It may not require a village, but sometimes it takes a well coordinated team to control a child’s asthma.
Asthma is a complex inflammatory disease of the lungs and airways that affects more than 20 million children and adults in the United States. Anyone of any age can have asthma, but it disproportionately affects poor children and adolescents living in crowded urban areas with, sometimes, limited access to quality health care.
Particularly during certain times of year, the disease can cause symptoms severe enough to send many children to the emergency room or to hospital inpatient admission. On the other hand, with a dedicated treatment team, better understanding of the disease and daily attention, most patients can avoid these episodes and live a fairly normal life.
Inflammation of the airways is a major factor in asthma. The body’s immune system produces an inflammatory reaction in response to what it considers a threat: bacteria, viruses, pollen, dust or other irritants. A person with asthma is hyper sensitive to these irritants and over-reacts, causing additional problems.
• The lining of the airways becomes inflamed and swollen, leaving less room for air to move through.
• The muscles around the airways tighten and cause what is known as a bronchospasm.
• Excess mucus is produced, making it even harder for air to move through.
The result is coughing, wheezing, tightness in the chest and shortness of breath, particularly in reaction to certain triggers.
Emergencies Can Be Prevented
These can be very frightening, and, in fact, about 200 American children die of asthma-related issues every year. But emergencies can be prevented with careful use of medications and understanding of triggers.
Over the long term, inflammation can be lowered and managed with antiinflammatory medications taken daily to keep asthma symptoms from occurring in the first place. These drugs include inhaled corticosteroids, cromolyn sodium, long-acting beta2-agonists, leukotriene modifiers and theophylline. They work slowly and cannot be expected to have an instant effect.
For quick relief, when and if symptoms do occur, rescue medications such as short-acting beta2-agonists, must be prescribed and handy for use. These act quickly to relax the tightened muscles around the airways.
Finally, a person with asthma has to be aware of certain triggers in the environment–allergens, pollen, dust, molds, cigarette smoke, air pollution, cold air or exercise. For some of these, such as allergens, medications may be useful; generally speaking, though, the patient must learn to avoid these triggers whenever possible and be ready to respond should they trigger an attack.
With so many variables in terms of severity of disease, medications, individual triggers and the environment, most doctors recommend having a personal asthma action plan. By age 10, a child is expected to know and be able to follow his or her own action plan. Before that age (and, realistically, even after it for many children), the plan must be understood and followed by everyone who cares for the child–babysitters, day care staff, teachers, school nurses and camp counselors.
If all of that is not complicated enough, there is more. Most of the long-term and the quick relief medications involve not just popping a pill but using specialized devices and equipment–inhalers, spacers, discuses, compressors, peak flow meters, spirometers, nebulizers and masks.
There are many steps involved in using most of these devices properly. And a mistake means the child is not getting the proper dose and may be at risk of severe symptoms.
When emergency department staff see asthmatic children being brought in repeatedly–usually in the fall and spring when allergens are more prevalent–it’s pretty easy to figure out that at least some of these children either have no long-term Asthma Action Plan or else it is not being followed as closely as it should be.
The IMPACT DC (Improving Pediatric Asthma Care in The District of Columbia) program was based on such an observation. Doctors found that very few of the children being brought in to the emergency department were going back to primary care providers who could help them re-establish daily control of medications.
The Asthma Clinic that was established as a result made substantial use of asthma educators, reviewing with families the basics of asthma care, possible environmental triggers and the need for a coordinated treatment approach involving the family, school nurses, community pharmacists and subspeciality doctors and nurses.
A study that randomly assigned 488 children either to care within the IMPACT DC Asthma Clinic or usual followup care found that subjects at the clinic had dramatically fewer emergency department visits, significantly better use of daily controller medications and dramatic improvements in asthma-related quality of life.
Another study in 2007 at Cincinnati Children’s Hospital found that only 44 percent of patients and their families brought to the ER had an asthma action plan and only 53 percent had been told about changes they could make at home, school and work to reduce asthma flare-ups.
After establishment of a weekly clinic for teens with asthma and a mechanism to track and coordinate data and family outreach, the situation changed dramatically. Four years later, the percentage of patients with a written action plan increased to 100 percent; 85 percent of teens and their parents were now confident about being able to manage their asthma.
In each case, the clinic was considered a means to an end–greater understanding by the patient and his or her family about the importance of day-to-day self management in order to prevent short-term flare-ups.
It all starts with education–how and why to monitor your breathing and take control medications even when you don’t have symptoms.
Monitoring is done with peak flow meters and spirometers. Most medications come as sprays or powders in an inhaler. A spacer (or holding chamber) can make a metered dose inhaler easier to use. A nebulizer delivers the medicine in a fine mist rather than a spray.
All of these devices are designed to make the job of asthma control easier, but they do so only if they are used properly. The best way to learn is to have a health professional demonstrate proper use, then have you demonstrate back to them to make sure you have it right.
As frightening as the symptoms may be when an attack occurs, it’s possible to go through life with few emergencies and a normal quality of life.
REFERENCES:
Children’s Hospital–St. Louis, “Breathe easy–keep asthma under control.”
Marianne Doz, et al, “The association between asthma control, health care costs, and quality of life in France and Spain,” BMC Pulmonary Medicine, 2013;13(15).
Marcia Freilick, “Parents may not report smoke exposure in kids with asthma,” Medscape Medical News, January 20, 2014 (Pediatrics, January 20, 2014).
Diedtra Henderson, “Quality initiative boosts asthma control in teens,” Medscape Medical News, January 27, 2014 (Pediatrics, January 27, 2014).
Mayo Clinic Staff, “Diseases and conditions–asthma,” MayoClinic.com, July 13, 2013.
National Heart, Lung and Blood Institute, “So you have asthma,” NIH Publication No. 07-5248.
National Heart, Lung and Blood Institute, “How is asthma treated and controlled?”
Laurie Scudder, DNP, PNP, and Stephen J. Teach, M.D., MPH, “Asthma care in at-risk kids: can an emergency department lead the way?’ Medscape Pediatrics, November 12, 2013.
Laurie Scudder, DNP, PNP, “Do parents know how to use metered-dose inhalers?”
04/25/2014
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