Asthma - What No One Tells You About Asthma
New Treatment: A Vaccine for Asthma
Asthma - Guidelines to Follow to Prevent EIA
New Treatment: A Vaccine for Asthma
Immunoglobuline (IgE) plays a major role in the release of symptom causing chemicals in asthma. A genetically engineered monoclonal antibody vaccine known as anti-IgE is currently undergoing human trials. Monoclonal antibodies are tiny proteins that are produced by white blood cells involved in immune reactions. These antibodies target substances such as IgE and neutralize it. Unlike conventional treatments such as corticosteroids that reverse inflammation after it has occurred, anti-IgE aims to curtail the inflammatory process before it starts.
The results of the early trials of anti-IgE (rhuMAb-E25) are encouraging with no significant side effects reported to date. Anti-IgE should also be helpful in allergic rhinitis and possibly food allergies.
New Medications
New and modified asthma medications are likely to improve treatment of bronchial asthma. Several medications already in general use in Canada and Europe are to be marketed in the United States in the near future. Many other medications are being investigated.
Anti-leukotrienes
Additional anti-leukotriene medications are likely to join montelukast ,zafirlukast, and zileuton, which are currently in use in the United States. An agent, MK-0591, which inhibits the action of an enzyme (5-lipoxygenase) involved in the formation of leukotrienes, has been found to be effective and appears promising. Verlukast and pranukast, two agents which block the action of leukotrienes after they are produced, also appear effective.
Mediator Antagonists
Asthma mediators are irritating chemicals that are either stored within allergy cells (mast cells, eosinophils) or produced when these cells are activated. These substances produce many changes that lead to inflammation of the bronchial tubes. Examples include histamine, leukotrienes, prostaglandins, cytokines, thromboxanes, and platelet-activating factor (PAF). Additional mediator antagonists which would have anti-inflammatory properties are currently under development. Two inhibitors of PAF (WEB-2086, L-659), have already been shown to reduce inflammation in bronchial asthma and appear promising.
Choosing Your Asthma Physician
Many types of physicians administer treatment to patients with bronchial asthma. Family physicians, internists, allergists, and pulmonologists are all involved in treatment of patients with asthma. Excellent care may be provided by any of these types of physicians who are well trained and experienced in treatment of asthma. An asthma specialist is often a physician who has specialty training in asthma as well as other chest diseases, such as a pulmonologist. Patients with unstable asthma or disease that is unresponsive to treatment should certainly be seen by an asthma specialist who can work in concert with the primary physician. Even patients with mild disease may benefit from a specialist's review of their diagnosis and treatment. Patients with asthma should undergo an allergy evaluation, which may be administered under the direction of an allergist.
Many factors enter into your choice of a physician in addition to training and expertise. It should be apparent to each patient if the "chemistry is right" and that a good rapport has been established with a physician. How the physician responds to questions and listens to concerns about chronic disease, fears of medication effects, and descriptions of side effects should make it clear if the right choice of a physician has been made. Other important considerations are availability and how emergency calls are handled, as well as access to facilities for evaluation and treatment. Finally, the patient must feel that a partnership has been established with the physician for achieving the best possible care.
Factors to Consider in Choosing an Asthma Doctor
In addition to personal and professional recommendations, other things to consider when choosing a doctor include:
* Insurance coverage – What healthcare insurance plans does the doctor accept?
* Accreditation and board certification – Is the doctor accredited and board certified in an asthma-related specialty?
* Location and hours – Is the doctor's office close to work and/or home? Are the hours convenient? Is the office open in the evenings and on weekends?
How Can I Find a Professionally Trained Allergist?
You can start by looking in the white pages of your phone book for your local medical society. They are usually listed as (city name) Medical Society.
You can also look in the Yellow Pages of your phone book under Physicians. The physicians will be listed under their specialty area, such as "Allergy & Immunology." Choose an allergist that is "Board Certified."
Future Considerations For Asthma
B2-Agonists
Formoterol is a long-acting inhaled B2-agonist aerosol that is already in use in Europe. Like salmeterol, it has a duration of twelve hours but appears to have a different mode of action. Formoterol appears to have faster onset than salmeterol and may be used for sudden attacks of asthma as well as for maintenance therapy. A multidose DPI preparation of formoterol (Oxis) is currently undergoing trials in the United States and should be available soon.
Bambuterol is a drug that is converted by the body into another B-agonist, terbutaline. It is given by mouth and is effective for twenty-four hours. This once-a-day approach should be helpful, especially for patients with nocturnal asthma.
Inhaled Corticosteroid
Mometasone
Mometasone is a highly potent topical steroid that is currently undergoing evaluation in the treatment of asthma and appears extremely promising. This medication has recently been introduced into the United States as a nasal spray (Nasonex) and has been found to be highly effective in the treatment of rhinitis.
Investigational Corticosteroids
Investigational agents in the inhaled steroid group undergoing trials at this time include rofleponide palmitate and tipredane. Further data on these and additional agents should be available soon.
Immunomodulators
Medications called immunomodulators that affect the immune response are also being investigated. These agents work along the same principle as corticosteroids that suppress the immune reaction.
Anticholinergic Agents
Oxitropium bromide is an anticholinergic bronchodilator similar to ipratropium bromide in its action. It appears to have a more potent effect and longer duration of action than ipratropium bromide.
Xanthines
Xanthines belong to the medication group that contains theophylline. Two agents, doxofylline and enprofylline, have been studied and used in Europe. Doxofylline appears to have fewer side effects compared to theophylline and has been approved for use in Europe. The lower risk of adverse effects should reduce the need for blood level monitoring.
How to Participate in Managing Your Asthma
For an asthma treatment strategy to succeed, the patient must be an active participant. Patients who take an active role in their care have better control over their disease. The health benefit from patient participation can be applied to any illness but seems particularly true in diseases such as asthma and diabetes. Patients who participate in their own care are better educated in regard to their illness and communicate well with their physicians. These characteristics are extremely important in managing bronchial asthma. This topic discusses the steps patients can take to become active participants in their care and specific suggestions are offered regarding diet, stress, and work.
Self-Monitoring and Education
In managing bronchial asthma a patient can play an active role in decision making by closely monitoring airflows with a home peak flow meter. From the record of the peak flows a physician can judge the effectiveness of treatment, evaluate the patient's response to new drugs, pinpoint adverse environmental influences at home and work, and determine the need for emergency management. Peak flows may also be used for special situations such as before and after exercise to determine a patient's response to various asthma triggers.
Your physician should be your primary source of information. Limits on time may prevent discussion of all important issues on an initial visit so make a list of topics you want to discuss so you can raise these issues during follow-up visits. Ask your doctor about recommended reading to further your education. Before leaving the physician's office you should have been taught the correct use of an MDI, peak flow meter, and spacer if they are prescribed. Ask lots of questions. Videotapes of proper inhalation techniques for using MDIs are available. Written instructions on the use of your medications should be given to you. "What are the side effects I should be aware of?" "Are there any drug interactions with my other medicines?" are excellent questions you should ask.
At home, keep a record of your doctor's office visits and appointments. A diary of your peak flow measurements should also be maintained. Mark your calendar when you started using an MDI so you can mark ahead the date when it should be refilled. Always carry a list of your medications with you as well as a fresh bronchodilator spray for emergency use. If you travel, carry a set of your prescriptions in case your medication is mislaid. Research the climate you will be traveling to as well as important aspects of the locale such as local allergens or the altitude. Ask your physician about the effects of altitude on your condition and whether you should have prescriptions for emergency medications such as antibiotics or corticosteroids.
Treating Nocturnal Asthma
Treating nocturnal asthma is based on the goal of achieving sufficient medication levels during sleep hours as well as eliminating environmental allergens. However, studies have shown that if patients are well controlled during the day, they will experience fewer and/or milder attacks at night. Asthma should always be regarded as a twenty-four-hour illness and treatment should not be directed solely at the nighttime hours.
Choosing Medication for Nocturnal Asthma
Many medications may be used to treat nocturnal asthma. More than one agent may be needed for patients with severe and frequent attacks.
B2-agonists are available in long-acting forms both in aerosol (salmeterol) and tablet form (albuterol) that may be administered at night. By improving lung function and preventing nocturnal attacks, these agents may actually improve quality of sleep.
Theophylline in sustained-release forms allows once-or twice-a-day dosing and is suitable for nocturnal asthma treatment. The physician can time administration of this medication so peak blood levels are obtained during sleep. A common approach is one sustained release preparation after the evening meal. Remember, theophylline blood levels can be measured and each sustained preparation is unique. One drawback of theophylline for nocturnal asthma is its potentially adverse effect of insomnia. Patients who limit their caffeine intake may reduce this effect.
Because overactivity of the cholinergic nervous system has been implicated in nocturnal asthma, anticholingeric agents have been administered at bedtime in patients with nocturnal asthma. High doses (ten puffs) of ipratropium bromide have been administered with conflicting results in several studies. At this time it does not appear that this agent is more effective than long-acting B2-agonists for treating nocturnal asthma.
Patients with moderate to severe nocturnal asthma may need oral corticosteroids to control their symptoms. Studies of the timing of administration of this medication have shown dosing in early morning or evening does not achieve better control of nocturnal asthma. In these studies, patients who took steroid dosages at three P.M., however, significantly reduced the likelihood of nocturnal attacks.
Patients who continue to suffer nocturnal attacks despite aggressive therapy may need to awaken one hour before their usual night time attack to administer a short acting B2-agonist, an approach termed "therapeutic awakening."
Beta-Blockers and Asthma
A commonly prescribed group of medications, beta-blockers may produce severe, life-threatening asthmatic attacks. These medications are widely prescribed for multiple illnesses, including hypertension, cardiac arrhythmia, angina pectoris, glaucoma, and migraine.
The beta-receptors located in the lung (called beta-2 receptors), when active or stimulated, produce relaxation of the muscle surrounding the bronchial tubes, which widens the bronchial passage (bronchodilatation). If these receptors are blocked from receiving nerve input, the reverse effect (bronchoconstriction) results. This may have devastating effects on patients with underlying bronchial asthma. One theory for the nature of asthma postulated that the disease represented a "blockage" of the beta-receptor that was either inherited or established through acquired illness. It is easy to see why using beta-blockers in patients with asthma has produced fatal asthma attacks.
Beta-receptors are present in other organ systems such as the heart and circulation; these are referred to as beta-1 receptors. Beta-blockers that affect beta-1 receptors more than beta-2 receptors are termed "selective." These medications vary in potency and duration. A number of the selective beta-blockers produce less blockade of lung receptors, but there is still significant risk for exacerbating bronchial asthma. As a rule, all beta-blockers should be avoided by asthma patients.
Don't Forget Eyedrops!
Beta-blockers in the form of eyedrops are commonly used to treat glaucoma. Medication may be absorbed from the eye and delivered into the general blood circulation before reaching the bronchial tubes. Patients with bronchial asthma have suffered asthmatic attacks from beta-blockers introduced into the eye for treating glaucoma. Selective beta-blockers have been developed for glaucoma but may also produce bronchoconstriction. All patients with bronchial asthma should inform their ophthalmologists of their lung condition before treatment for glaucoma is initiated. In severe glaucoma cases where a beta-blockers is felt to be necessary, a selectine agent should be used and the patient's airflows closely monitored.
Antidepressant Medication and B-Agonists
Monoamine oxidase (MAG) inhibitors are commonly prescribed for depression. These drugs inhibit the enzyme responsible for breaking down epinephrine released from the adrenal gland. When a B-adrenergic agonist is administered to patients receiving a MAG inhibitor, there is a greater risk of adverse effects on the circulation, such as blood pressure elevation. This is more likely when the B-agonist is given by mouth or by injection since there is higher total-body absorption of the drug. By inhaling a B-agonist there is less chance of producing an adverse effect in a patient receiving a MAG inhibitor. When possible, an alternative antidepressant should be substituted in asthma patients to permit safe administration of a B-agonist. Patients who must receive both medications should be monitored closely for adverse circulatory effects.
Sedatives and Asthma
In asthma, as in other chronic illnesses, patients may experience increased levels of anxiety as well as sleeplessness. Requests for tranquilizers and sleeping pills are common. In patients with severe asthma, shortness of breath and fear of hospitalization may further heighten anxiety levels. Sleep may also be interrupted by asthmatic attacks.
Why to Avoid Tranquilizers and Sleeping Pills
All tranquilizers and sleeping pills affect the brain center that drives breathing. This reduces the activity of this vital center and causes more shallow breaths. Shallow breathing does not produce full expansion of the lung and results in lower oxygen levels. In patients with severe asthma, tranquilizers and sedatives may depress breathing which worsens attacks with possible life-threatening results. These patients should always avoid these agents.
New Devices and Asthma
Combination Sprays
Combination sprays containing both a bronchodilator and an inhaled corticosteroid are likely to become available. One example is Seriflo by Glaxo, which will combine the long-acting B2-adrenergic agonist salmeterol with the inhaled steroid fluticasone. A combination spray containing two bronchodilators (Combivent), albuterol and ipratropium bromide, has already been marketed in the United States.
Battery-Powered DPI
One of the disadvantages of current DPls is that they are "breath activated." A patient who is unable to inhale vigorously may not receive a full dose of medication. A battery-driven, multiple dose DPI should be available in the near future. A device known as Spiros has been developed by Dura and is awaiting FDA approval. This device has a battery operated motor that provides the energy necessary to whip the powdered drug into an aerosol that can be inhaled. Recent studies of the Spiros device have shown consistent levels of drug delivery to human subjects. Albuterol, beclomethasone, and ipratropium bromide are expected to be made available in a Spiros delivery system within the next two years.
"Soft Mist" Inhaler
A novel alternative to both CFC-containing MDls and DPls is the RESPIMAT device (Boehringer Ingelheim), which is currently under study. This handheld, multidose device uses mechanical power from a spring rather than gas propellants to release doses of solutions for inhalation through a system of nozzles. Studies of this "soft mist" inhaler have revealed that it delivers greater lung deposition of medication compared to propellant MDls and most DPls. This greater delivery of medication may allow asthmatics to be treated with lower daily dosages of medication.
The Next Generation
The next generation of asthma medications will most likely provide more sustained relief of symptoms with fewer puffs of medication. This should allow patients to use medication once or twice a day and still maintain control over their asthma. These new drugs will also be more specific antagonists of the chemicals that produce inflammation and bronchoconstriction. Future treatment of asthma will also likely include an anti-IgE vaccine that prevents allergic reactions and reduces the frequency of asthmatic attacks.
Some simple guidelines are helpful in preventing exercise-induced asthma. First, do not exercise if you have been experiencing frequent attacks or are still recovering from a recent attack. After an attack, consult your physician before you embark on or resume an exercise program. Second, always premedicate with either a B-agonist and/or cromolyn sodium as directed by your physician. Third, always perform warm-up exercises followed by a brief rest before starting your full workout. Fourth, wear a face mask or scarf across your nose and face to warm inspired air if you exercise in the cold. If you experience any difficulty with exercise, tell your physician so you can obtain his or her instructions on adjusting your routine. It would help your physician review your case if you obtain peak flow measurements recorded at the time of distress.
How Does Conditioning Affect Asthma?
Recent evidence suggests regular conditioning exercises may have a favorable effect on asthma and the use of medications. Conditioning increases the muscle fitness and improves your body's ability to supply oxygen as fuel. Regular exercise eases breathing effort and increases stamina.
A recent study demonstrated that conditioning of patients with asthma resulted in a greater degree of dilatation of the bronchial tubes after exercise, an effect that reduced their potential for exercise-induced asthma. Clearly, if patients follow these guidelines for preventing exercise-induced asthma, they may benefit greatly from regular exercise.
How Does Conditioning Affect Asthma
Recent evidence suggests regular conditioning exercises may have a favorable effect on asthma and the use of medications. Conditioning increases the muscle fitness and improves your body's ability to supply oxygen as fuel. Regular exercise eases breathing effort and increases stamina.
A recent study demonstrated that conditioning of patients with asthma resulted in a greater degree of dilatation of the bronchial tubes after exercise, an effect that reduced their potential for exercise-induced asthma. Clearly, if patients follow these guidelines for preventing exercise-induced asthma, they may benefit greatly from regular exercise.
Tips for exercising with asthma
* Make sure the people you are exercising with know you have asthma.
* Increase your fitness levels gradually.
* Always have your reliever inhaler with you when you exercise.
* If exercise triggers your asthma use your reliever inhaler immediately before you warm
up.
* Ensure that you always warm up and down thoroughly.
* Try not to come into contact with things that trigger your asthma.
Asthma - Which System Is Better For Your Child, Symptom Recognition Or Peak flow?
Every child is different, and the choice of a system will depend on your individual child. Let's look at how two children, Tyrone and Tammy, learned to gain control of their asthma by these two systems.
Tyrone, twelve, has had asthma for six years. His asthma symptoms used to appear anytime he caught a cold, especially in the first few days, when he'd wake at night, coughing and wheezing. As his cold improved, his night symptoms disappeared, but the cough hung on for about ten days.
His doctor had given Tyrone a quick-relief (albuterol) inhaler with a spacer to use whenever he had a cold. That solution had worked well-until recently. Tyrone began to need his inhaler even when he didn't have a cold. He used it when playing basketball because he got short of breath and started coughing five minutes into a game.
After three months of increasing symptoms, he went back to his doctor. Tyrone's lung function tests had decreased. His peak flow meter reading was 68 percent of his personal best. His doctor started Tyrone on inhaled corticosteroids, gave him an asthma management plan, and told him to begin the plan whenever his symptoms start to change: for example, when he needs albuterol twice in one day, and again when he feels short of breath.
At a follow-up appointment three months later, Tyrone reported that he could play basketball without problems. But when he caught a cold, the wheezing and coughing made him miss two weeks of school. When the doctor asked if he was following his management plan, Tyrone said he started it after he'd had the cold for two or three days.
That was the problem. His physician explained: "You need to begin your management plan as soon as you start waking up at night with wheezing or coughing, or when you need to use your albuterol two times in one day, because those are signs your asthma is starting to flare." Tyrone agreed and added that he could usually tell when his asthma was about to get worse because he'd feel a tightness in his chest the day beforehand. By his next follow-up visit, Tyrone had absorbed the lesson. He'd had one cold but started his management plan immediately and didn't miss any school.
What can we learn from Tyrone? This young man has good symptom recognition. He can spot early signs of a flare and recognize when his asthma is getting worse. And he learned to use his management plan to enable him to control his asthma.
Let's look at another child, ten-year-old Tammy:
Tammy had been feeling well, with no apparent symptoms, when she suddenly couldn't breathe. Her father rushed her to the nearest ER. A week later, she had a follow-up appointment with her pediatrician, who also happened to be Tyrone's doctor. Tammy reported that she has no problem playing soccer. She is her team's goalie and never coughs or wheezes at games. When the doctor asked why she played goalie, Tammy said she got out of breath faster than her teammates so the coach made her goalie.
The doctor started Tammy on inhaled steroids and gave her the same management plan as Tyrone's. On a three-month follow-up visit, Tammy excitedly told the doctor that she could now keep up with her teammates on the field, had switched positions to offense, and scored her first goal. But Tammy and her mother were confused about something. A month ago, Tammy again got sick suddenly and went to the emergency room. Her spirometry was improved but not to the normal range.
Her doctor asked about her medicine use. Tammy had been taking her daily medicines but hadn't started her management plan at any time during the last three months. So the doctor taught her how to use a peak flow meter. Green, yellow, and red zones were set based on her persqnal best and her spirometry.
A few months later, Tammy told the doctor that she was doing fine no problems in sports and no sudden asthma flares that sent her to the ER. Her peak flow readings were all above 230, except for one week when they dropped into the yellow zone. Then she started her management plan and her peak flows returned to the green zone within five days. Interestingly, Tammy didn't notice any difference in symptoms during that time.
What can we learn from Tammy? Some children have flares without obvious symptoms. Peak flow meters are perfect for youngsters like Tammy. Many people recognize symptoms before changes in their peak flow readings, while others see a drop in peak flows before they notice any symptoms. Tyrone's and Tammy's experiences represent two typical situations: either symptom recognition or a peak flow meter will work for different children. You and your doctor will decide which way works best for your individual child.
Asthma Care In The Home
Home care is a growing area of medicine that is very applicable to asthma. In addition to teaching about asthma in the comfort of a child's usual setting, home care staff can check asthma equipment, such as nebulizers, and assess the condition of the home. Eliminating allergens and improving the air quality of a home can dramatically improve asthma symptoms for some children. Some health insurers recognize the value of home visits and may provide these services in selected cases. If you feel that a home visit would be helpful for your child, discuss this possibility with your primary care provider.
An asthma nebulizer, also known as a breathing machine, changes asthma medication from a liquid to a mist, so that it can be more easily inhaled into the lungs. Home nebulizer therapy is particularly effective in delivering asthma medications to infants and small children and to anyone who is unable to use asthma inhalers with spacers.
Making The System Work For Your Child
Many different types of health services are available for children with asthma. Most children will do well with simple interventions, but if your child is having difficulty, it is important to ask about what else can be done. Obtaining additional services may require
approvals from your primary care provider or insurance company. Well run insurance companies have recognized that although these services cost money, in the long run they may prevent expensive emergency visits and hospital care.
Since asthma is such a common condition, many insurance companies have developed asthma programs that attempt to identify children who are not doing well and link them with services such as home nursing visits, asthma education classes and printed materials, and asthma specialists. A case manager, often a nurse or social worker with experience in asthma, may be assigned to your child to help make sure that appropriate services are provided. You may want to ask your insurance company about the availability of such a person. If not, don't hesitate to advocate for your child and take on this role with the help of your primary care provider.
Although caring for a child with asthma can be a daunting journey, many supports and services are available to help families along the way. Viewing asthma care as a team approach your family, your primary care doctor, nurse practitioner, office staff, and others as needed will help make treating asthma smooth sailing for your child.
Asthma treatment via Honey
Honey is one of the most common home cures for asthma. It is supposed that if a jug of honey is held beneath the nose of an asthma patient and he inhales the air that comes into contact by means of it, he starts breathing easier and deeper. One of the popular home remedies for asthma.
Asthma treatment with Figs
Amongst fruits, figs have proved very precious in asthma. They provide comfort to the patient by draining off the phlegm. Three or four dry figs must be cleaned thoroughly with warm water and soaked during the night.
Asthma and the Health Care System
Parents of children with chronic diseases know all too well, there's more to caring for a child than giving medicine and getting to doctors appointments. There's also a sea of bureaucracy the "health care system" of insurance forms, referrals, specialists, bills, copays, deductibles, prescriptions, medical devices.
Caring for a child with asthma may sometimes feel like a journey across unfamiliar waters. Your primary care provider's office may serve as a home base, but other important ports of call may include subspecialists, visiting nurses, medical supply companies, and other providers. Unfortunately, the coordinates for this journey are not mapped out clearly for you in advance. Our health care system is complex and ever changing. Financial and bureaucratic obstacles still prevent many children from receiving the care they need.
Social workers can help families work through these challenges. You are fortunate if a social worker is playing an active role on your child's team. If not, an experienced social worker has contributed information to this topic that will give you insight into successfully navigating the health care system. You can use this information to help create a team that includes your child's doctor and other health care professionals. Parents should not have to carry the burden alone.
Private Health Insurance
Asthma care and medicines are expensive, and obtaining the right health insurance is an important first step in accessing the health care system. Recent changes in the law provide the opportunity for virtually every child in every state to qualify for some form of health insurance. The rules and steps involved are complex, however, and may leave many gaps in the care that is provided. Gone are the days when parents could assume that any type of health insurance would pay for all the care that a child with asthma requires.
If your child has private insurance through your employer, you need to explore what it covers. Inpatient (in-hospital) and outpatient (office) benefits may be treated differently and may include copays and deductibles that come out of your pocket before the insurance coverage starts to pay. Some insurance plans provide full payment only to providers who are within the plan's own "network." If this is the case, it's important to be sure that the network includes your child's primary care doctor or pediatrician, nurse practitioner, and other health care professionals. A referral from your primary care provider may be needed
for the insurance plan to cover fully any specialists, such as allergy or pulmonary doctors.
With the increasing costs of medicines, most insurance companies have cut back on prescription plans. Many plans include copays, prior authorization, or require the use of a mail order prescription company. Generic forms of some asthma medicines are available and may result in lower costs if prescribed by your doctor or nurse practitioner. By and large, generic drugs for asthma work just as well as name brands.
If your insurance does not cover prescriptions, there are other options to consider. Some pharmaceutical companies offer assistance plans; information can be obtained by contacting the individual company directly. Clinical research trials also will sometimes cover the cost of medicines. Information about clinical trials can be obtained through drug companies, your physician, or through an Internet site set up by the National Institutes of Health. Durable medical equipment, such as nebulizers and other home care needs, are covered differently by insurance plans. Some forms of equipment, such as spacers, can be ordered at low cost from organizations such as the Allergy & Asthma Network: Mothers
Asthma - The Challenge: Remembering To Take Daily Medicines
Asthma is a chronic, or long-term, disease. If you have asthma, at times your airways (the air passages of your lungs) become inflamed (see picture). When this happens, your airways get red and swollen. They become narrow, making it harder for you to breathe. You may also wheeze or cough. This is called an asthma flare-up (or "attack").
A big part of keeping asthma under control and preventing flares is to make sure your child takes everyday medicines regularly even when feeling well. This isn't easy, but it is critically important to managing asthma. Nobody likes to take medicine every day. People remember to take medicine when they are sick because they want to feel better. But it's normal for children, as well as adults, to overlook daily medicine when they feel fine.
Although there is no cure for asthma, there are some excellent medicines available to help you to control your asthma so that is does not interfere with your daily life. There are two main types of medicines for asthma:
* Quick-relief medicines—taken at the first signs of asthma symptoms for immediate relief of these symptoms. You will feel the effects of these medicines within minutes.
* Long-term control medicines—taken every day, usually over long periods of time, to prevent symptoms and asthma episodes or attacks. You will feel the full effects of these medicines after taking them for a few weeks. People with persistent asthma need long-term control medicines.
Parents can take several steps to make taking asthma medicines a normal part of life and not a daily battle.
Explain why the medicine is needed. Because children and adults feel the benefits of quick-relief medicines right away, they immediately understand why they need them. Taking everyday medicines to prevent symptoms is a bigger challenge. Explain, in language your child will understand, that this medicine keeps asthma away just like daily toothbrushing keeps cavities away.
Be firm and matter-of-fact without nagging. Once your child understands that taking the daily medicine is simply the way it is-it's not negotiable or optional he'll accept the situation. And you can always say, "The doctor said."
Set a routine. Many parents find that setting up a regular routine helps their child remember to take the medicine every day at the same time. If your child uses inhaled steroids, for example, a good time to take the medicine would be right before he brushes his teeth in the morning and at night. This helps him take the medicine regularly, and it also makes sure he rinses out his mouth after using it. For any once-a-day medicine, set a time to take the medicine, such as at breakfast or dinner.
When your child first starts to take everyday asthma medicines, you and he probably won't notice much improvement right away. Improvement happens gradually, usually over several weeks. After a couple of months on the medicine, your child should have fewer or no asthma symptoms. At this point, help him look back over the past couple of months. When you count up all the nights he slept straight through and the days he went to school and played normally, you'll both realize that the everyday medicines really are helping. That should do a lot to help everyone stick with the medicine routine.
Traveling With A Child Who Has Asthma
Mindy is a toddler with mild persistent asthma. She had never been hospitalized or treated in the emergency room. On a family trip to Florida, she ended up in the emergency room with an asthma attack. This took her parents totally by surprise because her asthma had always been under control. She was treated at a local hospital emergency room that did not specialize in pediatrics. Mindy did well, but this little detour in the family vacation certainly fright ened her parents.
When planning any trip, you map out a route and make reservations. When you pack for a trip, you consider where you are going, how you will be getting there, how long you will be away, and what the weather will be like. You don't just randomly throw things into a suitcase. You select the right type of clothes and accessories (such as sunscreen), make sure they are in good condition, and pack them so you will be able to get to them when you need them.
Asthma never takes a vacation, so asthma therapy shouldn't either. Planning ahead to keep asthma under control during travel requires similar planning. When you're prepared, there should be no interruption in therapy during travel. Being prepared means figuring out in advance where you can get expert treatment if your child develops an asthma flare, both along the way and at your destination. Think about the environment you will be visiting. Is it dry, dusty, damp? Could there be potential triggers to which your child isn't normally exposed? Remember that your child may seem fine, but in an environment away from home, you never know what triggers your child might encounter.
Your daily schedule on a trip will probably differ from routines at home, so figure out when asthma treatments can be realistically given during the trip, make a schedule, and stick to it. If you miss a dose or two, your child could possibly develop a flare, and that would put a damper on your plans.
Some other travel tips are:
Make sure you have a full supply of controller and quick-relief medicines, as well as their necessary delivery devices. A vacation is not the time to let your teenager use his inhaler without the spacer just so he doesn't have to pack it.
Bring contact information for your child's physician or nurse practitioner, and pharmacy.
Be sure to take along a copy of your child's asthma management plan.
If you are planning a car trip that will take more than a few hours, plan treatment stops along the way. It is safer and more efficient to give medicine especially inhaled medicine when the car is stopped so you can give your full attention to the treatment.
Before you leave home, identify hospitals at your destination where you can go for urgent care, just in case.
Asthma and Camp
Dylan went to camp for the first time last summer. His parents did everything right. They organized all his medicines, sent an extra spacer, got him a special backpack to hold his medicines for day outings, and gave the camp nurse a copy of his asthma management plan. So what could possibly go wrong?
Dylan loved camp. He made new friends in his bunk, learned to swim, and showed no asthma symptoms until the third week of camp, when his group went horseback riding. Dylan excitedly climbed on his horse and within a few minutes his eyes started to itch and water. His nose got congested, and he started sneezing. An alert counselor took him back to the infirmary where the camp nurse treated his allergic reaction, gave him a dose of albuterol, and Dylan quickly improved. The nurse then called Dylan's parents to notify them of his allergic reaction to the horse, report that he was fine again, and suggested that they have him evaluated by an allergist.
Everything worked smoothly for Dylan in this case, but his parents learned that they must make sure they know ahead of time how medical emergencies will be handled. If you're planning to send your child to day or overnight camp, ask about the camp's policies and procedures for emergencies and what medical personnel will be available to handle them.
Whenever Some Else Is In Charge
Common sense and planning are essential when children with asthma: go away from home without a parent. You need to communicate with anyone who will be taking care of your child. This includes relatives, baby sitters, day care personnel, teachers, coaches, school nurses, friends' parents, camp counselors, and other adults who will be responsible when you aren't with your child. Keep in mind that many people don't have an accurate understanding of asthma. A lot of old myths about asthma are floating around that people still believe are true (common myths are listed in Resources).
Here is a basic list of what other adults need to know:
Names of your child's medicines
When to give them (daily and/or when symptoms occur)
How to give the medicine
What symptoms indicate a problem
What to expect from the medicine (for example, they shouldn't expect immediate relief from a long-term controller medicine but should from a quick-relief medicine)
What to do if the child doesn't improve or gets worse after taking a quick-relief medicine
Who to call in an emergency (parents' work/cellular numbers, backup person if parents aren't reachable, child's physician, ambulance, nearest hospital)
Much of the above will be listed in your child's written asthma management plan, a copy of which should be given to those who are caring for your child.
If you don't know the answers to all these points, sit down with your child's physician or nurse practitiqner and come up with a list together. Request prescriptions that you need now or in the near future, especially if you're planning a trip. Do you need an extra spacer, inhaler, or nebu-lizer that will stay at day care, school, camp, or Grandma's house? It's just a matter of being prepared.
Asthma and Sleepovers
Jasmine was doing well when she was invited to sleep over at her friend Katelynn's home. Jasmine's mother didn't know that Katelynn had a dog and a cat. At the time of the sleep over, Jasmine's asthma was under good control. She was doing so well, in fact, that her mom forgot to tell Katelynn's parents about her asthma and her allergy to dogs and cats.
Soon after arriving at Katelynn's, Jasmine developed a stuffed up, runny nose and began sneezing. With three other children visiting for the evening, Katelynn's mother didn't think much about it. She noticed that Jasmine was sneezing quite a bit, but she knew that several school friends had been passing colds around that week.
During the night, Jasmine coughed and wheezed so much that she woke herself up. She knew she was starting to have an asthma flare and called home. Her dad came and picked her up in the middle of the night. As soon as they got home, they started her asthma management plan and she improved quickly. But it was an embarrassing lesson for Jasmine and a serious one for her parents. They decided that the next time she was invited to a party or a friend's home, they would talk to the host family about possible triggers in their home. They would also give Jasmine medicine before going to the friend's house, talk about possibly having the party at another location away from pets or other triggers, and would send medicine with a copy of her asthma management plan with her.
Children with asthma want to sleep over at friends homes just like other children. In general, parents have to decide if the environment will be okay for them. Children shouldn't be in a position offeeling sick but too embarrassed to tell anyone a recipe for a serious flare. Some general guidelines include:
The sleepover site should be "tobacco smoke free" and have no pets if your child is allergic to them.
It will probably not be dust free, but you can send along a sleeping pallet (something as simple as a thin blanket or plastic sheet) in addition to her sleeping bag to create a barrier between your child and the carpet.
Once you decide that she is allowed to sleep over, contact the adult in charge regardless of what your child says. Let your child know that this adult needs to be aware of how to help her if she starts having problems.
Talk to your child about possible activities that may happen at the sleepover (like pillow fights that would produce clouds of dust). Also talk about where she would feel comfortable taking her medicines and when would be the best time. Encourage her to be open with her friends about having asthma.
Make a pouch with her quick-relief medicines, her control medicines, and her asthma management plan.
If it's her first time staying at a new place, take the time to review the plan with the adult in charge. As your child gets older, she should be able to take on more responsibility to the point where she can manage her medicines independently. Let her know that ultimately the goal is for her to take control of her asthma.
Asthma Specialty Care
Asthma causes the airways of the lungs to swell and become narrower. This can make it hard to breathe and cause wheezing as you breathe in and out. Asthma cannot be cured, but can be relieved with medicine. Repeat attacks are common.
Specialty care for asthma can be confusing because each type of provider may have a different focus. Pediatric allergists specialize in the reactions of the immune system to common environmental allergens, such as pollens, dust mites, or pet dander, that can playa key role in asthma. Allergists use skin tests to detect allergies and may, in some cases, treat allergies by giving repeated small doses of the allergen . Pediatric pulmonary medicine physicians (also known as pulmonologists) specialize in lung diseases in children. These physicians perform lung function tests and procedures such as bronchoscopy, where a small camera is used to look inside the lung. Both allergists and pulmonologists treat asthma with the conventional medicines .In specific cases, however, they may have a somewhat different approach to diagnosis and management of asthma.
Whether your child needs to see a specialist is an individual question to be discussed with your primary care provider. In most cases, mild asthma can be managed successfully by your regular physician or pediatrician. But a specialist can be very helpful if your child does not seem to be responding well to treatment or if your primary care provider has specific concerns and suggests that further testing may be needed. Beyond having added experience and training, specialists usually schedule extra time to delve into the specifics of more difficult cases. Since they focus on asthma, they may also have educational material,
support staff, and other resources that can be very useful to you and your child.
Visiting a specialist may pose some potential problems. With more than one provider now treating your child, there is the potential for confusion and miscommunication. It's important to make sure that information flows well between the specialist and your primary care provider, who will continue to prescribe your child's medicines and see your child for acute illnesses.
Asthma Action Plans
Everyone should have an Asthma Action Plan. It will help keep your or your child's asthma under control by reminding you what triggers to avoid, which medicines to take and when to take them. The Asthma Action Plan will also tell you what to do when you have a good or bad asthma day. You and your health care provider should review and update the Asthma Action Plan at each visit.
Treatment Strategy: Severe Childhood Asthma
Severe childhood asthmatics require the addition of oral corticosteroids. These patients continue to have several attacks a week and reduced airflows despite maximal therapy. The adverse effects are similar to those of adults but are more significant in regard to growth and bone development in the youngest patients. Alternate day therapy should be attempted for patients who require maintenance therapy due to severe disease.
The National Asthma Education Program Report
The National Heart, Lung, and Blood Institute (NHLB) and its National Asthma Education Program (NAEP) convened a panel of experts on the management of asthma who released a comprehensive report ("Guide-lines for the Diagnosis and Management of Asthma") in 1991. This excellent resource included a suggestion for a "traffic light system" that would allow patients to easily remember how to manage their asthma. This green-yellow-red zone system has been adopted by many physicians and has been included in at least one peak flow meter design.
The Green Zone
As defined by the NAEP the green zone is a safe area in which the asthma patient experiences few or no symptoms. Peak flow measurements are 80 to 100 percent of a patient's predicted normal value or personal best with no more than a 20 percent swing in values. Medications are individualized for each patient, whether they are mild, moderate, or severe asthmatics.
The Yellow Zone
The yellow zone outlined by the NAEP signals "caution." The patient has peak flows that are 50 to 80 percent of his or her predicted normal or personal best and/or asthma symptoms that may include nocturnal attacks, coughing, wheezing, decreased activity, and chest tightness. This "zone" indicates that medications should be adjusted according to the management plan suggested by the physician. Patients who make frequent visits to the yellow zone should have their maintenance medications reviewed and adjusted.
The Red Zone
The red zone signals a "medical alert."Peak flows are below 50 percent of the predicted value or personal best and asthma symptoms are frequent, including at rest. The patient's management plan should immediately be put into place for this degree of attack, as previously outlined. Typically, this calls for immediate use of a B-agonist and introduction of oral corticosteroids. Patients who do not respond require immediate medical attention, usually an emergency room visit. Patients who fall into the red zone should certainly have their maintenance asthma program reviewed and adjusted.
Should This Terminology Be Used?
The simple terminology suggested by the NAEP may be helpful to patients in managing their asthma. For anyone familiar with traffic signals, it is certainly easy to remember. Peak flow meters with green-yellow-red colored scales or stickers are available. Remember, however, that treatment decisions should be based on prior consultation with the physician and the patient's record of personal best flows and not by color zones alone. Each patient should have green, yellow, and red zones defined with written guidelines for treatment decisions.
Putting Your Strategy to Work
Asthma has been defined as mild, moderate, and severe and specific treatment strategies proposed for each category. A system based on traffic signal colors has been introduced. Whatever strategy is used for the treatment of asthma, its success depends on a working partnership between patient and physician. Up to this point the physician has directed treatment and provided guidelines.
Asthma - At Day Care And School
Kia's asthma was diagnosed when she was a year old, only a few months after she started attending a day care program. Her parents gave copies of her asthma management plan to the day care director and Kia's teacher. They reviewed the plan to be certain that everyone could recognize symptoms and give Kia quick relief medicine when necessary. At home, her parents gave her controller medicine each morning and evening. Except when triggered by occasional colds which seem to make perpetual rounds of day care centers-Kia's asthma was well controlled for the four years she attended day care. When she began elementary school, her parents again made her teachers and other school personnel aware of her asthma, gave them copies of her management plan, and made sure they understood how to implement it.
By the time Kia started middle school, her asthma was so well controlled that her parents let down their guard. Kia was now old enough to recognize symptoms herself, and she always carried a quick-relief inhaler and spacer in her backpack. Her parents didn't bother to contact the middle school personnel about her asthma. But after a few months in middle school, which was an older building, Kia's symptoms appeared more frequently. She still used a controller medicine at home, but her parents noticed that she was coughing more at night and often seemed short of breath,
With a little gentle prodding, her parents discovered that Kia had been using her quick-relief medicine much more often. They took her to the doctor who did a spirometry breathing test, reviewed the technique for administering her metered dose inhaler and spacer, and wrote new prescriptions with refills. In the end, they agreed that Kia's recent problems were probably related to triggers at school.
Her parents called the school nurse and told her of Kia's condition. They said they would send in a copy of Kia's asthma management plan and asked the nurse to review it with Kia's teachers. The nurse said she was happy to cooperate and mentioned, almost as an aside, that since she had started working at this middle school a few years ago, she was seeing a lot
more students with asthmas.
Kia's story had a happy ending. The school nurse and her teachers kept an eye on her, watched for symptoms, and quietly reminded Kia when to use her inhaler and spacer without making a big deal of it or drawing attention to her. More importantly, the school nurse took the lead in alerting the principal and faculty to the growing incidence of asthma at their school. By the end of the year, the old building had been thoroughly cleaned air ducts, vents, radiators, shelves, ceiling tiles. As a school community, the PTA and staff made it a priority to be better informed about asthma and to keep triggers to a minimum.
One of the primary goals of successful asthma control is for children to be able to attend and participate in all day care and school activities. Since parents cannot guarantee this goal entirely on their own, the best way to achieve it is to work cooperatively with school and day care personnel. Some suggestions for doing that include:
At the beginning of each school year, contact your child's teacher, school nurse, and any other personnel who are in contact with your child and inform them that she has asthma.
Provide written instructions for your child's medicines and devices (nebulizer, MDI/spacer, DPI, or peak flow meter) to make sure your child doesn't miss any doses of medicine.
Ask your child's doctor or nurse practitioner to fill out the necessary paperwork well ahead of time so your child won't miss any doses of medicine.
Fill out school forms at the start of every school year. If your child's school has it own form with instructions for administering medicine, fill it out completely and be sure that your physician completes and signs the appropriate part. Attach a copy of your child's asthma management plan to the forms.
When a permission slip comes home for a class trip to a zoo, farm, or other destination where your child might encounter asthma triggers, attach a note to remind the teacher to look over your child's asthma management plan and take along contact information (for you and your child's doctor or nurse practitioner) in the event a flare occurs.
Treatment Strategy: Mild Childhood Asthma
In mild intermittent childhood asthma the initial treatment is use of the B2-adrenergic agonist. Due to difficulty using MDIs in younger patients (under age five) there must be increased reliance on nebulized medication and oral preparations (tablets or elixirs). A trial of the powder form of a B-agonist such as albuterol may be easier for a child to use than a metered dose inhaler. Use of an MDI with a spacer with face mask attachment may be particularly helpful in young patients, to ensure better delivery of aerosol medication. As with adult patients there is a greater chance of side effects (nervousness, tremor) in a child receiving oral or nebulized medication.
Children with mild persistent asthma should add an anti-inflammatory agent such as cromolyn or nedocromil to the B2-adrenergic agonist. Cromolyn is the preferred choice due to the absence of total body effects. It is approved for children aged five and older with insufficient data for younger patients. Cromolyn is available for nebulizer use, which may be more suitable for younger patients as well as an MDI. Nedocromil has been approved for children aged six and older and is only currently available as an MDI. A nebulizer preparation of nedocromil should be available shortly. Alternative agents include the anti-leukotriene montelukast and the inhaled corticosteroids.
The inhaled corticosteroids have been found to affect bone growth and adrenal function in children in dosages above 400 p.g per day but are considered safe up to this dosage. A DPI preparation of fluticasone (Flovent Rotadisk) has recently been approved for children four years of age and older. The side effects of using higher dosages of inhaled corticosteroids in children should be weighed against the effects of uncontrolled asthma. There is insufficient data on the use of the inhaled corticosteroids in children below the age of four.
Treatment Strategy: Moderate Childhood Asthma
Children with moderate persistent asthma experience daily symptoms and have more than two attacks each week. These patients require higher dosages of the inhaled corticosteroids and the addition of a long-acting B2-agonist such as salmeterol. The anti-leukotriene montelukast may also be used as an alternative anti-inflammatory agent.
Salmeterol
The long-acting B2-adrenergic agonist, salmeterol, may be used for the control of moderate persistent asthma in children aged five and older. The pediatric dosage is one to two inhalations every twelve hours. Children with primarily nocturnal symptoms may use one dose nightly.
Theophylline
Theophylline should be considered for use in the childhood asthmatic who is uncontrolled on the above therapy. Unfortunate side effects such as nervousness, however, limit its usefulness. Recent studies have raised the question of a learning disability that may be attributed to theophylline. Additional adverse effects are stomach upset and headache. As in adults, blood levels must be monitored to ensure an effective therapeutic level.
Anticholingergic Agents
The anticholinergic agent ipratropium bromide may be used in children aged twelve and older as a second or third-line agent. Since most childhood asthmatics are allergic, it is not likely that this agent would provide significant bronchodilatation. It is available in a nebulizer form as well as an MDI.
Asthma and Public Insurance
If you do not have private insurance, several options are available for public insurance. These programs use funds from the federal government but are organized differently in each state. You can learn the specific rules for your area by calling your local county Board of Assistance. Medical Assistance (also known as Medicaid) offers coverage to children under the age of nineteen based on income, residency, and other requirements. Many state Medicaid programs involve managed care plans that have rules about specialty care similar to private insurance plans.
In 1997, the federal government established the Children's Health Insurance Program (CHIP) to expand the availability of health insurance coverage to working families beyond what Medicaid provides. The federal government funds the states to help pay for this program. Since the program is administered by each state, the specific rules may vary in your area. In most states, children from a family of four, with earnings up to $34,100 per year (in 2002), are eligible. More information about the CHIP program can be obtained by calling 1-877-KID-NOW
Some children with chronic diseases like asthma may be eligible for Supplemental Security Income (SSI) as determined by financial and medical criteria. There are strict guidelines, but an eligible child may receive cash assistance as well as medical insurance. Information about SS1 can be obtained through the Social Security Administration at 1-800-772-1213 or through your local Social Security office.
Primary Care
Every child should have a primary care provider for well-child checkups and immunizations. With a chronic disease like asthma, it is particularly important to see consistently the same physician, nurse practitioner, or other professional over time so the primary care provider can get to know your child well. This primary care provider will play the lead role in assessing your child's asthma, prescribing medicines, and making referrals for other services or specialty care if needed.
Primary care providers differ in many ways, including their training background (for example: family medicine, pediatrics, and nurse practitioner programs), the structure of their offices (private office, hospital, or public clinic), and the size of their practice
(a single provider or a large group). Choosing a primary care provider is a personal decision, but several factors are important
to consider when your child has asthma. Experience with young asthma patients: The provider should be familiar with treating asthma in the pediatric age range. Children have many unique needs that require a treatment approach different from that for adults.
Access: Since asthma flares can occur at unpredictable times, you should always be able to reach someone for advice. Many offices are open for evening and weekend hours, which can be very convenient for working parents.
Support systems: Last but certainly not least, the other staff and support services are important. A friendly, accessible office staff and a well-organized system for teaching about asthma, refilling prescriptions, and following through on patients needs can add a great deal to your child's care. Some offices may have specifically trained staff, such as social workers or case managers, available to help with obtaining services. A team approach to primary care has the most to offer.
Asthma - School Policies On Medicines
Some schools don't have a full-time school nurse, so ask the principal or your child's teacher who will be responsible for giving medicine when the nurse is not in school. Policies about children carrying and taking their own medicine vary, depending on state and school regulations, so it's important to learn your local policies and plan ahead before a crisis arises.
The use of medicine in school can be controversial. Health experts agree that children with asthma should have ready, easy access to their quick-relief medicines. But medicine is included in many schools "zero tolerance" drug policies, so students are not permitted to keep medicine in their pockets, bookbags, or lockers. Although it is very rare, prohibiting students from carrying medicine with them has had fatal results. The worst possible result, reported by the New York Times in 2002, was the death of a child who developed asthma symptoms in school but had not been allowed to carry his quick relief medicine with him. By
the time he received any medicine, it was too late.
This rare tragedy highlights the need for parents to be proactive and educate not only their child's teachers but also school administrators about asthma and its consequences. Parents can make a difference by becoming involved when school boards make policies that could be a matter of life and death.
Triggers At School
The risk of exposure to triggers is another important consideration at day care or school. You may have done everything necessary to remove asthma triggers from your home, but your child spends six or more hours each day in school or day care. Take a look around that environment. In Kia's old middle school building, triggers were easy to spot. But most schools whether the building is new or old contain a slew of asthma triggers: dust in carpeting or from chalk; class pets (those cute gerbils, hamsters, and rabbits); cockroaches; strong odors and chemicals used in science, art, or other classes and for cleaning the school; and smoke. Although smoking should be banned in schools, it still occurs.
As an individual parent, you can influence some positive changes if you discuss asthma triggers with school personnel. You can request that animals be removed from the classroom and moved elsewhere. If your child is bothered by chalk dust, he could be seated farther away from the blackboard. If he naps at day care or school, provide his own pillow with a protective covering. Suggest to the school principal that cockroaches are reduced by thorough cleaning, especially in the kitchen and cafeteria areas and through regular exterminating treatments and use of traps. Exterminating, cleaning with chemicals, or maintaining the grounds (mowing the grass or playing fields) should be done before or after school hours.
If you don't want to stand out as a solitary critic, find other parents of children with asthma and approach school administrators as a small group to make these recommendations. At home, you work hard to keep your child's asthma under control, so don't hesitate to ask others to make a collective effort to protect all children with asthma from triggers at day care and school. Children shouldn't miss school because of this disease. They should be able to pay attention to their schoolwork, participate in all activities, and rarely need to take quick relief medicine if triggers are eliminated.