Category Archives: Asthma

What is asthma, and what can I do about it?

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Suzanne Berman, M.D.
Think of children you know who have a “sensitive” body part. Some children have skin which is very sensitive to inflammation, and they get rashes easily. Other children have “sensitive” allergic eyes, and the smallest amount of dust makes their eyes red and teary.Children with overly-sensitive lungs and lung passages have asthma. These children start to have cough, wheezing, and trouble breathing when something (a virus, pollen, mold, dust, smoke, an allergy, an animal, etc.) triggers inflammation in their lungs. “Inflammation” is just what it sounds like – red, irritated, swollen tissue. The lung inflammation causes air passages to shrink down, making it hard to move air in and out of the lungs.

Asthma affects about 7% of American children and is a very serious disease. It causes millions of lost school and work days for children and their parents, and costs billions of dollars a year in prescriptions, doctor visits, and hospitalizations. In America, even now with modern treatment, children die every year from asthma attacks.

Asthma often runs in families, although some children with asthma have no family history of it. Children with sensitive skin or eczema (called atopic dermatitis) or sensitive allergic eyes or nose (called allergic conjunctivitis and rhinitis) have a tendency to have sensitive lungs as well. Children who live with cigarette smokers have worse asthma and are hospitalized three times as frequently as children with asthma whose parents don’t smoke.

Asthma flare-ups or “attacks” can be scary to watch. Sometimes, they are so severe that children need oxygen and must be hospitalized. However, asthma attacks are preventable if patients take preventive medication. In fact, some children with severe asthma never have to go into the hospital, because they take daily medications to prevent asthma. It is important to realize that children with asthma are not “cripples.” Many medal-winning Olympic athletes have asthma, but they take adequate medication to control their asthma.

Medicines which treat asthma can be divided into two groups:

  • daily preventive medications, which include:
    • low-dose steroid inhalers (like Flovent and Pulmicort),
    • anti-inflammatory inhalers (like Cromolyn)
    • anti-inflammatory tablets (like Singulair)
    • slow-acting bronchodilators (medicines that open up tight air passages) like Serevent
    • medications which combine two of these products
  • treatment of flare-ups, which include:
    • fast-acting bronchodilators like albuterol
    • high-dose oral steroids which cut down on inflammation, like prednisone

As you might expect, the “preventive” medications aren’t enough during a flare-up. And “flare-up” medications, even if used daily, don’t prevent future attacks; they only help treat the current one.

Children with mild asthma might need only one of the preventive medications daily to keep their asthma under control. Children with severe asthma might need all four types of preventive medication (from group one) to keep them out of trouble.

Inhaled medications are a wonderful advancement in asthma medicine. However, to be effective, children must use them with spacers or chambers. Just holding the “puffer” close to the mouth and squirting it – usually most of the medicine ends up in the air or on your face. Spacers or chambers help the medicine end up where it belongs — in the lungs. Read our page on how to properly use an inhaler.

Some asthma medications come in an inhaled powder form. Read our page on how to properly use a dry powder inhaler.

Some parents want to know why their child needs to take asthma medications every day, when the child has attacks only a few times a year. Reason: preventive daily medicines are better for children than “heavy-hitting” medications, such as high-dose steroids and frequent breathing treatments. Also, asthma attacks can damage the lungs permanently, and so it is best to prevent them in the first place. It can be difficult to take medication every day, even if your child is breathing well, but it is much better than watching a child suffer from shortness of breath during an acute attack. Even once a year is too much! One reason children get into trouble with asthma is that they stop taking their preventive medication because they feel fine. Don’t let your child wind up in the hospital because of this.

Your red, yellow, and green asthma action plan

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Suzanne Berman, M.D.

Treatment of your child’s asthma is based on his or her daily peak flows. Read our asthma information pages and our page on how to do peak flows for more information on why we do peak flows.

Your child’s expected best or personal best peak flow is: _______________.

 

If today’s peak flow is above ______________, you’re in the green zone. ( > 80% of personal best.)

Good job! You should be in this zone every day or nearly every day. Today’s plan is:

 

  • Continue your daily preventive medications as prescribed:
  • Your inhaled steroid with spacer/chamber: ___________________ puffs _______ a day
  • Your by-mouth anti-inflammatory tablet: _______________________ once a day
  • Your inhaled anti-inflammatory with spacer/chamber: _________________ puffs _______ a day
  • You don’t need to use your albuterol today.

 

If today’s peak flow is between ___________ and ___________, you’re in the yellow zone. (60-80% of personal best.)

Watch out. You may be coming down with a cold virus or might have been around something that triggered your asthma. Today’s plan is:

  • Use your albuterol today. At first, use 2 puffs and repeat 2 more puffs in 30 minutes. If you are feeling short of breath or coughing a lot, or if your peak flow doesn’t improve to your green zone, you can continue use the albuterol as often as every 4-6 hours. If you need the albuterol more than every four hours to get relief, call us immediately and go to the red zone plan.
  • Continue your daily preventive medications as prescribed, the same as in the green zone.
  • If this is the third day in a row (or more) you’ve been in the yellow zone, call us at the office. Depending on the circumstances, we might like to see you in the office, or give you additional instructions for home care.

 

If today’s peak flow is below _________, you’re in the red zone. ( < 60% of personal best.)

This is an asthma attack. Today’s plan is:

  • Immediately use your albuterol. Use 2 puffs at first, then use 2 more puffs in 30 minutes. After giving the albuterol, be seen by a doctor immediately.
  • If it is a weekday during our usual office hours, call us. Tell our receptionist that you need a “Red Zone” asthma appointment, and we will see you right away.
  • If our office is closed, or if you are out of town, you will probably need to be seen in the local hospital’s emergency room. Please let our office know that you are going to the ER.
  • Continue your daily preventive medications as prescribed, the same as in the green zone.

Peak flow logsheet

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Suzanne Berman, M.D.

It is very important to keep a daily log of your child’s peak flows. Just as we are giving medication every day, we want to make sure that it is being effective every day. Keep a pencil and this sheet next to your peak flow meter and inhalers. Doing and recording your child’s peak flows will become as natural to you as giving your child his or her asthma medications.

Month: ______________________

Date Peak flow reading Date Peak flow reading
1st 17th
2nd 18th
3rd 19th
4th 20th
5th 21st
6th 22nd
7th 23rd
8th 24th
9th 25th
10th 26th
11th 27th
12th 28th
13th 29th
14th 30th
15th 31st
16th

My child was prescribed albuterol. What should I know about it?

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Suzanne Berman, M.D.

In healthy kids, the bronchial tubes are open and relaxed, allowing air to move in and out easily.
Sometimes, as part of an illness, the muscle around the bronchial tubes reacts by squeezing tight, making the airways smaller. It’s harder to get air in and out, so kids will begin to make a wheezing sound when they breathe. They will cough more as they try to force air through small “pipes.”
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Albuterol is a medication that is used as a bronchodilator — it opens up tight airway passages by relaxing the muscle that surrounds the airways. Albuterol is used most commonly for asthma, but it is sometimes prescribed for other conditions too.

How long will my child need the albuterol?
In general, your child may need some albuterol as long as the wheezing trigger lasts. For illnesses that run their course (like bad colds), it may take about a week. On the other hand, if your child is frequently exposed to things that cause wheezing (like cigarette smoke or animal dander), it may seem like he or she always needs albuterol. (In that case, the best thing to do is to get rid of the allergic trigger!)

How often should I use albuterol?
In general, a dose of albuterol (either 2 puffs from an inhaler or one breathing treatment) may be given every four to six hours as needed. Give it for dry, hacking cough (especially nighttime cough), wheezing you can hear, or if your child is working harder to breathe.

Unlike some other medicines, albuterol is safe to use occasionally on an as-needed basis. It can be started when there is a need for acute relief, tapered as the child improves, and stopped when he is better. However, if your child seems to need it very frequently for more than a day or two, doesn’t seem to be getting better with it, or seems to have frequent wheezing spells, he or she may need other medications and should be checked again in the office.

Remember, albuterol only helps one cause of cough: tight airways. It won’t help other kinds of coughs, like coughing from nasal drainage from a bad cold.

What side effects does albuterol have?
Most kids do well with it, but the most common side effects are rapid heartbeat, flushing, and jitteriness. In some kids, the jitteriness becomes hyperactivity! In most kids, these side effects wear off, or at least are much less bothersome, after about 10-15 minutes. If your child experiences side effects that are bad enough that you don’t want to give him or her albuterol, pleaes let us know.

Should my child get albuterol through an inhaler or a nebulizer machine?
In general, inhalers (with spacers and masks) work better in most situations than nebulizer machines. They are also more convenient, since it only takes a minute to administer a few puffs from an inhaler (while it can take 10-15 minutes to give a breathing treatment.) Occasionally, there are some circumstances in which breathing treatments may work better, however. If you are not sure which method is best for your child, or need a demo on how to use one or both devices properly, ask us.

Does this mean my child has asthma?
Not every child who wheezes has asthma.

Many infants and toddlers wheeze with bad colds and other respiratory viruses but never wheeze again after they get to school-age. Other children who do have asthma start having wheezing spells as infants, and although it improves as they get older, they continue to have flare-ups from time to time as older kids. Because of this, we generally won’t diagnose asthma just based on one or two wheezing episodes in a baby or toddler.

Kids with true asthma tend to have other allergic symptoms (like eczema, food allergies, and allergic rhinitis) and family members with asthma. They tend to have persistent coughs, even when they don’t have cold or other illnesses. Learn more about asthma here.

What about liquid albuterol (by mouth)?
Albuterol also comes in a liquid form that can be taken by mouth, and a few doctors still use this for wheezing in babies. However, studies show it doesn’t give nearly as much relief as inhaled albuterol, so most pediatricians don’t use it anymore. Also, oral liquid albuterol tends to have more bothersome side effects than the inhaled method.

What about Xopenex?
Xopenex is the brand name of a kind of albuterol which is more concentrated than regular albuterol. There are a few studies which show its side effects may be slightly less bothersome than regular albuterol. However, it’s also about ten times as expensive as regular albuterol, which seems to work just as well for symptom relief in almost all kids.

How do I use a spacer with my inhaler?

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Suzanne Berman, M.D.

What is the right way to use an inhaler?
When your child takes medication — pills or liquid — you know immediately whether she got it down or not. It’s not as easy with inhaled spray medication. This kind of medication can end up in the air, up the nose, on the cheeks, etc. When you’re not sure if the medication is getting in, it’s hard to tell if it’s helping or not!

That’s why we recommend that ALL our patients use spacers with inhaled medications. Very young patients should use masks on the end of their spacers. This ensures that the medication gets where it needs to be: the lungs.

How do I use a spacer with my inhaler?
  1. Shake the medication canister for at least 15 seconds. This mixes the medication well.
  2. Remove the cap from the canister.
  3. Hook up the spacer to the canister.
  4. Have the child “empty his lungs” by blowing out slowly.
  5. Before your child breathes in again, put the spacer in your child’s mouth.
  6. “Shoot in” one puff of medication by compressing the canister.
  7. Have your child breathe in slowly and evenly. (Some spacers make a whistling or “tooting” sound if the child breathes in too fast.)
  8. At the end of the deep breath, have your child hold her breath for at least 5 seconds.
  9. Take the spacer out of the child’s mouth and let her exhale and take some normal breaths.
  10. If your child is prescribed 2 (or more) puffs, repeat steps 4 through 9.
  11. Unhook the canister from the spacer and replace the cap.
  12. Don’t forget to take your other asthma preventive medications (if any) and do your peak flows today!

How do I use a mask with my child’s inhaler?

  1. Shake the medication canister for at least 15 seconds. This mixes the medication well.
  2. Remove the cap from the canister.
  3. Hook up the spacer to the canister.
  4. Hook the mask up to the spacer.
  5. Bring the mask up near your child’s face. If the child is scared by the mask, reassure him and let him calm down. Wait until he or she is breathing in slowly and evenly. Follow your child’s inhalations and exhalations.
  6. Cover your child’s nose and mouth with the mask at the end of an exhalation.
  7. Before your child breathes in again, “shoot in” one puff of medication by compressing the canister.
  8. Let the child breathe in and out a few times. Keep the mask firmly on the child’s face.
  9. Take the mask away from the child’s mouth and let her take some normal breaths.
  10. If your child is prescribed 2 (or more) puffs, repeat steps 5 through 9.
  11. Unhook the spacer and mask and replace the cap on the canister.
  12. Don’t forget to give your child’s other medications (if any) today!

If you have any questions about how to use the spacer or mask, be sure to let us know. We can give you an in-office demonstration.

How do I use a dry powder inhaler?

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Suzanne Berman, M.D.
What is the right way to use a dry powder inhaler?

Dry powder inhalers (DPIs) are one of the devices used to administer preventive medicines for asthma. They require a little more coordination on the part of the child, but children as young as 5 years old have been able to use them correctly.

How do I use a dry powder inhaler?

  1. Open the device and load the powder. (This will vary from product to product.)
  2. “Empty your lungs” by blowing out slowly, away from the device.
  3. Place the device in your mouth and hold it level.
  4. Inhale in, as deeply and quickly as possible.
  5. Hold your breath for at least 5 seconds.
  6. Close the device.
  7. Rinse your mouth out with water. This helps prevent side effects like thrush if some of the powder stays in the mouth.
  8. Don’t forget to take your other asthma preventive medications (if any) and do your peak flows today!

How do I do peak flows?

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Suzanne Berman, M.D.

A peak flow meter is the most important tool you can use to monitor your child’s asthma. A peak flow meter is a little tube with a gauge on it that measures lung function. A child blows as hard and fast as he can into the tube. The resulting number on the gauge is your child’s peak flow number.To get the best number, have your child:

  1. Stand up straight and take a few slow, deep breaths.
  2. Reset the gauge on the peak flow meter to 0.
  3. Take a big deep breath and close the lips around the peak flow meter.
  4. Blow out as hard and as fast as possible through the peak flow meter.
  5. Check the result on the gauge.
  6. Repeat steps 2 through 5 twice.
  7. Record the highest number of the three tries on your peak flow log sheet.

Common problems children have with peak flows:

  • Not getting a good lip seal around the tube. Air can blow out the corners of the mouth. This falsely reduces the peak flow number.
  • Not blowing out as fast as possible. Tell your small child to blow out “like a dragon breathing fire, not like blowing a kiss.”
  • Not remembering to write down the result. Be sure to write down your daily peak flows in your log sheet. It’s much easier than trying to remember a month’s worth of numbers in your head!