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| :: Treatment Of Childhood Asthma :: |
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A Common Story
It is a typical scene as I walk into the examination room. There on the exam table sits Roger, a 7-year-old young man with whom I am all too familiar.
Roger is doing what he usually does when I see him in my office: struggling to breathe. As I watch his chest heave up and down, I am struck by his loud wheezing and the exhausted face of his mother, who has been up all night with him. As you might guess, Roger is a frequent visitor both to my office and to the Emergency Room. He has been hospitalized several times. Despite what I think is good management on my part, Roger does not seem to get well.
Upon my persistent questioning, I find that his mom really hasn't been giving him his medicine regularly, despite my instructions. Whenever he does get well, she stops it, because she doesn't want him on medicine all the time...
The above story represents many of the difficult problems in treating asthma in children. Despite a growing understanding of the disease in the medical community, and the development of many new treatments, asthma continues to take a heavy toll on the health of millions of children.
The Basis Of Asthma Treatment
Before I can tell you about the specifics of treating childhood asthma, you must learn a few basics about the disease.
The two stages of asthma
There are really two parts to an asthma attack. The first, called the early phase, begins in minutes and can last for hours. It is caused by a clamping down of the muscles that surround the airways. When these muscles contract, they narrow the breathing tubes, making it harder to move air in and out of the lungs. This process is called bronchospasm. The second part of the attack is called the late phase. It begins in hours and can last for weeks. The cause of the late phase is the over-reaction of the "defense systems" in the lungs. When triggered, these defense systems call up an immune system response causing inflammation.
The makings of an inflammatory response in the lungs
Special cells in the lungs, called mast cells, release chemicals that call up this inflammatory response. One such chemical, histamine, makes the lining of the lungs leak, just like it does to lining of the nose in hay fever.
Another set of chemicals, called leukotrienes, call in more white blood cells, even when they are not really needed. So many of these inflammatory chemicals are released into your airways, already made smaller by bronchospasm, get clogged up with mucus plugs, fluids, and cellular debris. The end result is further narrowing of the breathing tubes and increasing difficulty breathing. What's more, there is increasing evidence that all of this inflammation may cause permanent changes in the structure of the airways, making them more prone to future illness. Therefore, managing the inflammatory response at a young age takes on even greater importance.
The take-home message of this rather complex process is that asthma is an inflammatory disease. If one treats only the first part, the bronchospasm, and does not adequately treat the inflammation, then treatment will not be as effective. Inflammation is a slow and chronic process, and its presence may not be all that obvious once bronchospasm goes away. Its treatment must be a long and continuous process. It is quite natural to resist giving children medicine when symptoms are not obvious. Many parents and many doctors fall into this trap. As you will see later, it is absolutely critical to treat the inflammation in order to get asthma under control.
Classification Of Asthma
The treatment of your child's asthma depends also on how severely the disease affects your child.
Asthma is classified into 4 categories:
Severe persistent
Moderate persistent
Mild persistent
Mild intermittent
It is important to realize that the classification may change depending on the time of year. Children whose asthma symptoms are triggered by viral infections may be sick all winter and clear the rest of the year. Children triggered by pollens will have problems in the spring and fall. The treatment intensity can therefore change from season to season. A few unfortunate kids are sick all year round.
Severe persistent asthma: This type of asthma is not hard to diagnose. These are the kids who are in the hospital frequently and in the ER or the doctor's office all the time. They have very frightening episodes and often need intense medical support. They are rarely clear and their activities are often limited despite frequent use of several medicines.
Moderate persistent asthma: Children with moderate persistent asthma can also experience symptoms that are quite frightening. They have occasional severe episodes that require hospitalization and ER visits and often do not clear between episodes. They require daily use of medications.
Mild persistent asthma: Children with mild persistent asthma are children that may once in a while have a frightening episode. They have prolonged periods of coughing and do not always clear between episodes. They use inhaled medications more than twice weekly but not every day.
Mild intermittent asthma: These kids have occasional episodes that are usually not severe. They clear completely between episodes and use inhaled medicines less than twice weekly.
The most important point to make is that all children with persistent asthma of any type need daily use of anti-inflammatory medications even when they appear to be clear. It is also important to note that, in children who have seasonal variations in their asthma, the medications and their dosing may vary.
Creating an Effective Treatment Plan
Parents hate to give children medicine. Most children hate to take medicine. My philosophy about medicine is that you should use as little as possible, but as much as you need. People like to ignore that last part. You must use all the medicine necessary to get a good outcome. But if your doctor is just writing prescriptions, you are not getting everything that you need, because the treatment of childhood asthma involves much more than medicines.
The first step is education of the patient and parent. Asthma is a complex disease process, which the patient and his family must understand in order to cooperate with the often-confusing treatments that are prescribed.
Education
Education takes time, a commodity that is often in short supply in a busy pediatrician's office. In my opinion, all asthmatics need to have at least one long (45 min - 1 hour) visit devoted solely to patient education and decision making. Many insurance companies will cover a home health nurse for this type of education as well.
Environmental control
The second step is called environmental control. There are many things in our environment that are known to make asthma worse. Every effort must be given to reducing the potential "allergic burden" in the household, particularly in the child's room. There are many resources available at your doctor's office and on the Internet that discuss how to "dust proof" a room.
Dust: Many asthma patients are allergic to dust, and removing its sources is very important. These include stuffed animals, heavy drapes, plants and heavy carpets, all of which collect dust. Dust proof covers can be obtained for mattresses and pillows. Bedding should be washed in hot water weekly to kill dust mites. There are chemical carpet treatments to control mites if removal is not an option. Special filters can be placed on forced air heating systems.
Additional triggers: In addition, exposure to toxins must be minimized. Most importantly, no one is allowed to smoke in the house and preferably not at all, since smoke on clothing can be enough to cause symptoms in a sensitive child. Also, pets are not a good idea for the child with asthma, particularly cats which are very "asthmagenic". Chemical fumes from perfumes and paints should be minimized. There are also steps to reduce mold in the household. If you can reduce the allergens in the house, it is less likely that other irritants, such as viral infections, will actually trigger an attack.
Monitor symptoms
Teaching parents how to monitor the severity of symptoms is the third step in asthma control. This is only useful for children able to cooperate with the use of a peak flow meter. This is a device that measures how much air your child can blow out when he tries his hardest. The peak flow meter gives you a number that indicates how obstructed the airflow is, and therefore how severe the asthma is at that moment. A child must be at least 5 years old to use a peak flow meter. There are known "normals" for children based on their height, and these numbers can be obtained from your pediatrician. Knowing your child's peak flow value can be very helpful in answering questions like: "How sick is she?" and, "How did she do when we changed her medicine?"
Proper equipment
Lastly, there is the matter of proper equipment. Not only must you have the equipment, you must take it out of the closet and use it. We already mentioned the invaluable peak flow meter. There are 2 other devices that are usually necessary: a spacing chamber for the inhaler, and a nebulizer.
Spacing chamber: Many asthma medicines come in the form of inhalers (although better devices will be available in the next year or so). Children are not very adept with inhalers. Much of the medicine is lost in the air and is not actually inhaled into the lungs. Everyone (including adult asthmatics) should use a spacing chamber with their inhalers. This is a tube with a one-way valve into which you put the inhaler. The inhaler is then puffed into the tube, which has a mouthpiece or mask at the other end. The child breathes the contents of the tube after the puff. Studies have shown that this device vastly increases the amount of medicine that actually gets into the lungs, where it needs to go to do its work.
Nebulizer: Another useful device is called a nebulizer. This is a compressed air generator that makes a 'mist' of the medicines. Studies have shown that delivering medicine with this device is most effective in getting the medicine where it needs to be: the lungs. This is the device that is used in most doctor's offices and emergency rooms.
Medicines For Asthma
The following is a brief outline of the various types of medications that can be used to treat childhood asthma.
Beta Agonists
These are the most commonly prescribed asthma drugs in children. The most widely used of the beta agonists is albuterol, sold under a number of trade names such as Ventolin and Proventil. These drugs work by stimulating beta receptors on the surface of the muscles surrounding the airways. When these receptors are stimulated, they send signals to the muscle to relax, thereby easing the bronchospasm during the early phase of asthma. This will help asthma symptoms, but do little to control the underlying inflammation. Beta receptors exist in other parts of the body and when stimulated can cause side effects, most notably hyperactivity, increased heart rate, and jitteriness. These medicines can be administered in a several ways, including orally, by injection, inhaler, or in a nebulizer.
Theophylline
This is one of the oldest drugs used to treat asthma. While still widely used in adults, it is not as frequently used in children any more. Its method of action is still not entirely known, but it is used primarily to relieve symptoms, not control inflammation. It has a lot of side effects. When first taken, this drug may make a child feel jittery or nauseous. If too much medication is used, it can cause heart palpitations, insomnia, agitation, or vomiting, and blood levels must be monitored to insure safe use of the medication. Theophylline is administered orally or intravenously.
Mast cell stabilizers
This class of drugs is very useful. They prevent mast cells from calling up the inflammatory response and thus are very effective in preventing inflammation. They are not useful in an acute attack since they do not actually relieve symptoms, but instead help control the underlying inflammatory process. The most commonly used of these drugs are cromolyn and nedcromil, sold under the brand names of Intal and Tilade. These medicines are available by inhaler or nebulizer only. They have extremely few side effects.
Leukotriene inhibitors
This is a new class of drugs and has just recently come into use. These drugs inhibit the inflammatory effects of leukotrienes. They help control the inflammatory response in asthma and are taken orally. Trade names include Singulair and Accolate. The medications have some side effects and are not helpful in relieving immediate symptoms.
Steroids
Steroids are the most potent anti-inflammatory agents known. Taken orally, they are very effective in the relief of all asthma symptoms as well as in the relief of inflammation. Unfortunately, oral steroids such as prednisone, dexamethasone, and others can have severe side effects, particularly when used for more than 1 week at a time. If used for extended periods, they may result in a number of unfortunate side effects, including poor wound healing and stunted growth. They are most useful for short "bursts" of treatment to improve the condition of the patient. Fortunately, steroids have been developed that can be used in an inhaler. These can be given chronically with excellent results and much fewer side effects. Close monitoring is essential when using this class of medications.
Monoclonal Antibodies are also finding their way into the management of Asthma. Omalizumab (?Xolair) was approved by the FDA in 2003 for patients who are inadequately controlled on the current regimen of corticosteroids and broncodilators. This medication is indicated only for patients 12 years and up, with a positive skin test, who have moderate to severe uncontrolled asthma. Omalizumab works by blocking the IG-E antibody from attaching to some of the inflammatory cells, such as mast cells and basophiles, thereby reducing the symptoms of asthma.
Some of the major concerns of this new approach to treating asthma is the growing concern of malignancy and sever allergic reaction known as anaphylaxis. The other major drawback is the fact that it is currently only available in an injectable form. Thus it is important to consult with the doctor regarding such precautions.
The Art Of Treating Asthma
As you can probably see by now, there are a lot of things to consider when deciding on asthma treatment. The first thing to understand is the difference between a symptom-reliever drug and a controller drug. Think about ear infections. You can use Tylenol to treat the symptoms, pain and fever, but it does nothing to treat the underlying problem. The same is true in asthma. You can use beta agonists like albuterol to treat the symptoms, but since asthma is an inflammatory disease, you very often must use something to control the inflammation.
Symptom-relievers vs. controller drugs
Symptom relievers can be given on an as-needed basis when symptoms such as wheezing and cough are present. They can be stopped when the symptoms go away. Controller medicines, such as the anti-inflammatory drugs, must be given on a regular basis, day in and day out, even when there are no symptoms. I see far too many parents who stop all of their child's medicines the moment the symptoms disappear, leaving the chronic ongoing inflammation free to progress without opposition. This will increase the frequency and severity of the child's asthma symptoms, and could possibly cause irreversible changes in the lungs. Consistency in using daily controller medication is essential.
The use of controller drugs is mandatory for all but the mild intermittent asthma patient. That is why proper classification and review by the physician is so important. It is also why education is so important. You, as parents, must understand why the medication must be continued, even when your child appears to be better.
Conclusion
Treating asthma is an art. There are many different drugs to use, and they can be administered in a number of ways: orally, by inhaler, by nebulizer, by injection, or into the vein. They can be given some of the time or all of the time. The treatment of asthma becomes an art when you and your child's doctor craft an individualized treatment plan based on the history of your child's illness, and all the considerations described in the article above. The success of this plan for your child depends on your doctor's recognition of the fact that asthma is an inflammatory disease, on your recognition of the level of your child's sickness, and on how well you and your child comply with the treatment plan. Without more educated partnerships between parent and doctor, pediatricians like me will continue to see too many patients like Roger, struggling to breathe.
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