Asthma — What is it, and How is it Treated?

Few diseases commonly affecting children are as confusing to families as asthma. The presenting symptoms can vary, causing parents to debate even whether or not they should start treatment. This discussion will attempt to clarify what asthma is, which will hopefully lead to a rational approach for treating your child.

Asthma is a long-term, often lifelong condition, in which the bronchi, or airways develop excessive inflammation in response to a number of triggers. Triggers might include exercise, cold air, cigarette smoke, or pollens, but in children, are almost always viral upper respiratory infections. The tendency to develop the excessive inflammation of asthmatic airways is primarily genetic, more likely to occur if parents have one of the four Atopic conditions: Asthma, Allergy, Food Allergy, or Eczema. But environmental factors like chronic exposure to passive cigarette smoke can cause a child to develop asthma, even if there is no family history.

The inflammation causes the walls of the bronchi to swell, narrowing the size of the airway, and produce excess mucous, which triggers the characteristic cough of asthma. Finally, the muscles lining the bronchi spasm, or contract, further narrowing the airway. This often produces the wheezing, or whistling sound that is the second characteristic of asthma.

So the symptoms of asthma are cough, or wheezing, or both. It is my strong belief that children, particularly young children, are far more likely to have incessant coughing than wheezing, which is why they often initially “fly under the radar” of medical providers. Asthma should be considered a possibility if the cough starts early (first day or two) in the course of the cold, and is significantly worse when your child lies down.

The signs (what you can observe with your eyes) in a child with asthma often include retractions (skin between the ribs sucking in with each breath in), abdominal breathing (the abdomen pooching out as the child breaths in), and expiratory slowing (it takes up to 2 to 3 times longer to breathe out as it does to breath in). What’s going on?

The narrowing of the bronchi caused by the combination of airway swelling and muscle spasm means that the airways are too narrow. The muscles that pull the air into the lungs are the diaphragms, one at the base of each lung. Because of the narrowed airways, the diaphragms have to generate extra negative pressure to pull air into the lungs. It’s this increased vacuum that also pulls on the skin between the ribs, producing the retractions. And the increased downward movement of the diaphragms pushes on the bowels, causing the abdomen to push out. Thus, the retractions and abdominal breathing both result from the increased effort of the diaphragm.

Finally, the increased expiratory time: When an asthmatic child breathes in, the airways, even though they’re swollen, dilate, allowing air in fairly easily. But when the child breathes out, that same airway tends to collapse, resulting in a much smaller airway through which that same volume of air has to escape: it simply takes longer.

So if your child is coughing a lot, especially at night, or is wheezing, then look at these signs. If they are present, symptoms are originating in the chest, and asthma treatment should be considered.

So how do we treat asthma? This is where I love the analogy of asthma symptoms being a fire, for it will make clear which medication you should be using. Cough and wheeze, the symptoms of an asthma flare, are like the sudden appearance of a fire. Just as you might use a fire extinguisher or fire trucks to “rescue” you from a house fire, albuterol, the primary “rescue” drug is used to put the cough or wheeze “out.”

For most patients, called Intermittent asthmatics, that’s all you need. But just as a fire marshal might recommend a better fire retardant the second or third time your house catches on fire, Persistent asthmatics need a “fire retardant” for their lungs, called an anti-inflammatory. And when would your child be considered persistent? By the Asthma Rules of Two: Albuterol is required more than two times every week (rare in kids), night cough occurs more than two nights a month, more than two albuterol inhalers are used per year, or oral steroids are required two or more times within a year.

Although oral steroids often produce dramatic improvement if your child develops a significant flare (typically requiring albuterol every 4 hours, or needing it two or more times during the night), they can have serious side effects, including slowing height growth. That is why I ask myself, every time I prescribe an oral steroid, whether an inhaled steroid (which is far safer even if used long-term) should be prescribed to try and prevent a future attack, which might require additional oral steroids.

A word about intermittent inhaled steroids: Although inhaled steroids, even taken all the time are significantly safer than oral steroids, they are often difficult to remember to give when your daughter is well. There is now increasing evidence that starting high-dose inhaled steroids at the very first sign of a cold and continuing until the cough is gone for several days, works virtually as well as taking the inhaled steroid all the time. You might ask your provider about this alternative if she’s been prescribed inhaled steroids.

Finally, what do we do for the child who keeps requiring oral steroids despite being on inhaled steroids? I typically first turn to an incredibly safe non-steroid anti-inflammatory chewable tablet, montelukast (brand Singulair). Though not as potent as the inhaled steroids, for some kids it adds just enough boost to the inhaled steroids they’re already on to keep them out of trouble.

And if montelukast isn’t enough, Advair, a combination of inhaled steroid and a 12-hour bronchodilator (versus the 4-6 hour bronchodilator albuterol), is usually the next choice.

I apologize if you finished reading this more confused than when you started. Though the treatment choices can be somewhat complex, the decisions about what one uses in each setting are based on simple principles: treat the fires when they occur, but consider a better retardant (anti-inflammatory) if the fires keep occurring.