Pediatric Asthma Guide Booklet. Allergy and Immunology Awareness Program (AIAP)

Transcription

1 Pediatric Asthma Guide Booklet Allergy and Immunology Awareness Program (AIAP)

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3 Pediatric Asthma Guide Booklet Prepared by: Dr. Mehdi Adeli, MD, FAAAAI, FAP Senior Consultant, Allergy and Immunology Assistant Professor Well Cornell Medical College-Qatar Allergy and Immunology Awareness Program (AIAP) Pediatrics Department Hamad Medical Corporation Doha, Qatar

4 Introduction This booklet was prepared as part of the Allergy and Immunology Awareness Program (AIAP), is intended to provide information to the families of children with asthma. Our goal at the AIAP: To teach patients and families how to manage asthma, so that they can lead healthy and productive lives. For more information, please write to us at: We look forward to receiving your feedback. Prepared by: Dr. Mehdi Adeli, MD, FAAAAI, FAP Senior Consultant, Allergy and Immunology Assistant Professor Well Cornell Medical College-Qatar Allergy and Immunology Awareness Program (AIAP) Pediatrics Department Hamad Medical Corporation Doha, Qatar

5 Table of Contents Lung function 02 Asthma Definition 03 Developing Asthma 06 Diagnosing Asthma 07 Treatment Goals 09 Asthma Triggers and How to avoid them 10 Considering Allergy Shots (Immunotherapy) 16 Exercise-induced Asthma 18 Obesity 20 Infections 20 Does Changing the House Location Help? 22 Nocturnal Asthma 24 Medication Therapy 25 Useful Advice for Memorizing Medications 26 Long-Term Control Medications 27 Quick Relief Medications 29 Routine Steroids 30 Monitoring Asthma Symptoms 37 Using an Asthma Action Plan 40 Living with Asthma: 44 Schooling 44 Disciplining an Asthmatic Child 45 Counselling 46 Diet 46 Sleeping 48 Vaccinations 50 Patient Education Checklist 51 Easy Illustrations: 52 Use Metered Dose Inhalers (MDIs) with a Spacer 52 How to Use Your Dry Powder Inhaler (DPI) 54 How to Use a Peak Flow Meter 56 Epilogue 58 References 58

6 How do the lungs work? The lungs are part of a group of organs and tissues called the respiratory system, that all work together to help you breathe. Oxygen, a gas, is needed by every cell in the body to live. The air that comes into the body through the lungs contains oxygen. In the lungs, the oxygen is moved into the blood and carried through the body. At each cell in the body, the oxygen is replaced with carbon dioxide. The blood then carries carbon dioxide back to the lungs where it is removed from the body by breathing out. This important process happens automatically by the lungs. Respiratory System Air enters through the nose or mouth and passes downward to the trachea (windpipe).the trachea is the passage leading from the throat to the lungs. The trachea divides into the two main bronchial tubes, one for each lung, which then subdivide into each lobe of the lungs. These divide further into the smallest parts of the bronchial tubes called bronchioles and end at the alveoli (air sac). 2 Pediatric Asthma Guide Booklet

7 What is the definition of Asthma? Asthma is a chronic respiratory illness, occasionally troublesome and difficult, but a manageable disease. With understanding, good medical care and monitoring, families can keep asthma well controlled. If your child has asthma, he or she is not alone. In Qatar, asthma affects around 20% of children in school age and, in the United States, it affects 22 million people. It is the most widespread chronic childhood disease. Asthma, also known as reactive airway disease, is defined as a chronic lung condition with: Inflammation (swelling) of the airways Increased sensitivity of the airways to a variety of things that make asthma worse Obstruction of airflow Pediatric Asthma Guide Booklet 3

8 Characteristic changes in the airways consist of: Inflammation Research has revealed that inflammation of the inside layer of the airways is the most common characteristic of asthma. When they are stimulated, certain cells facing the airways release chemical substances (mediators), which lead to inflammation. This causes the airway lining to swell up and narrow. The inflammation may last for weeks subsequent to the incident. The majority of patients with asthma have some level of inflammation all of the time. Longterm control treatments can help avoid and decrease inflammation. Amplified Sensitivity An extra feature of asthma is increased sensitivity of the airways. Once inflammation occurs in the airways, the airways turn out to be more sensitive. When the airways are more sensitive, the patient is more likely to have asthma symptoms when exposed to materials that affect asthmatics. When there is less inflammation, the airways are not as sensitive and the patient is less likely to have symptoms of asthma when exposed to things that can make asthma worse. Airway Obstruction In addition to inflammation, airway obstruction occasionally occurs with asthma. Obstruction is caused by the contraction of muscles that encase the airways. This is also called bronchospasm. Bronchospasm adds to the narrowing of already swollen airways. Inhaled rapid relief medications are usually very successful in reversing the bronchospasm. In some children with asthma, the mucus glands in the airways produce too much mucus, promoting further obstruction. 4 Pediatric Asthma Guide Booklet

9 Normal Airway Airway with inflammation, bronchospasm, and mucus production Image: Pediatric Asthma Guide Booklet 5

10 How does Asthma develop? The cause of asthma is unidentified. However, it is well known that more children develop asthma if they have allergies or if one or both of their parents have asthma or allergies. Asthma symptoms can develop at any age. How each child is affected can vary with age. The airways of an infant/toddler are more easily obstructed because of their smaller size. This age cluster can therefore be prone to more obvious symptoms. As the child grows, these symptoms might decline. Most families do not experience longterm physical effects of asthma. But, constant and poorly-controlled asthma may have a prohibiting effect on growth and may result in reduced lung function as an adult. As with any chronic disease there may be an emotional effect on children with asthma. Emotions such as annoyance, anxiety, depression, hopelessness and guilt may be experienced. 6 Pediatric Asthma Guide Booklet

11 Diagnosis of Asthma The initial step in diagnosing asthma is a good assessment. In many cases, an asthma diagnosis is made based upon the child s history and symptoms at the time of assessment. Younger children may experience recurrent episodes before an actual diagnosis of asthma is made. The family history is also taken into consideration, as this increases the child s probability of having asthma. Tests: To be entirely certain that asthma is the diagnosis, following a careful physical examination, the physician will need to do a number of tests to evaluate breathing. These may include: Spirometry (breathing tests) Chest X-rays Skin tests The doctor may order other tests based on the history and physical exam. When to run tests: We recommend referring patients to an asthma specialist (allergist, immunologist or pulmonologist) if any one of the following occurs: Severe asthma attack Several visits to the hospital or emergency room in the last year Conditions that complicate asthma such as chronic sinusitis, nasal polyps or vocal cord dysfunction Frequent treatment with steroid tablets or syrup Uncertainty with the diagnosis Allergies are being considered Asthma seems to be getting worse Poor response to medicine. The initial step in diagnosing asthma is a good evaluation. Pediatric Asthma Guide Booklet 7

12 It is important to ask the doctor for: His/her philosophy about asthma and its treatment. Time to explain what is happening with your child, and provide education. An asthma action plan to treat an asthma episode. In evaluating your child s improvement, keep in mind that asthma is a chronic disease, which will vary in course from time to time. If you think that your child is not making improvement with his or her existing management, talk to your doctor regarding your concerns. If things are not progressing as you would like, you should not feel uncomfortable about asking for a different opinion. Come to your appointment prepared with the questions you want to ask your child s doctor. It is also OK to ask for a second opinion when needed. 8 Pediatric Asthma Guide Booklet

13 Treatment Goals Your child should be able to: Contribute to activities, including physical activity without asthma symptoms Sleep through the night without asthma symptoms Have normal or near normal lung function Have few, if any, emergency room visits and hospitalizations Have few, if any, side effects from the medications taken Feel good about his or her asthma care Asthma management includes: Knowledge and understanding about your child s asthma Recognizing and commanding and/or treating things that make asthma worse Medication therapy Monitoring asthma Asthma action plan There is no cure for asthma. However, you can become skilled at managing it so that your child has an ordinary life. With well controlled asthma, you can often change asthma from a major troublesome issue to a moderately unimportant annoyance. Pediatric Asthma Guide Booklet 9

14 Identifying what trigger asthma attacks and how to avoid these triggers Patients with asthma might have airways that are constantly inflamed. So, the airways are more sensitive to things that contribute to asthma symptoms. These, either individually or together, are root causes of asthmaattacks in children. Recognizing and controlling or treating things that make asthma worse, is vital to excellent asthma management. Factors that can make asthma worse include: irritants, allergies, exercise, infections, sinusitis, weather, emotions and gastro esophageal reflux. These differ from child to child. Controlling and/or treating multiple factors that make asthma worse is the desired outcome. Avoidance of just one of the factors is often not sufficient. Irritants A myriad of substances are able to irritate the nose, throat or airways. Widespread irritants consist of smoke (tobacco smoke), aerosol sprays, strong odors, dust, and air pollution. Cigarette smoke is one of the most frequent irritants and is a main contributor to asthma symptoms. Recommended actions Smoking should be prohibited in the home or car with a child who has asthma. If you smoke, try to quit smoking. Ask the doctor about techniques that are supportive. Avert smoke exposure in the child s school or day care setting Look for non-smoking sections in public areas Shun aerosol sprays, perfumes, strong cleaning products and other smell sources in the home. Clean when your child is not home. Lots of substances can irritate the nose, throat or airways. Cigarette smoke is a key contributor to asthma symptoms. 10 Pediatric Asthma Guide Booklet

15 Allergies Although not all children with asthma have allergies, and not all children with allergies have asthma, allergies can make asthma worse. In children with allergies, the immune system becomes more sensitive to usually risk-free substances identified as allergens. Widespread allergens are generally comprised of pollens, mold spores, animal dander from feathered or hairy animals, dust mites (a major component of house dust in humid climates) and cockroaches. When people who have allergies come into contact with the allergen, their body makes chemicals that aggravate the inflamed airways and directly impact symptoms. Though many of these actions are for the whole home, preventative action in the bedroom is the most important, since the bedroom is where children generally spend 30-50% of their time. Pollens Pollens from trees, shrubs, grasses and weeds can cause allergy symptoms. Pollen may travel many miles. Therefore trees, grasses and weeds in your general area can cause allergy symptoms. Recommended actions Windows and outside doors should remain closed throughout pollen season, especially during the daytime. Allergy symptoms might comprise runny nose, asthma symptoms, itchy eyes, skin problems (eczema) and/or a rash. Depending upon your child s medical and family history, age and environment, allergy testing may be suggested. We advocate that testing be done under the regulation of an allergist. In the majority of cases, skin testing for allergens is favored to blood tests. Recognizing if your child is allergic, and what they are allergic to, can help you take preventative action in your home to reduce contact to these allergens. Pediatric Asthma Guide Booklet 11

16 Mold Spores Mold can rise in humid areas of the house, such as the kitchen and bathroom. If your child is allergic to mold, take measures to reduce mold growth. Recommended actions Use an exhaust fan in the bathroom or open a window to get rid of humidity following showering. Wipe down surfaces following showering. Clean bathrooms with a mold-preventing or mold-killing solution. Use an exhaust fan in the kitchen to remove steam vapor when cooking. Throw away spoiled foods. Empty the trash on a daily basis. Keep indoor humidity low. The ideal humidity level is percent Air conditioning can help decrease humidity. Animal Dander Animal dander (dead skin that is persistently shed), urine, feces and saliva from feathered or furry animals can cause allergy symptoms. Cats, dogs, birds, rodents (hamsters, gerbils) and horses are common examples of feathered or furry animals. If the patient s home doesn t have a feathered or furry pet, it s advisable to not obtain one because your child can develop allergies with frequent contact. 12 Pediatric Asthma Guide Booklet

17 Recommended actions Remove pets from your home environment. If a pet is a must, keep it away of the allergic person s bedroom at all times. Ensure the child s bedroom door closed and put a filter over air vents in the bedroom. Keep the pet away from upholstered furniture and carpet as much as possible. Avoid visits to friends and relatives who have pets, where feasible. Consult your doctor about using an inhaled medication prior to visiting a home with a pet. Select a pet without fur or feathers. Fish can be good pets. House Dustmites Dust mites are insects, not able to be seen with the naked eye, that survive in bedding, carpets, stuffed furniture, old clothing and stuffed toys. They survive primarily on human dander. Dust mites are common in humid climates. Recommended actions Surround the mattress and box springs in a zippered dust-proof encasing. Dust-proof encasings have a layer of material that keeps the dust mites inside. Wash all bedding in hot water (130 F around 50 C) weekly. Place pillows in zippered dust proof encasings and/or wash the pillows weekly with the bedding. Do not use a humidifier or evaporative (swamp) cooler Keep the indoor humidity below 50% Keep stuffed toys out of the bedroom or wash them weekly in hot water Pediatric Asthma Guide Booklet 13

18 Cockroaches Cockroach allergies are common in inner cities and humid areas. Recommended actions Keep food out of the bedroom. Keep food and garbage in closed containers. Discard spoiled food immediately. Empty the garbage daily. Use poison baits, boric acid or traps to control cockroaches, and keep these out of children s reach. If chemical sprays are used, the home should be well ventilated and the child with asthma should stay away from home until the smell dissipates. Allergies can make asthma worse, although not all children with asthma have allergies, and not all children with allergies have asthma. Knowing if your child is allergic, and to what, can help you take appropriate measures in your home to decrease exposure to these allergens. 14 Pediatric Asthma Guide Booklet

19 Devices for Allergy Control The events described above are first line actions to manage allergy exposure: Air filtration systems In addition to first line actions, air filtration systems can also assist some children by diminishing the presence of allergens. An appropriate air filtration system should be selected and correctly maintained. Purchase such equipment only if your doctor advises that it will be beneficial. Air conditioning Central or room air conditioning may decrease the amount of airborne allergens by making it easier to keep windows and doors closed in hot weather. This may be useful for children with pollen and outdoor mold allergies. Central air conditioning also has the advantage of lowering the humidity within the home. This is useful in controlling mold and house dust mites. Portable air conditioner Pediatric Asthma Guide Booklet 15

20 Humidifiers, vaporizers, and evaporative (swamp) coolers The use of humidifiers, vaporizers and evaporative coolers is not recommended in the homes of children with asthma. All three raise the humidity level in the home creating a perfect setting for house dust mites and mold growth. If you must use any of these devices, clean them regularly. Allergy Shots (Immunotherapy) If the patient is allergic, procedures to avoid exposure are recommended. This can be hard if the patient is allergic to pollens, molds and dust mites. Allergy medications, including prescription nasal sprays and antihistamines, can help control symptoms. If actions to avoid exposure and medications are not effective, allergy shots can be considered. Allergy shots have been shown to decrease symptoms associated with pollens, certain molds, dust mites and animal dander. Allergy shots should be given in the health care center / hospital, where trained staff can manage any lifethreatening reactions. Allergy shots 16 Pediatric Asthma Guide Booklet

21 consist of a series of injections with solutions containing the allergens. The purpose is to decrease your child s sensitivity, which in turn reduces symptoms. Treatment usually begins with shots of a weak solution given once or twice a week, with the strength gradually rising. When the strongest dosage is reached, the shots are usually given on a monthly basis. Allergy shots do not produce a direct outcome. A period of six months to one year may be necessary prior to improvement being seen. A normal path of treatment for the shots is three to five years, although some children with asthma may benefit from a longer course. Not everyone responds well to this treatment. The cause of asthma is unknown. However, we know children are more likely to develop asthma if their parents have asthma or allergies. Pediatric Asthma Guide Booklet 17

22 Food Allergies Food allergies seldom cause asthma symptoms to get worse. Common food allergies consist of nuts, eggs, milk, seafood and peanuts. Food allergies are more common in children ages five and below. If certain foods are assumed to trigger troubles, they can be removed from the diet. But, it is extremely essential that diet changes be made only when there is strong proof that these foods are causing problems. If food allergies are a worry, the case should be evaluated by certified allergist/immunologist. This specialist can associate the information from a comprehensive diet history, allergy (skin) testing and food challenges, if required. However, fundamental changes in diet should not be based on skin testing alone. This is because it is possible for a child to have a positive skin test to food although it is not playing a role in causing symptoms. Exercise Exercising can exacerbate asthma. Symptoms may comprise coughing, wheezing, shortness of breath or a feeling of chest tightness during or after exercise. Some children are not conscious of these symptoms, but identify that they exhaust easily and cannot exercise to the degree that their friends do. In the majority of children with asthma, protracted exercise (at least five minutes) almost always causes asthma symptoms. In spite of this, children with asthma should be encouraged to exercise. Research shows that they can benifit to a great extent from exercise - physically and in terms of self-esteem and selfbelief. Contribution in swimming, soccer, bowling, basketball, rollerblading and Research shows that children with asthma can benefit from exercise. 18 Pediatric Asthma Guide Booklet

23 bike riding are only some of the activities children with asthma can benefit from. It is uplifting to realize that even some olympic athletes have asthma. Recommended actions If exercising exacerbates your child s asthma, consult your doctor. Your child may need extra inhaler medication, which prevents exercise induced asthma. Short acting B agonist, when taken minutes before exercise, is effectual in preventing asthma symptoms. Older children may depend on using a pre-treatment before exercise. Patients with exercise-induced asthma need to learn to decide when they are having asthma symptoms during or after exercise. If coughing or wheezing begins, the child should take a short rest and follow their asthma action plan. The patient should warm-up before exercise. It is vital that children become skilled at pacing themselves. Pediatric Asthma Guide Booklet 19

24 Obesity Medical literature has revealed associations between obesity and asthma. This extends to the development of asthma and possibly, the severity of the disorder. Moreover it is difficult to determine if a child s breathing issues are a consequence of obesity itself and/or asthma. Consequently, a management program to decrease weight in obese children is recommended in order to gain better control of asthma. Infections The cold and flu season can be hard for children with asthma. An upper respiratory infection, even a common cold, can make asthma worse. Viruses are the most common causes of upper respiratory infections. Antibiotics do not have an effect on the virus or the related inflammation. They are not typically indicated except where a bacterial infection manifests. Recommended actions Hand washing has been proven to be the most efficient way to avoid the spread of the common cold. This is particularly useful to protect against close contact in the home, school and day care center. Alcohol based gels also provide efficient protection. Influenza and other flu-like sicknesses augment and extend asthma symptoms. Your physician may advocate an annual influenza flu injection. 20 Pediatric Asthma Guide Booklet

25 Sinusitis Sinuses are part of the upper respiratory structure. Very young children have sinus routes rather than entirely formed sinuses. The skulls in older children have four groups of sinus cavities. Lots of children with asthma have chronic sinusitis as well. Sinusitis is an inflammation of the mucus membranes that line the sinus cavities. This can impede normal sinus drainage and cause increased mucus production. The drainage from the nose and sinuses is recognized as postnasal drip. Sinusitis can make asthma worse, particularly at nighttime. A sinus infection can significantly worsen asthma as well. This kind of upper respiratory infection can require treatment with an antibiotic. Recommended actions Sinus care is a vital element of an overall management map for lots of children with asthma. Treating the inflammation and decreasing the post-nasal drip can decrease cough and throat annoyance, and decrease asthma symptoms. Sinus treatments usually comprise of: Nasal irrigation (wash) saline solution with positive pressure to clean the nasal passages thoroughly, helps remove mucus and bacteria from the nose and sinuses. It can decrease post-nasal drip, when it is done routinely. For the best results nasal wash should be done prior to using a steroid nasal spray. Steroid nasal spray this assists in reducing irritation and inflammation in the nasal and sinus cavities. As a result mucus production and inflammation diminish. Antibiotics an antibiotic might be suggested if a bacterial infection is present. Pediatric Asthma Guide Booklet 21

26 Emotions Asthma can t be caused by emotions. However, emotions can make asthma worse in asthmatics. Strong emotional feelings such as anger, panic and stress can affect changes in breathing patterns. In asthmatics with airway sensitivity, this can make asthma symptoms worse. Uncomplicated reactions such as laughing or crying can also cause asthma symptoms. Excellent asthma management can reduce the consequence of emotions. If an asthmatic in your family is suffering from depression or has long-term emotional issues, it is vital that you consult your doctor for additional support. Weather Asthma symptoms sometimes arise with changes in the climate. However, there is no one type of environment which is bad or good for all children with asthma. Cold winter days may be hard for children who are sensitive to cold air, but the winter can be helpful for those with pollen allergies. Does changing the house location help? There is no ideal place for children with asthma to live. Occasionally moving may appear to provide a respite in asthma symptoms. This may be due to different weather, or evading of certain allergens or other unidentified factors. Frequently, moving provides only brief or no enhancement, and it is extremely hard to predict. Consult your physician regarding the factors that worsen your child s asthma and create a management plan to keep their asthma under control. Then, if you think moving will help, discuss this option with your doctor. Keep in mind, there is no assurance that your child s asthma condition will improve as a result. 22 Pediatric Asthma Guide Booklet

27 Gastro esophageal reflux (GER) GER is usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the lower esophageal muscle/sphincter, which normally holds the top of the stomach closed. When this muscle does not work correctly, it allows some back flow of stomach acid into the esophagus, which may cause a stomach ache. This acid may also cause a reflex response that can result in asthma symptoms. Asthma symptoms and heartburn, particularly at night, can indicate GER. Recommended actions Elevate the head of the bed to level of 30 degree. Keep away from food or liquids 2-3 hours before bedtime. Medications can be given to help avoid GER. Pediatric Asthma Guide Booklet 23

28 Nocturnal Asthma Asthma symptoms frequently occur at nighttime. Various factors can influence symptoms including: Contact with allergens in the bedroom, mainly dust mites. Late allergic reaction, which may take place three to eight hours after exposure. Chronic sinus issues and/or postnasal drip. Gastro esophageal reflux. Airway cooling from a fall in body temperature at night. Medications wearing off in the early morning hours. Sleep apnea-short, recurring pausing of breathing during sleep caused by an upper airway obstruction. Recommended actions Lots of children experience a deterioration of their asthma symptoms at night. Treatment of root causes is vital. Overcoming allergen exposure in the bedroom, treating sinusitis and/or post-nasal drip and gastro esophageal reflux are central for managing nighttime symptoms. Your child s medications may need to be adjusted to give additional protection all through the night. Keep in mind, your child should be able to sleep during the night with no asthma symptoms. Many asthmatics experience a deterioration of their asthma symptoms at nighttime. Management of root causes is vital. 24 Pediatric Asthma Guide Booklet

29 Medication Therapy Although there is no cure for asthma, there are a variety of asthma medications that can lead to fewer asthma attacks and less frequent symptoms. The appropriate use of asthma medications allows people with asthma to lead more active lives. Research has provided an enhanced understanding of how the airways can become inflamed and the cellular mechanisms at work that affect it. This has resulted in better management of asthma. Depending on the severity of the patient s asthma, medications can be given on an as-needed basis or on a regular basis to avoid or reduce breathing difficulties. Most children with asthma benefit from preventive treatment because this decreases the inflammation in the airways and the likelihood of developing chronic asthma. This gives constant defense even if there are no obvious symptoms. For many children, a collection of medications is given. Most existing medications are inhaled. When the correct technique is being used, medication enters straight into the airways. This usually produces fewer side effects than oral treatments (tablets or syrups). With a few children, oral treatments may also be prescribed. There is no one ideal drug regimen for everyone. Medication programs must be directed to every individual patient s needs. Monitoring a patient s asthma and collaborating with the child s doctor on a constant basis is the best way to make sure that the medication program is suitable for the asthmatic. Medications generally prescribed for children with asthma There are two general categories of asthma medicine: Long-Term Control Medications Quick-Relief Medications Long-Term Control Medications Long-term control medications are prescribed to be used every day to control asthma and avoid asthma symptoms. Pediatric Asthma Guide Booklet 25

30 Quick-Relief Medications Quick-relief medications are prescribed to be used in treating asthma symptoms or asthma exacerbations (attacks). Useful Advice for Memorizing Medications Apply a daily schedule for remembering your child s medications. Select something your child does every day, for example, combing hair, eating meals or watching cartoons. Plan to give medications around the same time. Create medication checklist or worksheet to record when your child takes medications. Put the checklist somewhere noticeable to use as a reminder. Pack your child s medications in medication boxes to help you remember to give them. 26 Pediatric Asthma Guide Booklet

31 Long-term Control Medications Long-term control medications are used on a daily basis to keep control of asthma and avoid asthma symptoms. The patients need to continually take these medications even when their asthma seems improved. Inhaled Steroids Long-term control medications are prescribed to be used every day to control asthma and avoid asthma symptoms. Common inhaled steroids include: Flixotide (fluticasone) Pulmicort (budesonide) QVAR (beclomethasone) Asmanex (mometasone) Alvesco (ciclesonide) Acerobid, Acerobid-M (flunisolide) They reduce swelling inside the airways and may also decrease mucus production. Some can increase lung function and have also been shown to reduce the necessity for oral steroids and hospitalization. Some parents have concerns about the use of corticosteroids suppressing growth in children. Studies do not support this theory and have shown no growth inhibition in users, even over several years of treatment. Inhaled steroids are taken on a regular basis and cause few, if any, side effects in normal doses. Using a spacer with inhaled steroids (metered-dose-inhaler) and rinsing mouth after inhaling the medication decreases the risk of thrush. Thrush, a probable side effect, is a yeast infection causing a white staining of the tongue. Leukotriene Modifiers Common leukotriene modifiers are: Accolate (zafirlukast) Singulair (montelukast) Zyflo (zileuton/not indicated for children under 12 years) Some cells in the airways produce chemical signals called leukotrienes that lead to inflammation in the lungs. The inflammation results in airway smooth muscle contraction and tissue swelling. Leukotriene modifiers are longterm control medications. They decrease swelling and relax muscles around the airways. They are less effective than inhaled steroids. Accolate and Singulair are available for use in children and have few, if any, side effects. They are efficient at improving asthma symptoms and lung function, but not to the same extent as inhaled steroids. Pediatric Asthma Guide Booklet 27

32 Cromolyn Sodium and Nedcromil Intal (cromolyn) and Tilade (nedocromil) are long-term control medications. They are available in inhaled forms. When used regularly, cromolyn or nedocromil help avoid swelling in the airways. Because cromolyn and nedocromil are preventive, they must be taken on a regular basis to be efficient. These medications are not suitable for quick relief. They may be slow to show beneficial effects and may require several weeks before any major improvement is seen. In addition, they are less effective than inhaled steroids and leukotriene modifiers. Inhaled Steroid and Long-Acting Beta-Agonist Common combinations of an inhaled steroid and long acting beta-agonist include: Advair (fluticasone and salmeterol) Dulera (mometasone and formoterol) Symbicort (budesonide and formoterol) This combination is efficient at improving asthma symptoms and lung function. The inhaled steroid aids in preventing and minimizing swelling inside the airways. The long acting beta-agonist opens the air passage to the lungs by preventing bronchoconstriction and relaxing smooth muscle around the airways. They last up to 12 hours. They are often used in combination with inhaled steroids as a long-term control medication to open the airways in people with moderate to severe asthma. Consult your doctor about possible side effects. Immunomodulator Xolair (omalizumab) is a medication prescribed as an injection that intervenes with the function of an immune system antibody called IgE, which tells immune cells to begin allergic reactions. This may bring on symptoms such as coughing, wheezing, nasal congestion, hives and swelling. This medication can be additional to medications in people with severe persistent asthma. Consult your doctor about side effects, and special safety measures to take when using this medication. Theophylline Theophylline is a long-term control medication and relaxes the smooth muscle around the airways. A theophylline blood level should be between 5-15 mcg/ml to relieve symptoms and prevent side effects. Theophylline is not one of the first medications used for long-term control of asthma. There are safer and more successful medicines, such as inhaled 28 Pediatric Asthma Guide Booklet

33 steroids and leukotriene modifiers. Consult your doctor about side effects, and special safety measures to take when using this medication. Quick-relief Medications Quick-relief medications are used to treat asthma symptoms or an asthma attack. Quick-relief medications are not a replacement for long-term control medications. Short-Acting Beta-Agonists Common inhaled beta-agonist include: Ventolin HFA (albuterol) Xopenex (levalbuterol) Short-acting beta-agonists work fast to reduce asthma symptoms. Betaagonists relax the smooth muscle around the airways. Your child s doctor may prescribe a beta-agonist to use as needed to alleviate asthma symptoms. Inform your child s doctor in case your child uses this medicine for asthma symptoms more than twice a week. Also talk with your child s doctor if your child uses more than one metered-dose inhaler a month. This is a sign that your child s asthma is badly controlled and your child s longterm control medication may need to be adjusted. Anticholinergics Atrovent (ipatroprium) is a quickrelief medication. Atrovent opens the airways by blocking reflexes through nerves that control the smooth muscle around the airways. It is slower-acting than the short-acting beta-agonists and can take minutes to demonstrate a significant effect. Atrovent may be useful following an inhaled beta-agonist to get a longerlasting result, especially throughout an asthma attacks. Atrovent is available in inhaled forms. Albuterol and ipatroprium can be combined in one medication Combivent is a combination metered-dose inhaler. DuoNeb is a combination solution for the nebulizer. Steroids Pills Common steroid pills and liquids include: Prednisone Methylprednisolone Prednisolone Steroid tablets and syrups are very efficient at decreasing swelling and mucus production in the airways. They also help other quick-relief medication work well. They are often essential for managing more severe asthma attacks. It is essential to note that the steroids used in asthma treatments are not the same as the anabolic steroids used Pediatric Asthma Guide Booklet 29

34 illegally by some athletes for body building. Corticosteroids do not involve the liver or cause sterility. Steroid Burst Many children with asthma every so often require a short-term burst of steroid pills or syrups to reduce the severity of asthma symptoms and avoid an emergency room visit or hospitalization. A burst may last two to seven days and may not need a slowly declining dosage. For others, a burst may need to carry on for several weeks with a slowly declining dosage. Your child might experience a few mild side effects such as amplified need to eat, fluid preservation, moodiness and stomach upset. These side effects are brief and typically fade away after the medicine is stopped. Routine Steroids A small percentage of children with severe asthma require steroid pills or liquid as part of their ongoing treatment. It is essential that your doctor prescribe a combination of long-term control medications before recommending routine steroid pills or liquid. Steroid pills or syrups alone should not be used to treat asthma! The use of long-term oral steroids may be associated with significant side effects. These may comprise: growth repression, weight gain, fluid retention, osteoporosis, high blood pressure, cataracts, thin skin, easy bruising, muscle weakness, diabetes, or weakened immune system. Not everybody experiences these side effects, but because of the potential danger, longterm steroid pills or syrups should be sustained only when extremely needed. We advocate that any child requiring long-term steroid pills or syrups be under the care of a specialist (allergist or pulmonologist). Steroid pills and syrups can be given in ways that reduce side effects. The lowest possible dosage ought to be used, and it is frequently taken in the morning. It can be prescribed every other day (every 48 hours) to minimize some side effects. Consult your doctor about side effects, and special safety measures take when using these medications. 30 Pediatric Asthma Guide Booklet

35 When using inhalers for Asthma, always remember to use the spacer (Aerochamber) each time so the medicine can reach the lungs in sufficient quantities Pediatric Asthma Guide Booklet 31

36 Recommended Actions: Quick-relief and Controlled Medications When your doctor gives you an asthma medicine, he or she will tell you whether this medicine is a controller or a quick-relief medicine. Contoller Medications: A controller medication is used every day to decrease the inflammation (swelling) that occurs in the airways of patients with asthma. If taken regularly, controller medications can prevent asthma episodes from occurring, or make symptoms less severe when they do occur. Some controller medicines are inhaled, and others may be taken by mouth. Controller medications will not help you feel better right away when you do have an attack. That is why it is always important to have quickrelief medication available. You should continue to take your controller medication(s) even if you fine. Studies have shown that it is better to take controller medicines every day than to have frequent attacks requiring quick-relief medicines. You cannot become addicted to the controller medicine, and long-term use does not weaken your lungs. If you go a long time on your controller medication without having any asthma attacks, you can talk with your doctor about decreasing or stopping your controller medications. Never make any changes to your controller medications without first talking to your doctor. Quick-relief Medications: Helps to decrease or stop asthma symptoms once they have already started. Usually has an effect within 15 minutes. Works by relaxing the muscles that surround the airways. Those muscles can tighten around the airway during an asthma episode, and make the airway narrower. Use your quick relief medicine when you have symptoms such as: - Chest tightness - Coughing - Wheezing - Shortness of breath If these symptoms do not get better with your quick-relief medication, or if you are in need of your quickrelief medication more often than every 4 hours, contact your doctor immediately. 32 Pediatric Asthma Guide Booklet

37 Your asthma may not be under good control if: - you are using your quick-relief medications more than 2 times per week - you visit the emergency department for an asthma attack - you are hospitalized for an asthma attack If any of these happen, see your doctor about changing or adding a controller medication for your asthma. Inhaled Medications: Inhaled medications are an essential element of asthma treatment. Inhaled methods transport medication straight to the airways. Aerosol devices for inhaled medications may include: Metered-dose inhaler with spacer Dry powder inhaler Nebulizer Your doctor will prescribe the method that is most helpful for your child. Pediatric Asthma Guide Booklet 33

38 Metered-Dose Inhaler with Spacer: It is important that your child use the metered-dose inhaler properly to obtain the full dosage and advantage from the medication. It is frequently tough to use a metered-dose inhaler correctly. At our medical center, physicians often recommend using a spacer. A spacer is a device which can be attached to the metered-dose inhaler. A spacer helps deliver the medication to the airways of the lungs, instead of the mouth. This helps the medication function better. Common Spacers include: Vortex AeroChamber These are available with a mask for younger children. Ask your child s doctor about using a spacer, which helps transport the medication from the mouth into the airways of the lungs. Using a metered-dose inhaler might be hard for your child. However, it helps transport the medication from the mouth into the airways of the lungs. 34 Pediatric Asthma Guide Booklet

39 Dry Powder Inhaler: Dry powder inhalers are breath activated. When your child inhales fast enough, the medication is released, and inhaled. Common dry powder inhalers include: Flexhaler Diskus Nebulizer: A nebulizer or breathing machine is used to inhale medications. A nebulizer treatment is prearranged with an air compressor machine. Pressurized air is mixed with the medicine solution to form a vapor which the child inhales for approximately 5-10 minutes. When the metered-dose inhaler is used properly with a spacer, it is as efficient as the nebulizer, but you may find a nebulizer more helpful when your child has episodes of excessive breathing difficulty. Your doctor may ask for an air compressor to provide your child breathing treatments at home. A nebulizer is suggested for most inhaled medications for young children and anyone having difficulty using a metered dose inhaler with a spacer. At our medical center, we favor using a mask for younger children, rather than the mouthpiece on the nebulizer, as this allows for more medication to be inhaled into the airways. No matter which device your child uses, a metered-dose inhaler with or without a spacer, a dry powder inhaler or a nebulizer, you have to use it correctly to get the most advantage from the medication. Your doctor may ask you to demonstrate your inhaler technique to ensure it is done appropriately. Pediatric Asthma Guide Booklet 35

40 No matter which device your child uses, a metered-dose inhaler with or without a spacer, a dry powder inhaler or a nebulizer, you have to use it correctly to get the most advantage from the medication. Your doctor may ask you to demonstrate your inhaler technique to ensure it is done appropriately. 36 Pediatric Asthma Guide Booklet

41 Overseeing Your Child s Asthma: Monitoring Asthma Symptoms Asthma symptoms can range from very mild to severe. A number of children with asthma have only infrequent or seasonal symptoms. Others have a more chronic form of the illness and develop symptoms on a weekly or daily basis. Some children have asthma episodes, in which symptoms show up abruptly. In the majority cases, the family can be taught to distinguish signs and symptoms, and take safety measures to reduce the severity of an asthma episode. It s important to identify and treat even mild symptoms. This can assist in reducing the quantity of inflammation and decrease the danger of a more severe episode. Reading the signs Often, you get clues that an asthma attack might be coming - earlier than breathing difficulty begins. These clues are called early warning signs. Listed below are some common early warning signs. They are often exclusive for each person. Keep track of these signs for a few weeks. It is also helpful to look back on past attacks and see if your child had any of these early warning signs. Common early warning signs include: Breathing changes Sneezing Moodiness Headache Runny/stuffy nose Coughing Chin or throat itchiness Feeling tired Dark circles under eyes Trouble sleeping Poor tolerance for exercise Downward trend in peak flow numbers Mild asthma symptoms Asthma symptoms suggest an asthma attack is about to occur. Persons with asthma experience some or all of the below symptoms during the onset of an asthma attack: Breathing changes Shortness of breath Tightness in the chest Wheezing A response should be taken to treat these symptoms before it turns into a full asthma attack. Pediatric Asthma Guide Booklet 37

42 Severe Asthma Symptoms Severe asthma symptoms can be a life threatening emergency. They can be any of the following: Severe coughing, shortness of breath, tightness in the chest and/ or wheezing Difficulty talking or concentrating Walking causes shortness of breath Breathing may be shallow and faster or slower than usual Hunched shoulders (posturing) Neck area and between or below the ribs moves inward with breathing (retractions) Gray or bluish tint to skin, beginning around the mouth (cyanosis) If one of these symptoms happens, ask for emergency treatment right away. Have an action plan for receiving emergency care rapidly in the occasion of severe asthma symptoms. It is essential to seek medical attention (emergency room) when your child is not responding to treatment at home. Peak Flow Monitoring In addition to watching out for asthma symptoms, a peak flow meter can assist with monitoring your child s asthma. A peak flow meter can be particularly practical if a child has moderate to severe asthma or has difficulty recognizing asthma symptoms. A peak flow meter is a small, easy-to-use instrument that measures the peak expiratory flow-how fast you blow out air after a maximum inhalation. It shows how well your child s lungs are functioning. Young children, by age five or six, can learn to use a peak flow meter and make dependable, steady assessments. It is essential to recognize that peak flow numbers are dependent on the user. This requires your child to put forth a good effort to provide an accurate result. Your doctor may have your child demonstrate their peak flow meter technique during visits to ensure it is being done correctly. A daily (or regular) documentation of peak flow numbers can give you an important early warning sign. Occasionally, peak flow numbers will reduce in the hours, or even a day or two, prior to other asthma symptoms become obvious. When you observe peak flow numbers on a daily (or regular) basis, you can recognize this fall and take action to avoid an asthma episode. The peak flow numbers, along with monitoring asthma 38 Pediatric Asthma Guide Booklet

43 symptoms can be used to make decisions concerning asthma management. The maximum number your child can blow on a regular basis is the personal best. This is determined by recording peak flow numbers daily for two to three weeks when the asthma is under good control. Consult your physician about a practical training for how to determine your child s personal best. Once you recognize your child s personal best, it may be helpful for you and your doctor to start zones. Zones will prompt you about how well your child is breathing and type of responses you should prepare. The zone system can be matched to the colors of a traffic light. Green Zone Signals all clear This Zone points to good lung function. Follow the regular management plan for maintaining asthma. Yellow Zone Signals Caution This Zone indicates that your child may need medical intervention to control their asthma. This may consist of quickrelief medication and inhaled steroid medications, an oral steroid burst or other medications as prescribed by your child s doctor. Red Zone Signals a Medical Alert This Zone indicates that your child needs urgent treatment with quick-relief medication. Inform your child s doctor or go to the emergency room if peak flow numbers don t return to normal. Your doctor can help determine what your child s personal best is and what actions you should take when the peak flow numbers are in the green, yellow or red zones. Children by the age five or six are able to use a peak flow meter to produce reliable, consistent results. Pediatric Asthma Guide Booklet 39

44 Using an Asthma Action Plan An asthma action plan is a written, personalized plan to help you manage asthma attacks. The action plan is based on changes in asthma symptoms and peak flow numbers. It will give you information regarding when and how to use long-term control medications and quick-relief medications. If you know what to observe and what actions to take, you will be able to make well-timed and appropriate decisions about managing your child s asthma. It will also assist you in deciding when to ask for help and when to seek emergency medical care. It is essential to seek medical help when your child is not responding to treatment at home. Despite the care in doctor s office and emergency room seeming similar to what you were doing at home, the distinction is that the child is getting close medical supervision. Oxygen by nasal tubing or mask may be needed. There may be frequent nebulizer treatments and simple breathing tests (spirometry or peak flows). If breathing tests are not notably enhanced, medical personnel may start an intravenous solution of medications. Treatment with steroids is essential in these episodes. Hospitalization may be necessary for some asthma attacks. A severe attack of asthma that requires such rigorous treatment will not clear immediately. Your child will probably need to be on extra medication for a period of time. It is essential that your child take medications on schedule and use the peak flow meter to monitoring breathing ability. 40 Pediatric Asthma Guide Booklet