school room where there are 20 or 30 other children. Also, it's a good idea to leave some information about your child's asthma with the teacher and principal. Emergency medication should be kept at the school, preferably with the school nurse or a responsible teacher.

Resources

National Asthma Education Program
HMLBI Information Center
P.O. Box 30105, Bethesda, MD 20824-0105
(301) 951-3260

American Lung Association
(Check your local phone book for the chapter in your area)

Asthma and Allergy Foundation of America
1233 20th Street, NW Suite 402 Washington, DC 20036
p 202.455.7643 ext.231
f 202.466.8940 p 800.7.ASTHMA

Reference
Teach Your Patients About Asthma: A Clinician's Guide
National Asthma Education Program
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, MD 20892

From the Parent/Patient Education Series
Holmes Regional Medical Center Pediatric Services

Peds: Pt Ed 14. Revised 6/98, 6/00.