Treating Asthma

Preventing, Maintaining and Treating Asthma

Read on to learn about treating asthma including allergy prevention, asthma medications, methods for administering inhaled medications and which method is best for your child.

Allergy Prevention

Some forms of asthma, as described above, may be caused by allergies to substances in the environment such as: dust, mold, cigarette smoke, pets, dairy products, food, seasonal pollen and plants, or aerosol sprays.

The types of asthma that may benefit from allergy prevention include:

• Allergic asthma
• Infant asthma
• Seasonal asthma
• Nighttime cough

The types of asthma that generally do not have an allergic component are:

• Reactive airway disease
• Exercise induced bronchospasm

If you feel that there is an allergic component to your child’s asthma, click on Allergies or Food Allergies for a detailed discussion on how to minimize your child’s exposure to these substances. This prevention is vital to long- term management of your child’s asthma.

Asthma Medicines

There are a variety of inhaled and oral medications used today in the treatment of asthma. They are available only by prescription. These can be confusing at times, especially when your child is using more than one type of inhaler. Here is a guide to the different medications used for asthma.

Remember at the beginning of this discussion you learned about the two different processes in the airways of the lungs that cause wheezing – bronchoconstriction and inflammation. Medications for asthma treat either one or the other of these processes. There is no medication that can treat both.

• Bronchodilators (the medical term is Beta-agonists). As the name implies, this type of medicine dilates (enlarges) the bronchi (airway) in the lungs. It relaxes the tiny muscles that wrap around and squeeze the bronchi, therefore allowing the airway to open up again. The main example of a bronchodilator is inhaled albuterol. See below.
• Anti-inflammatories. This type of medicine decreases the inflammation, soreness, and swelling within the airway, therefore increasing the space within the airway. Examples of anti-inflammatories include inhaled steroids or antihistamines. See below.

The way medications for asthma are used falls into two categories: Rescue medications – mostly bronchodilators, and maintenance and preventative medications – mostly anti-inflammatories.

Rescue Medications

The term rescue refers to the fact that these medicines are designed to treat wheezing or chest tightness during an attack. These medicines are used on an “as needed” basis to “rescue” your child from active symptoms. Here is a brief discussion of the various types of rescue medications:

• Albuterol inhaled – short acting. This is the standard, most common inhaled asthma medication that is used by virtually all asthmatics. It comes as an inhaler and as a solution to put into a nebulizer machine. Common brand names include Ventolin. They usually give relief within 5 – 15 minutes. They can be used every 3 – 4 hours to treat an asthma attack.
• Xopenex. This is an exciting new form of albuterol, available in nebulizer form, and hopefully soon as an inhaler. It is much more potent than regular albuterol, which means that much lower doses can be used to achieve bronchodilation, with less side effects. It also does not become less effective with prolonged use (years) as is sometimes the case with plain albuterol. As of 2000, it is only approved down to age 12, but safety studies are being conducted as young as age two.
• Albuterol oral liquid. This works like the inhaler, but the medication is swallowed, gets absorbed into the bloodstream, and then travels to the lungs where it can work. This is an advantage for infants, with whom using an inhaler can be quite difficult. However, the oral liquid causes more side effects (discussed below). They can be used every 6 – 8 hours.
• Long-acting bronchodilators (brand name Serevent). These are designed to be more of a maintenance medicine (discussed below), but also deserve mention here. It is just like the albuterol inhaler but has two main differences. It doesn’t start working for 30 minutes. It therefore won’t “rescue” your child immediately from wheezing. It lasts much longer (up to 12 hours). It is therefore generally used twice daily more as a maintenance or preventative medication (see below) to keep wheezing from starting, but it can also be helpful to use for a few days during a persistence attack to decrease the need for the shorter-acting albuterol inhaler. It only comes as an inhaler, not for a nebulizer machine.
• Theophilline. This works similarly to albuterol but is a very different medication. It comes only in tablets. It has considerably more side effects and therefore is used very rarely in children. It is mostly used in the hospital to control very severe asthma attacks.

Anti-inflammatories

• Steroid (oral liquid or pills). Steroids can be used as a maintenance or preventative medication for asthma. During severe asthma attacks when a bronchodilator isn’t enough or is being used too much to keep the attack under control, oral steroids can “rescue” a child within 6 – 12 hours to calm down the inflammation and avoid a trip to the hospital. A five-day course of the steroid is typically used in this situation. See the discussion under steroids below.

Maintenance or Preventative Medications

These medicines are used to prevent wheezing or chest tightness from even starting. They “maintain” a symptom-free state. They are taken on a daily basis whether the child is sick or well in order to prevent an asthma attack from starting. These medications mainly treat inflammation, not bronchoconstriction. Therefore they don’t work to immediately open up a child’s airways during an attack (only rescue bronchodilators do this).

There are three main goals of maintenance therapy:

1. Keep the child in a symptom-free state on a daily basis. Proper maintenance therapy can help a child go through life without suffering from daily wheezing, chest pain, chest tightness, and shortness of breath.

2. Decrease the frequency and severity of attacks. Adequate maintenance therapy should prevent attacks from even occurring in the first place. When they do occur, they should be milder.

3. Decrease reliance on albuterol. If albuterol is used continuously for many months or years, your child may become resistant to it. It is important not to let this happen since albuterol is one of the only bronchdilators available to us. Important note – don’t be afraid to use albuterol. It takes several months to years of daily use to become resistant to it, and resistance is rare anyway. Most people use it frequently for years and have no problems with resistance. It is preferable to be on one of the maintenance medications daily than to use albuterol daily.

Here are two different types of medications used for prevention:

1. Bronchodilators

• Long-acting albuterol (Serevent). As discussed above, this long-acting medication can be used to help keep the lungs open in a child with moderate to severe asthma. It is a good alternative for children when they seem to need their albuterol inhaler 3 – 4 times a day. Instead, they can use this medication twice daily to keep the wheezing under control. There is a new disk inhaler combination of Serevent and Flovent (see steroid inhalers below) called Advair. Both medications are dispensed in one inhalation. This is a convenient form to use for people who need both types of medication to control their asthma.
• Albuterol sustained release tablets (brand name Volmax). This is for children 6 years and older. It works just like the oral liquid albuterol, but acts just like salmeterol in the duration of action. It is generally recommended as a maintenance drug for moderate to severe asthma for children who require several medications. May have more side effects than salmeterol since it is taken internally.
• Theophilline. This works similarly to albuterol and salmeterol but is a very different medication. It comes only in tablets. It has considerably more side effects and therefore is used very rarely in children.

2. Anti-Inflammatories

• Steroid inhalers and nebulizer solutions. Over the past decade these have become the mainstay of preventative therapy. There are many on the market, but only a few have been approved for children as young as two years. Common brand names include Flovent and Beconase. They act directly on the lining of the airways to prevent the immune cells that live there from reacting and causing inflammation and swelling. When used on a daily basis, they can be very effective in preventing asthma symptoms. An advantage is they only need to be used once or twice a day. There is a new disk inhaler combination of Serevent (see above) and Flovent called Advair. Both medications are dispensed in one inhalation. This is a convenient form to use for people who need both types of medication to control their asthma.
  These have previously only been available as inhalers, but in 2000 a steroid called Pulmicort was approved for children as a nebulizer form.
• Steroid pills. These are only used as maintenance therapy for children with severe asthma who require aggressive therapy. They work like the inhaled steroid, but also have effects all throughout the body. Long-term use is considered a last resort.
• Cromolyn inhaler or nebulizer solution (brand name Intal). This acts as an anti-histamine and prevention medication with the least side effects. It works like a steroid on the lining of the lung, but without the undesirable side effects of steroids. Histamine is largely responsible for the inflammation in the airways. This is an excellent alternative for those hesitant to use steroids. One drawback is that it needs to be used 3 – 4 times a day (you can eventually cut back to twice a day as tolerated).
• Leukotriene inhibitors (brand names Singulair and Accolate). These are new drugs released in the mid 1990’s. They come only in pill form. They work differently than steroids. Their anti-inflammatory mechanism is similar to ibuprofen. These medications can very effectively control asthma without the drawbacks of steroids.

Note: anti-inflammatory inhalers do not work right away. It usually takes one or two weeks for their effects to build up enough to prevent asthma symptoms. Parents should take this into account when deciding whether or not this type of medication is working.

Side Effects of Asthma Medications

Bronchodilators

Albuterol has side effects including:

• Fast heart rate
• Jitteriness
• Hyperactivity
• Headache
• Dizziness

All of these effects are uncommon, and most children tolerate the medication very well. The effects are only temporary. If your child experiences any of these effects, but they seem tolerable, then it is safe to continue the medication. These effects are well known and usually don’t mean you need to stop the medicine.

Oral bronchodilators cause side effects both more often and more pronounced, therefore inhalers are preferred when feasible.

Theophylline side effects include the above, plus heart arrhythmias, nausea, vomiting, and very rarely convulsions.

Steroid Oral Liquid or Tablets

There are two different situations when these are used:

1. Short course steroid “burst”. A short five-day course is often used to help a child get over a severe asthma attack. The side effects from this short- term use are minimal. You virtually never see any of the severe side effects that occur with months or years of use. These mild effects include:

• Headache
• Stomach upset
• Hyperactivity

2. Long-term use. When steroid pill (not inhaled steriods) are used for months to years to control severe asthma, many severe side effects can slowly begin to occur, such as:

• Weight gain
• Glaucoma or cataracts
• Susceptibility to infections
• Metabolic imbalances
• High blood pressure
• High blood sugar
• Stomach ulcers
• Osteoporosis

We would like to emphasize again that these serious side effects are almost unheard of with the commonly used and very effective five-day short course of steroids, and they are not a concern with inhaled steroids.

Steroid Inhalers

Side effects include:

• Hoarse voice
• Sore throat
• Dry mouth
• Cough
• Oral thrush (yeast)
• Rash
• Wheezing
• Nasal congestion
• Can slow down growth. This is a very rare effect that has been noted in some kids, especially with high doses. This effect is virtually never seen with low doses. Your child’s height should be accurately monitored every three months while on this medication. The height speeds up again when taken off the medication. This effect can worry parents and cause then to shun this type of medication. Keep in mind that it is better to have your child’s asthma under control than to allow him to have chronic symptoms, which may also affect growth.

To help minimize these side effects, gargle and rinse with water after using the medication.

Cromolyn Inhaler

Side effects are minimal but may include:

• Sore throat
• Cough
• Wheezing
• Nasal congestion

Leukotriene Inhibitors

Side effects include:

• Headache
• Fatigue
• Fever
• Stomach upset
• Sore throat
• Hoarse voice
• Respiratory infections

Methods for Administering Inhaled Medications

There are a variety of different ways to give a child inhaled asthma medications, depending on the child’s age. Here are the different ways to give inhaled meds:

Dr. Sears advice:

Before using an inhaler ask your physician or pharmacist to demonstrate the proper use. Also, carefully read the package insert. One of the main reasons inhalers are ineffective is because they are used improperly.

Inhalers work well for older children who can coordinate the spray and inhalation. Inhaler technology is now going through some changes. For many years inhalers have used Freon as a propellant, and most inhalers were the same. Because Freon destroys the ozone layer, it has now been banned from use. New dry powder inhalers are available which don’t use Freon. Studies have shown these new inhalers work better than the Freon ones.

How to Use an Inhaler

Follow these five steps:

1. Shake the inhaler well and attach it to the spacer
2. Hold inhaler upright with both hands.
3. Take a deep breathe in, and then comfortably exhale.
4. DON’T FORCE EVERY LAST BIT OF AIR OUT. It is unnecessary and can increase wheezing.
5. Hold the inhaler up to your lips.

For standard Freon inhalers:

• DON’T PUT INHALER INTO YOUR MOUTH. Move inhaler approximately once inch away from lips.
• Begin to breath in slowly and deeply.
• Spray the inhaler a split second after inhalation begins.
• DON’T SPRAY FIRST, THEN INHALE. THIS CAUSES MEDICINE TO STICK TO YOUR MOUTH. THE WIND CREATED BY INHALING FIRST PICKS UP THE SPRAY AND CARRIES IT DOWN INTO THE LUNGS.

New dry powder inhalers. Instructions for these can vary. Basically, you place your lips over the mouthpiece and inhale deeply and slowly. The powder is picked up by your inhale and carried down into the lungs.

• Continue the deep breath and hold it for a count of 7 to 10 seconds, then exhale.
• DON’T HOLD YOUR BREATH UNTIL YOU TURN BLUE. THIS INCREASES WHEEZING.
• Rest for two minutes, then repeat another dose if instructed to on your prescription. This waiting time allows the first dose to open up the lungs a bit so the second dose goes down deeper.

Inhaler with aerochamber or spacer device with mouthpiece. this is a small, palm-sized tube that attaches to the inhaler. It has an empty air space inside. This is ideal for younger children who can’t coordinate spraying or aiming the inhaler while breathing in. Follow these steps:

• Shake the inhaler and attack it to the spacer.
• Prepare your child
• Hold the spacer up to your child’s mouth and place mouth over mouthpiece.
• Spray the inhaler. The medication fills the airspace inside the device.
• Have your child take a deep breath through the mouthpiece and hold it for 7 to 10 seconds.
• Repeat the process two minutes later.

Inhaler with aerochamber or spacer device with mask. This is designed for younger infants but instead of the mouthpiece, a mask is used that fits snuggly over baby’s mouth and nose. The instructions are the same except that after spraying the inhaler, you hold the mask snuggly to baby’s face while he breathes for 10 seconds. He may cry, but will still inhale the medication.

Nebulizer machine. This is a lunchbox-sized portable air compressor. You may be familiar with this machine from your pediatrician’s office. You squirt in the prescribed amount of liquid medication, often with some saline to dilute it, into a reservoir. The machine turns the liquid into a mist that comes out the end of a tube. You can direct the spray at your baby’s face (best for protesting babies), hold a facemask over baby’s face, or have a child inhale through a mouthpiece. The treatment takes several minutes. You can rent or buy this machine and it is generally covered by health insurance. Nebulizers are the best way to deliver the most medication to infants and young children.

Which Method is Best for Your Child

Infants and young children. The nebulizer is the most reliable way to deliver the medication to this uncooperative age group. However, if it seems your child may only need the medication for a short time, you can probably get by with an inhaler. You should definitely use a spacer device with a mask for infants and a mouthpiece for children.

Older children. You can decide when your child no longer needs a spacer device for his inhaler. In general, a spacer is needed for children younger than ten years old. Nebulizers are usually only needed in this age group for children with moderate to severe asthma who require frequent treatments. The nebulizer can help keep you out of the emergency room.

Guidelines for Choosing Medications for Specific Asthma Scenarios

The world of asthma medications can be a very confusing one. Choosing the right combination of medications is important. It is important to avoid treating too aggressively, but you also want to keep your child symptom free. Here are some standard guidelines to help you understand what medications may be right for your child’s case.

Reactive airway disease. If you feel your child falls into this category, she should only need treatment during colds. The best medication for this condition is inhaled albuterol or the new Xopenex. Inhalers are generally the most appropriate. However, if your child has frequent colds that require albuterol treatments, and you find the inhaler difficult to use, then a nebulizer is a must. Some infants also do well with the oral liquid. This is a good choice if the side effects are tolerable in your infant. Here’s how to treat these attacks:

• Begin albuterol at the first sign of a cold. if you stay on top of the wheezing and don’t let it start to get the best of your child during a cold, you are much more likely to avoid a trip to the doctor’s office.
• Give your child a treatment every 4 – 6 hours, depending on what’s needed. You may need to continue this for up to a week, or only one or two days, depending on your child.
• “Steam clean” your child’s breathing passage two or three times a day after an albuterol treatment, turn your bathroom into a steam room using the hot shower. Let your child breath the steam for 10 or 15 minutes. Pound on her chest – front, sides, and back. This helps get all the congestion out of her chest and helps keep infections from setting in.

Exercise induced bronchospasm. The main treatment for this condition is also an albuterol inhaler.

• Take two puffs of the inhaler 20 to 30 minutes before exercise. This will help keep the lungs open during exercise.
• You can repeat the inhaler during and after exercise if needed. Be aware that your prescription will probably say use only every 4 hours, but it is generally safe to use sooner if needed during exercise. You should let your pediatrician know if your child needs the inhaler several times throughout a certain sports activity.

Nighttime cough. If your child is generally healthy during the day, but has had a tight cough or wheezing at night that sometimes wakes her up for as long as you can remember, there is probably something in the bedroom she is allergic to. We suggest before you use medication, do everything you can in the bedroom to prevent the allergy. If you need to resort to medication, albuterol or Xopenex may be the best choice. Try either the long-acting or just plain albuterol. If it seems your child needs this almost every night, then nightly cromolyn or an inhaled steroid may be a better choice. Discuss this with your pediatrician.

Infant asthma. If your infant develops persistent asthma (not just reactive airway disease due to colds), there is probably a strong allergic component to it. The first step to take is to have the breastfeeding mom eliminate foods in her diet that the child may be allergic to. Click on elimination diet for this. If formula feeding, switch to another type. If using a cow’s milk formula, switch to soy. If using soy, switch to a cow based formula. It may take two weeks for symptoms to improve. If these don’t work, try a more specialized hypoallergenic formula such as Nutramigen or Alimentum. If medication is needed, then follow the guidelines below under allergic asthma.

Allergic asthma. This is by far the most complicated type of asthma to treat. After you have done this, here are some guidelines for medication use. These guidelines go in order from least aggressive treatment for mild asthma to most aggressive treatment for severe asthma.

• Mild, occasional symptoms. This is a child who is well most of the time, but has mild flare-ups maybe three to six times a year that only last a few days. The wheezing and slight labored breathing don’t slow him down too much. These don’t seem to be caused by colds. This type of mild asthma may not even warrant extensive allergy prevention, depending on how much it affects the child. You can decide this.
  • Inhaled albuterol or Xopenex as a “rescue” treatment is the most appropriate medication in this case. No maintenance treatment is necessary during well times since it isn’t happening often enough to make it worth preventing.
  • Simply use two puffs on the inhaler every 4 – 6 hours as needed during these mild attacks. You may need to do this for several days.
  • Oral albuterol can also be effective for infants who don’t do well with inhalers.
• Moderate to severe, but occasional symptoms. This is similar to the mild situation above, but the flare-ups are more severe, causing rapid, labored breathing and retractions. The flare-ups last for several days, but only occur three to six times a year. Your child is very healthy in between episodes, and may go for two or three months at a time without trouble. This degree of asthma does warrant allergy prevention measures at home. Here are some guidelines for medication use:
  • Inhaled albuterol or Xopenex. May be used for rescue treatment during attacks. We suggest getting a nebulizer since it may help you avoid ER visits. An inhaler is adequate most of the time.
  • Salmeterol or Foradil. (long acting) can be helpful for several days during a flare-up to decrease the need for albuterol.
  • Oral steroid liquid or pills. This are used as a short five-day course should be started during the more severe attacks if symptoms don’t subside after one day because often the albuterol just keeps the bronchoconstriction under control, but a steroid is needed to overcome the inflammation. Your doctor may give you a prescription to keep on hand.
  • Maintenance therapy. The decision to go on maintenance therapy really depends on how frequent the attacks are, and how severe and life threatening they are. You and your doctor should decide when your child’s asthma gets to a point where daily preventative treatment is preferable to occasional treatment for attacks.
• Mild but persistent symptoms. In this situation your child doesn’t really seem to have many moderate to severe attacks. He may have a few flare- ups each year, but they are generally mild and easily controlled. However, your child seems to have mild, underlying shortness of breath, exercise intolerance, mild wheezing, and nighttime cough that seem to be affecting him more often than not. He seems to have these symptoms two weeks out of each month, or sometimes one or two month’s straight.
  • Allergy prevention is must for this condition.
  • Albuterol or Xopenex for flare-ups or occasional symptoms.
  • Oral steroid liquid or pills used as a short five-day course should be started during the more severe attacks if symptoms don’t subside after one day because often the albuterol just keeps the bronchoconstriction under control, but a steroid is needed to overcome the inflammation. Your doctor may give you a prescription to keep on hand.
  • Maintenance therapy is the most important aspect for this degree of asthma. You can decide with your doctor what medications would best suite your child. Here are some suggestions, going from least aggressive to most aggressive:
    • Intal – inhaler or nebulizer. Start 3 – 4 times daily, then decrease as symptoms improve.
    • Intal plus long-acting albuterol. The added prolonged effect of this albuterol can keep symptoms better controlled. Wean off the long-acting albuterol as able.
    • Inhaled steroid. May be more effective than the Intal.
    • Inhaled steroid plus long-acting albuterol. This is a very effective combination.
    • Leukotriene inhibitor tablets. This is an excellent alternative for those hesitant to use steroids. It is also easier to administer.
    • Inhaled steroid plus leukotriene inhibitor. Very effective at controlled symptoms. You can wean off one or the other as able.

  Most of these medications can be used in any combination, even three at a time. The main idea is to get symptoms under control for a while, then wean off the medications as able. When symptoms flare up again, increase the maintenance medications again.

• Moderate to severe persistent symptoms. This is the most troublesome degree of asthma. Not only does your child have flare-ups throughout the year, but always seems to have underlying symptoms that significantly limit his daily activities more days than not.
  • Allergy prevention is of course extremely important. Click on allergies for help.
  • If your child has this degree of asthma, he should definitely be seeing an allergist for allergy testing and close monitoring.
  • Albuterol or Xopenex is still used as needed during flare-ups.
  • Maintenance therapy is essentially the same as the previous section, but you will probably have to be more aggressive and use two or three medications at a time.
  • Inhaled steroid plus a long-acting albuterol plus leukotriene inhibitor – these three medications are extremely effective together. Once your child’s symptoms are under control for a while, you can slowly wean off one of two of the medications.
  • Oral steroids, if the asthma is severe enough, longer courses of oral pills may be needed to keep it under control and improve quality of life.

   

• Seasonal asthma. In this type of asthma, your child is generally well all year round; except for a particular season that has the pollens and plants your child is allergic too.
  • Allergy prevention is important. Click on allergies and go to the section on preventing seasonal allergies.
  • Medications. This is essentially the same as the section “mild persistent” allergic asthma above. Work with your pediatrician to find the best maintenance therapy for your child.