NIH: Create Action Plans to Control Kids' Asthma

A boy using an asthma medicine inhaler.

Doctors say if families learn to control asthma better and stay ahead of the symptoms, there would be fewer hosptial visits for asthma. iStockphoto.com hide caption

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Asthma Q&A

  

Asthma is a complex disease with many causes, and doctors still don't understand why some people get it and others don't.

  

Read more about the triggers and treatments for asthma.

September is the peak month for asthma attacks that send kids to hospital emergency rooms. Experts call it the September epidemic.

"The most common precipitant of a bad attack of asthma is infection with the common cold virus," says Dr. Homer Boushey, of the University of California, San Francisco. "And what happens when kids get back together for school is they start exchanging viruses."

The National Institutes of Health has just released new guidelines to help parents prevent these flare-ups. The updated guidelines include the first distinct treatment recommendations for children ages 5 to 11 years old. They include recommendations on preferred medications, such as cortico-steroids which are used to reduce inflammation in the airways, and short-acting bronchodilators, such as Albuterol, which are used as "rescue" inhalers.

The guidelines include a new focus on self-monitoring of symptoms and urge physicians to work with their patients to develop written asthma action plans.

Asthma Action Plans

Alison Shelton, an economist in Washington, D.C., struggled with her 9-year-old son Kenneth's asthma for several years. He would start coughing at night, says Shelton, "And it would go on all night." After he was officially diagnosed, Shelton's family physician at Kaiser Permanente helped her develop a written action plan.

"It's a sheet of paper and it's got three parts or zones," Shelton says. There's a green zone, which includes instructions about which medicines to take daily.

When Kenneth starts with coughing or wheezing, or when he develops a cold, they step up to the yellow zone, which means taking higher doses of medications. Symptoms that put him in the red zone necessitate a call to the doctor for drugs they don't keep around the house.

Shelton says the written plan, and knowing when to use the medications, helps her feel a lot more confident about controlling her son's asthma.

Corticosteroids Recommended to Control Asthma

Shelton says that originally she wasn't convinced that her son needed daily medication when he didn't have any symptoms. She especially didn't like the idea of steroids.

"I thought, oh no, this can't be good," Shelton says. She associated steroids with bulked-up athletes and dangerous side effects. "But the doctor was very clear that this is not the same steroid, and that the benefits are overwhelmingly in favor of doing it."

Experts say the beauty of the inhaled cortico-steroids, which are sold under trade names such as Pulmicort and Flovent, is that they reduce inflammation in the lungs with small and targeted doses.

"We inhale tiny doses because the dose is deposited directly in the lung," Boushey explains. "And very little is absorbed into the circulation to cause systemic side effects."

Kids do grow slightly slower in the early years while using corticosteroids, but Boushey says, "Follow-up studies suggest they catch up and reach their adult height just as one would predict."

Controlling Asthma

When 39-year-old Kirstin Carlson-Dakes was a kid, there was little she could do to control her asthma. She recalls long nights in the ER, waiting for shots of adrenaline.

"I remember gasping for breath," Carlson-Dakes says. "My mom and I have talked about it and she's talked about how scared she was and how she never really knew going to the ER if I was going to make it or not."

When Carlson-Dakes was a child, there weren't effective preventive medicines, and kids didn't have inhalers. Parents had few ways of controlling symptoms, short of steaming up the bathroom. For many kids, activities such as sports and camping trips were a real challenge.

"I remember I tried to go on a Girl Scout sleepover," Carlson-Dakes says, "and my parents had to get me in the middle of the night because I had an asthma attack."

But things are very different now for her children. Although two of them suffer from asthma, they never end up in ER and don't miss out on activities.

"My daughter can go to Girl Scout camp and she can go on overnights and we don't have to worry," she says.

That's because her 9-year-old daughter has several medications to keep symptoms under control. And even on a campout, she knows exactly how much of which ones to take when she starts wheezing.

There are about 500,000 hospitalizations, and more than 2 million ER visits each year due to asthma attacks.

"Most of these could be prevented," says Boushey if more families learned to stay ahead of the symptoms.

The new guidelines urge all parents to team up with their doctors and young kids to develop a written action plan. So instead of fearing asthma, they can control it.

Asthma Triggers and Treatments

Asthma can be a debilitating disease, but doctors say most patients can control their symptoms with proper treatment. Here, a look at what triggers attacks, and a guide to the most common medical treatments.

What is asthma?

Asthma is a chronic disease that leads to a narrowing of the airways in the lungs. Symptoms include wheezing, coughing, chest tightness, and trouble breathing. During an asthma attack, symptoms become more severe. Though the condition cannot be cured, symptoms can be controlled and frequently prevented.

How do people get asthma?

It's not exactly understood why some people get asthma and others don't, but the disease tends to run in families. Dr. Robert F. Lemanske, a professor of Pediatrics and Medicine at the University of Wisconsin – Madison School of Medicine and Public Health, says there is no single gene responsible for asthma. He says multiple genes probably contribute to the tendency to develop asthma, in different ways that are not yet fully understood.

Environmental factors also seem to contribute to asthma. For example, Lemanske says, if a woman smokes while pregnant or when her infant is very young, the child is more likely to go on to develop asthma.

"Asthma is not one disease, it is multiple diseases, which present with a series of one or more components or symptoms which we then designate as asthma," says Dr. Stuart W. Stoloff, a Clinical Professor of Family and Community Medicine the University of Nevada.

What triggers an asthma attack?

Different people have different triggers. Many asthma-prone people develop symptoms after a cold or other virus causes swelling inside the airways. Others develop asthma symptoms during exercise. In this case, the smooth muscles around the airways tighten — which happens more often in cold weather, commonly during running. Some people begin wheezing after exposure to allergens such as grasses or animals. Stress can be a trigger, too.

How is asthma treated?

Asthma is treated with medicines, and also by avoiding common triggers, such as allergens. The goal is to avoid serious attacks by damping down early symptoms. Sometimes avoiding triggers is enough, and a patient can use a "rescue inhaler", usually an albuterol inhaler, to treat the occasional flare-up. If a patient finds they need to use that inhaler frequently, a doctor might prescribe a different daily medicine to prevent symptoms.

"Many of the treatments we use are not because you're symptomatic today, but because there's a risk of a bad outcome if you don't treat it," explains Stoloff.

What kinds of asthma medicine are there?

The most common kind of "rescue inhaler" is an albuterol inhaler. This is a bronchodilator that helps open up the airways in the lungs. It provides relief within a few minutes, and lasts for three to four hours.

If the rescue inhaler is needed more than two days a week, or if the patient wakes up more than two nights a month with asthma symptoms, doctors often prescribe a different daily medication to stop symptoms before they start.

The daily medicine most commonly prescribed is a low-dose inhaled corticosteroid. Doses can be adjusted, and other drugs might also be used, if patients continue to have difficulties.

Much higher doses of corticosteroids, taken orally, may also be prescribed when an asthma attack is severe. They are typically used for short periods of time, and only when inhaled corticosteroids have failed to control the symptoms.

Are the steroids used to treat asthma the same ones athletes get in trouble for taking?

No. "Inhaled corticosteroids not the anabolic steroides athletes are taking and getting disciplined for," explains Stoloff. The effects—and side effects—are very different.

Because of the bad reputation that anabolic steroids have earned, some parents of asthmatic children are overly concerned about the risks of corticosteroids, Lemanske says. "But there are risks and benefits with any medicine used for any disease," he explains. "The goal is to have the benefits far outweigh the risks."

Lemanske says the recommended doses of corticosteroids generally used to control asthma symptoms are safe. Doctors do monitor patients for adverse affects if it's necessary to increase the dose to control the symptoms.

What is the best way to use an inhaler?

A spacer – a tube that fits over the mouthpiece of the inhaler – can be very helpful, especially for children with asthma, says Lemanske. The spacer slows the speed of the particles coming out of the inhaler and helps them stay in the air longer, so they can be inhaled deep into the lungs.

Current inhalers, which rely on a less forceful propellant system than in the past, need to be primed to make sure they deliver the proper dose. Lemanske says when the inhaler is new, or hasn't been used for a couple of weeks, patients should shake it well and pump it a few times before each use.

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