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Asthma and Wheezing

What is Asthma?

Asthma is an inflammatory disease of the lungs that is characterized by recurrent cough and wheeze. If you were able to see inside the airways (bronchial tree) of a child with asthma, you would see redness, inflammation, and sticky mucous. There are tiny muscles in everyone's airways. When the overly sensitive airways of a child with asthma become irritated, these muscles constrict. This constriction, inflammation, and mucous production lead to the cough and wheeze associated with asthma.

What are the symptoms of asthma?

There are a lot of misconceptions about what symptoms constitute asthma. When many people think about asthma, they picture someone who has episodes of extreme breathing difficulty (commonly referred to as asthma attacks). Patients with asthma can have such asthma attacks, but that is really the most severe manifestation of asthma. For most children, the symptom that parents notice most is COUGH. Parents may hear an audible wheeze with their child's breathing. Often, however, a parent cannot tell if his child is wheezing. It really takes a physician listening to your child's lungs with a stethoscope to diagnose wheezing. Deep, frequent, and persistent coughing is often your only clue that your child is wheezing or having asthma symptoms. If asthma symptoms worsen and progress, the patient will start to have fast, difficult, or labored breathing. You may notice that your child's belly is moving up and down with breathing, or that you can see the outline of your child's ribs prominently as he breathes. Older children may be able to tell you that their chest hurts or feels "tight". Obviously, cough is a common symptom present in many other illnesses, so if your child is coughing excessively, for a prolonged period of time (generally longer than two weeks), or recurrently, please contact our office.

When should I suspect that my child may have asthma?

  1. Most children are able to get over viral colds in 10-14 days. Sometimes a cough may persist for another one to two weeks with a particularly bad virus. If your child consistently has trouble "getting over" colds, coughs more than most children when he has a cold, or always seems to take longer than other family members to get over the same cold, your child may have asthma.
  2. Children should not cough frequently if they are not sick. If your child consistently coughs with vigorous activity or while playing sports, or coughs at night when he is not sick, your child may have asthma.
  3. Recurrent wheezing that responds to breathing treatments such albuterol is almost always asthma. Infants and toddlers can have wheezing due to bronchiolitis (a viral lung infection) without having asthma. The main difference is that bronchiolitis typically does not respond to a bronchodilator such as albuterol, whereas asthma ALWAYS responds to albuterol if given in sufficient doses.
  4. Asthma runs in families. Therefore, if one family member has asthma or needs asthma medications such as inhalers, it is more likely that relatives will be affected as well. Also, children who have a personal or family history of nasal allergies or eczema are more likely to develop asthma.

How is asthma diagnosed?

In young children and infants, there is no easy or definitive test to determine who has and does not have asthma. Therefore, in young children and infants, asthma is a diagnosis based primarily on clinical history and symptoms. Generally, an individual who has recurrent wheezing that responds to bronchodilators and other asthma treatments has asthma. For older children (~7 years or greater), asthma can be diagnosed based on a breathing test. This is often done only if the diagnosis is unclear based on the clinical symptoms or lack of response to therapy.

Some children who have asthma do not wheeze, or they wheeze infrequently. For these children, the only symptom may be cough. This is called cough variant asthma. This type of asthma is more difficult to diagnose, because the wheeze is not there as the clue to diagnosis. This diagnosis is established based on response to therapy. If a child has a constant or recurrent cough that resolves with asthma inhaler therapy, then cough variant asthma is the likely diagnosis. If a child does not improve with asthma therapy, then another cause for the cough should be pursued.

What 'triggers' asthma symptoms in an individual with asthma?

Individuals with asthma have sensitive airways. When those sensitive airways get irritated, inflammation and broncho-constriction (wheezing) results. There are many things that can trigger asthma symptoms in an individual with asthma, and many asthmatics have multiple triggers.

  1. Viral Respiratory Infections: This is the most common asthma trigger, especially in younger children and infants. Often, these children don't have any symptoms in between colds, but then wheeze and cough for prolonged periods of time when they get a cold.
  2. Allergens: This includes indoor allergens such as mold, pet dander, and dust mites, and outdoor seasonal allergens.
  3. Environmental Pollutants and Cigarette smoke: Second hand cigarette smoke is devastating to a child with asthma. Smoking outside to limit exposure is not enough. We know that stopping smoking is extremely difficult, but we strongly recommend that parents of children with asthma quit smoking.
  4. Exercise or vigorous activity: This may be the only trigger, or asthma triggered by other causes may be made worse with vigorous activity.
  5. Cold air

How is asthma treated?

Asthma treatment has come a long way in the past 20 years. Properly treated, patients with asthma are able to lead normal, active lives (including participating in high level sports) with minimal or no symptoms.

Treatment for asthma involves two different types of medications:

  1. Quick acting rescue medications: examples include albuterol (brand names Ventolin, Proventil, and ProAir), and levalbuterol (Xopenex).

    Rescue medications are given by inhalation, either by an inhaler or nebulizer. Rescue medications work quickly to open up the airways when a patient is coughing, wheezing, or having difficulty breathing. These medications are essential in asthma management to control acute symptoms caused by airway constriction (wheezing). However, these medications are only treating the symptom (wheezing) and not the underlying cause (inflammation). These medications tend to wear off in 4-6 hours, or even sooner with more severe symptoms.

  2. Anti-inflammatory medications: examples include prednisone and prednisolone (brand name Orapred), montelukast (Singulair), and steroid inhalers or nebulizers (brand names Flovent, Pulmicort, Advair, and Qvar, among others).

    These medications are used to treat the underlying inflammation present in asthma, and thus the root cause. These medications can be given orally (by mouth), via inhaler, or nebuzlier.

    Oral Steroids (such as prednisone or prednisolone (Orapred): Steroids given orally work fast, typically within hours to 1-2 days, to decrease inflammation. They are typically given in 3-7 day 'bursts' for active asthma exacerbations. Parents are understandably concerned about giving steroids to their children. Although oral steroids have many undesirable side effects, these side effects are only experienced if oral steroids are taken for more than two weeks. In the short term (less than 2 weeks) side effects that can be expected include stomachache, increased appetite, and behavioral changes.

    Inhaled Steroids (such as Flovent, Pulmicort, and Qvar): Inhaled steroids can be safely given daily for asthma maintenance control. Because the medication is only going to the lungs (where it is needed) and not to the rest of the body, none of the long-term side effects of oral steroids are experienced. There have been exhaustive studies demonstrating that inhaled steroids given daily are safe and effective, and are considered first line therapy for asthma maintenance. These medications generally take a week or more to reach maximal effectiveness. One should NEVER attempt to use these medications in place of a rescue inhaler for acute symptoms. Because these medications work slowly, we will often start patients on a 3-7 day oral steroid "burst." When the oral steroid is finished, we will often then start an inhaled steroid to safely continue daily anti-inflammatory maintenance therapy.

    Montelukast (Singulair): Singulair is an oral medication that is often prescribed to treat asthma as well as allergic rhinitis (nasal allergies). Singulair is an anti-inflammatory medication, but it is NOT a steroid, and can be given daily without appreciable side effects. This medication is either given alone for mild asthma, or as an additional therapy to an inhaled steroid in more significant disease.

    Fluticasone/salmeterol (Advair): Advair is an inhaler that combines an inhaled steroid with a long acting bronchodilator. It is generally used in patients that need a step up in therapy from a steroid inhaler.

If your child is diagnosed with asthma, your doctor will work with you to create an Asthma Care Plan. The goal of treatment is to minimize or eliminate asthma symptoms with the least amount of medication necessary. This will be different for each child, and can change over time. It is therefore necessary to re-evaluate any child with asthma several times per year to review his individual plan.

It is often difficult for parents of children with asthma to know how to correctly treat and manage their child's asthma. It does get easier with time, and many children do outgrow their asthma. Please call our office at anytime if you need advice in caring for your child if you think he has asthma, or if his asthma seems to be flaring up.