Dr. Hensley’s Asthma Primer
Does your kid have asthma? Your grandkid? A kid you babysit for? Your neighbor’s kid? OK, grab a snack and a tasty beverage and settle in. In this post I’m going to cover all the things I want my parents of kids who have asthma to know and understand. This is important because I don’t really take care of patients with asthma, not the day to day care. I make recommendations and prescribe the medicines. I do my best to educate (in a double-booked 15 minute slot with a crying younger sibling in the room). BUT, it’s the moms and dads and grandparents and sitters and teachers who actually treat the asthma and keep these kids healthy. Thus, it is important that these caregivers understand what they’re doing, how to do it right and why, so that these little patients can go to school and play sports and do regular kid stuff without being incumbered by their asthma. More importantly, I would like these kids to stay out of the hospital and in particular not to do something silly like die.
Let’s start at the very beginning, a very good place to start . . .
What is asthma? Asthma is kind of an autoimmune disease. I use the words “kind of” because it is not like other autoimmune diseases where the immune system creates specific antibodies that attack your own tissues (e.g. type I diabetes). In asthma, you can think of the process as an overreaction on the part of the immune system to outside triggers such as allergens (dust, cats, pollens, etc.), infections (usually respiratory viruses), chemicals (perfumes, cleaning products), cold air, etc. These triggers set off an inflammatory cascade in the lungs leading to swelling, excess mucus and fluid production and bronchospasm (more details about that later). The result of all this inflammation is that the lungs can’t do their job and the patient experiences the horrible sensation that they can’t get enough oxygen. You want to know what an asthma attack feels like? For real, if you’re a parent of a child with asthma I want you to actually do this right now. Go get a straw. Breathe through it for a full minute, two if you can stand it. How do you feel? OK good, promise me you’ll never let your household be without a rescue inhaler ever again.
If you want to know all about the nitty gritty details of the inflammatory cascade that causes all this trouble, there are links to more information at the bottom, NERD!
WHY does my kid have asthma? Short answer: I don’t know. Longer answer: it’s complicated. We know that asthma tends to run in families, so having relatives with asthma increases your risk but it’s not an absolute. We also know that there are some environmental factors that increase risk, among them cigarette smoke exposure (even in the womb, including second-hand smoke exposure to pregnant moms), infection with respiratory syncytial virus, growing up in a sterile environment, being born prematurely, etc. There also seem to be some environmental factors that are protective, such as growing up in a household with dogs, living in a clean but not-too-clean environment. Even our microbiome and exposure to parasites may play a roll but this is cutting-edge research so we’re not certain about that yet. For a while we thought that breastfed infants had decreased risk of asthma but this hasn’t panned out in better studies that control for things like socioeconomic status, gestational age, birth weight, etc. Not that breastfeeding isn’t awesome for other reasons, it is. Kids with other atopic conditions are also at increased risk for asthma. Other atopic conditions are seasonal allergies, food allergies, and eczema. The pathophysiology of these other conditions is similar to that of asthma (which is also an atopic condition) and these diseases tend to occur together in the same people.
Is my child’s asthma going to go away? I sure hope so. Many children do eventually outgrow their asthma. Their chances are greatest if they develop the condition prior to the age of 24 months. Their chances are still pretty good if diagnosed before age 5. Older children who develop new asthma are more likely to keep the condition into adulthood. BUT, if managed aggressively and appropriately, we can prevent long-term changes in the lungs and improve their adult quality of life. This is an important point. Ignoring asthma or downplaying the severity of it does not make it go away. It increases the risk that it will persist longer and increase in severity. Parental denial doesn’t do kids any favors. No one wants their child to be sick. No one wants their child to have a chronic illness. No one wants to give their kid medication every single day for years on end. No one wants this. BUT, a child’s prognosis is going to be much better if their caregivers have a good understanding of asthma and the importance of treating it aggressively. This is not the time to try everything BUT medicine first. I may be stingy with the antibiotics but I love me some inhalers.
How do we treat asthma? The treatment of asthma is two-fold. This is because we are addressing two different processes. Asthma comes and goes. I meet parents all the time who believe that because their child only has asthma symptoms once or twice a month, they don’t have asthma. They do. That is the nature of asthma. The goal of asthma treatment is control, that is to minimize the frequency of symptoms. The symptoms of asthma include wheezing (a high-pitched, harmonica-like sound heard with breathing out). Think Wheezy the Penguin from Toy Story 2. Most people think of Darth Vader but actually he’s not wheezing so much as just congested. Bro has a man cold. However, at the end of Episode 6 when he’s dying in Luke’s arms? OK, THERE he’s wheezing. Parents of kids with asthma need to know wheezing when they hear it. Get yourself a cheap stethoscope. If your kid has a cough or is complaining of chest pain or tightness, USE IT. Work with your child’s pediatrician. Practice. Learn what wheezing sounds like and don’t wait until you can hear it with the naked ear. Asthma can also manifest as cough without wheezing. Often there is a wheezing character to the cough. It’s hard to describe in words, but it’s high-pitched and raspy. It will often come in long fits of coughing. This is the time to use our rescue medicine – albuterol.
Albuterol addresses bronchospasm (remember, I told you we’d come back to this). The tubes in your lungs have several layers and the middle layer is made of muscle. In an asthma attack, this muscle is spasming or held in contraction. This takes the space through which air can move down by about 75%. This has a huge effect on the amount of air that can get into (and out of) the lungs. In asthma, the primary problem is actually air-trapping – patients have a harder time getting air OUT than IN so it’s like they’re stuck in inhalation. Albuterol binds to receptors in the muscle tissue in the lungs and tells it to relax, opening the airways back up. It lasts for about 4 hours, so kids having an asthma flare may need to use their rescue albuterol inhaler pretty frequently. There is an alternative to albuterol called levalbuterol (brand name Xopenex) that some patients use because they cannot tolerate the side effects of albuterol (increased heart rate, anxiety). Most albuterol inhalers are prescribed as 2 puffs every 4 hours but you can typically adjust the number of puffs depending on the severity of the flare. Talk to your child’s doctor about this. Ask for an asthma action plan. Keep it on your fridge. Keep one on grandma’s fridge. Give one to the school nurse. If you’re using the albuterol as prescribed and your child is still having symptoms, it’s time to pick up the phone and call. This would be one of those totally appropriate 3AM calls so don’t apologize, CALL ME! If a child is experiencing respiratory distress, can’t finish a sentence, becoming lethargic, don’t call me, call an ambulance.
Acute flares may also be treated with oral or parenteral (IV or injected) steroids. These are not the steroids that made the Russian women’s swim team . . . um . . . never mind. These are anti-inflammatory steroids. When the immune system is overreacting and creating all that swelling and fluid and bronchospasm, the steroids calm it back down. These systemic steroids (i.e. they go all over the body) work like a charm, but they can also have some nasty side effects if used long-term. In the short term they tend to make kids hangry (hungry + angry = hangry) – side effects include increased appetite and irritability. In the long term they can affect growth, the endocrine system functioning, increase risk of obesity (if your kid is on a medication that increases appetite for a week once a month . . .), interfere with wound healing, lead to stomach ulcers, etc. I don’t really like putting kids on these medications too often. Don’t get me wrong, breathing is kind of key. If they need steroids, they need steroids. What I would really love is to prevent your child from even needing the steroids in the first place. This brings us to . . . DIFFERENT steroids (inhaled steroids).
Why does my child have to use this other inhaler every day when they’re not sick? Let’s talk about controllers, folks. Controller inhalers are steroids. Your kid is going to take these steroids twice a day every day for probably years. Yes, I know I just said long-term steroids are bad and evil. This is not the same thing. Oral/parenteral steroids go into the blood stream and go cause trouble all over the body. Inhaled steroids stay in the lungs and only act on the mucosal tissues in the lungs (the lining). In asthma, these mucosa tissues become inflamed – they swell (and get in the way of air movement) and secrete mucus and fluid (I’m pretty sure everyone understands that fluid in the lungs is bad). Here’s the thing with asthma – the inflammation can be going on for MONTHS without you realizing it because a child may not have obvious symptoms. Over time, this chronic inflammation leads to changes in the tissues of the lungs. They become less flexible, kind of like scar tissue. This leads to an increase in the risk of adult lung problems like COPD. This is why it is so important to use prescribed controllers consistently. Don’t stop using them just because your child is doing well. They are very safe medications, even in the very long term, and they can vastly improve your child’s quality of life. In the short term, they decrease frequency and severity of symptoms and allow kids to do regular kid stuff like play sports and sing in the show choir symptom-free, without fear that they’ll have an asthma attack out there on the basketball court. Isn’t that what you WANT for your child? To do everything they want to do without their asthma holding them back?
Now, I know it’s hard to remember to take a preventive medicine every day. I know this. SO, we need to talk about strategies for remembering. Ideally you want to have your child brush their teeth or at least rinse their mouth out after using their controller because this medication can cause thrush. Hmmmmm, what else do you make your child do twice a day . . . .OH YEAH, brush their teeth. Keep that inhaler (and a spacer, more on that later) right next to their toothbrush. Use the inhaler first, then brush teeth. Also, do you have a smart phone? Of course you do. You’re probably reading my blog on it right now, aren’t you? Did you know that your smart phone is capable of more processing power than NASA had when it put a man on the moon? Sorry, I squirreled, yeah so your smart phone can remind you to do stuff every day, like use your inhaler. This is a handy strategy for older teens.
The type of controller your child uses and for how long will vary by patient and we doctors make these decisions based on severity of asthma. You know what is SUPER helpful? If parents keep track of how much rescue medicine (albuterol) their kid is going through and report this to me at visits. SO helpful. I like to see my little asthma patients every 6 months if they’re doing well. That’s a minimum. This is because plans change. Asthma follow-up visits aren’t just to refill medications, they’re for me to assess severity and level of control and make changes to the plan accordingly. The whole point of pretty much every visit with me is to shepherd your child safely to adulthood. I’m sorry that coming to see me every 3-6 months to talk about asthma is a pain in the butt. I’m sorry. But you still have to come. So there.
What is the point of this spacer thingy? Speaking of pains in the butt, spacers. That’s that plastic tube thingy with a hole for the inhaler at one end and either a mask or a mouth piece at the other end. The spacer helps get the inhaled medicine where it needs to go, in short. It gets more of the medicine molecules deeper into the lungs than if you just stick the inhaler directly in your kid’s mouth. In small children, there is NO WAY they are going to coordinate their breathing just right and most of the medication will just hit the back of the throat. You want to know what else? Even adults get MUCH better effectiveness from their medications if they use a spacer. So yeah, it looks dorky. You know what looks dorkier (is that a word)? Having to pause while going up a flight of stairs because you’re short of breath. Just use the spacer, OK? NOW, that being said, spacers are ridiculously over-priced. It’s a friggin’ plastic tube and they want to charge you like 50 bucks for it because it’s a medical device. Sometimes docs have samples, so ask. Sometimes you can find coupons on the internet. Check GoodRX, check the manufacturer’s website. We have our ways of getting you a cheap spacer, so ask us.
But what about a nebulizer? Short answer: no. Burn it. Long answer: the inhaler and spacer work better. I know you don’t believe me, give me a chance to explain. A nebulizer treatment is a much bigger dose of albuterol than 2 puffs from an inhaler and if you’re not using a spacer, it’s pretty darn useless. BUT, 10 puffs from an inhaler used with a spacer is about the same dose as a neb treatment and the medicine will penetrate much deeper into the lungs. Can you give 10 puffs at once? Sure you can, but if your kid really needs a dose that big to get the wheezing under control, I need to be hearing from you. Start with 2 puffs. Talk to your doctor about when to give more and what the threshold should be for calling them. Remember that asthma action plan? Ask for it and make someone explain it to you.
Time for more confessions from Dr. Kate – I LOVE it when parents bring in a written list of questions. I LOOOOOOOVE it. It saves both of us so much time, y’all. It saves me having you interrupt me with questions when I have my stethoscope in my ears, it saves me from having to come back in the room when I’m already two patients down the line because you just remembered what you were going to ask, it saves me a lot of phone calls, but you know what, all that doesn’t even matter. It means that you ACTUALLY GET ALL OF YOUR QUESTIONS ANSWERED AND YOU KNOW WHAT TO DO TO CARE FOR YOUR CHILD! THAT’S AWSOME! Pleeeeeeeese, bring a list. Lists are my favorite.
Do you have more questions? Asthma is complicated. It may take several conversations with your doctor and a lot of reading before you feel comfortable with all this. You know what? That’s OK. Most children’s hospitals have certified asthma educators who will go over this stuff with you as many times as you need so ask your pediatrician about finding one. Sometimes your insurance company can hook you up with these kinds of resources, so call them too. If I can emphasize one take-home point here it’s that when it comes to asthma, aggressive treatment is good. Using those controllers every single day is important. Get over that instinct that medicine is bad, find a way to make yourself remember and use your controller. If you have an older child or teen, do not expect them to remember. They won’t. You have to remind them. Yes, every day. It’s important.
A Word On Flu Shots:
I’m gonna confess again. You know what makes me see red? Try it and watch closely, you’ll see my cheeks actually flush and my pupils actually dilate. If your child has asthma and I offer you a flu shot for them and you decline, I may have to take a moment to repress the urge to screech like a velociraptor. Children with asthma are at dramatically increased risk of serious illness and death if they contract influenza. Will the shot keep them from getting the flu? About 60% of the time, but that’s not really the point. The real benefit is to keep them from dying of the flu. It will keep them from ending up in the PICU on a breathing machine. Every child with asthma needs a flu shot every year. So do their household contacts, teachers, nurses, daycare workers, grandparents, etc. Get them a flu shot, get yourself a flu shot, get your other kids their flu shots. If your spouse refuses to get one, bring them to see me because I have some words I’d like to say to them. Go read my flu shot post. If you are my patient and you still don’t feel good about giving your kid a flu shot, we need to talk about this. I have lost patients to the flu. I have never seen a serious reaction to a flu shot. GET ONE! EVERY YEAR! DO IT! Thank you.
- Kids Health Asthma Center for Parents – http://kidshealth.org/en/parents/center/asthma-center.html?ref=search
- What is Asthma? – https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/What-is-Asthma.aspx
- Managing Asthma – https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Managing-Asthma.aspx
- Asthma Management at School – https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Asthma-Management-at-School.aspx
- Is My Child Going to Develop Asthma? – https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Asthma-Predictive-Index.aspx
- Tell Me More About These Medicines. – https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Medications-Used-to-Treat-Asthma.aspx
- What Is the Scientific Evidence to Support This Advice You’re Giving Me? – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831604/
- The Clinician’s Cheat Sheet – https://www.aap.org/en-us/Documents/medicalhome_resources_keypointsforasthma.pdf
- More About That Inflammatory Cascade, You Nerdy McNerd Face
- On Flu Vaccine Efficacy – https://www.cdc.gov/flu/about/qa/vaccineeffect.htm