Treatment:

General Approach for Treating and Managing Asthma

While medications play an essential role in the management of asthma, appropriate management of asthma involves much more:

• Identifying and avoiding allergens and other asthma triggers
• Following appropriate drug treatments
• Home monitoring performed by either patient or family
• Good communication between the doctor and patient
• Needed psychosocial support
• Treatment of asthma in all environments (school, work, exercise)

The severity of asthma has now been classified into four groupings: Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent. Six specific components of severity are used to classify patients. These components are:

• Symptom frequency, ranging from fewer than 2 days per week to throughout the day
• Nighttime awakenings, ranging from none to nightly
• Short-acting beta2-agonist use for symptom control, ranging from 2 or fewer days per week to several times per day
• Interference with normal activity, ranging from none to extremely limited
• Lung function as measured by FEV1 and FEV1/FVC, measured with pulmonary function testing at the doctor's office
• Number of exacerbations (sudden worsening) requiring oral corticosteroids, ranging from none to two or more in the last 6 months.

Once patients are placed into a certain severity grouping, there is a recommended treatment approach, which also takes into consideration three age groupings:

• 4 years old or younger
• 5 - 11 years old
• 12 years or older

Treating Symptoms Versus Controlling the Disease

Medications for asthma fall into two categories:

• Rescue (Quick-Relief) Medications. Medications that open the airways (bronchodilators or inhalers) are used to quickly relieve any moderate or severe asthma attack. These drugs are usually short-acting beta-adrenergic agonists (beta2-agonists). Other drugs used in special cases include corticosteroids taken by mouth and anticholinergic drugs. Beta2-agonists and anticholinergics do not have any effect on the disease process itself. They are useful only for treating symptoms. Frequent need for these medications indicates that the asthma is not well-controlled overall.
• Long-Term Control (Maintenance) Medications. Long-term control medications are essential to minimize long-term damage of the inflammatory response, to reduce the risk of serious exacerbations, and to enhance the overall function and well-being of patients with asthma. For adults and children over age 5 with moderate-to-severe persistent asthma, experts now recommend inhaled corticosteroids with the addition of long-acting beta2-agonists if necessary.

The goal of asthma therapy is to maximize long-term control of the illness with medications and other treatment approaches, thereby minimizing the frequency of asthma symptoms and asthma attacks. Parents can greatly reduce the frequency and severity of their children’s asthma attacks by understanding the difference between coping with asthma attacks and controlling the disease over time. Unfortunately, many patients do not understand the difference between medications that provide rapid, short-term relief and those that are used for long-term symptom control. Many patients with moderate or severe asthma overuse their short-term medications and underuse their corticosteroid medications. The overuse of bronchodilators can have serious consequences; not using steroids can lead to permanent lung damage.

These are the signs of well-controlled asthma:

• Asthma symptoms occur twice a week or less
• Rescue bronchodilator medication is used twice a week or less
• Symptoms do not cause nighttime or early morning awakening
• Symptoms do not limit work, school, or exercise activities
• Peak flow meter readings are normal or the patient’s personal best
• Both the doctor and the patient consider the asthma to be well controlled

Steps for Treating Asthma

A stepwise approach is recommended for treating asthma. Medications and dosages are increased when needed, and decreased when possible. Based on severity of patients' asthma and their age, there are specific recommendations regarding whether to use long-term control medications and which ones to use. Patient education, environmental control measures, and management of any other conditions are also included. Doctors may always adjust these recommendations based on a specific patient.

In choosing therapy, doctors must also consider the risk an individual patient has for more severe exacerbations. Factors that may contribute to this include parental history of asthma, atopic dermatitis, and known sensitivity to different allergens or foods. Patients should be reevaluated within 2 - 6 weeks to assess response.

Key points regarding recommendations for children 4 years old and younger include:

• Long-term control therapy is recommended for children who have had four more episodes lasting longer than 1 day over the previous year and who have some of the risk factors described earlier in this section. It may also be considered for other children who are experiencing impairment from their asthma.
• Nebulizers and certain other devices are available to help administer medications to children this age.
• Only certain inhaled corticosteroids and long-acting beta2-agonists are recommended for these children.
• Close follow-up is recommended
• Avoidance or management of environmental triggers is always important.

Key points regarding recommendations for children 5 years and older include:

• Participation in physical activities and sports should be encouraged.
• Schools, child care, and camps. should all have a copy of the asthma action plan.
• Inhaled corticosteroids are the preferred long-term control therapy. Long-acting beta2 agonists and leukotriene antagonists are additional therapies that are usually used in addition to inhaled corticosteroids.
• Avoiding or controlling environmental triggers is always important.

The variation between age groups consists mostly of which medications are recommended and how soon to start various medications and treatments.

Devices Used for Administering Inhaled Drugs

Most asthma drugs are inhaled using various forms of inhalers or nebulizers. Inhaled drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. Studies suggest that many children fail to use the devices properly, although newer devices are easier to use than others. The basic devices are the metered-dose inhaler (MDI), breath-actuated inhalers, dry powder inhalers, and nebulizers.

Metered-Dose Inhaler. The standard device for administering any asthma medication is the metered-dose inhaler (MDI). This device, particularly when used with a spacer, allows precise doses to be delivered directly to the lungs. (The spacer is a tube that is attached to the inhaler. It serves as a holding chamber for the medication that is sprayed by the inhaler.) MDI-delivered drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. Some patients hold the MDI too close to their mouths, or even inside them. Others may exhale too forcefully before inhalation.

The spacer helps improve medication delivery by allowing the patient additional time to inhale. They vary, however, in their effectiveness. It should be noted that MDIs can continue to deliver propellant even after the drug has been used up. Patients should track their medicine and throw the device away when the last dose has been administered.

Breath-Actuated Inhalers. Breath-actuated rotary inhalers (Easi-Breathe and Autohaler) deliver the drug directly to the back of the throat as the user inhales. Their primary advantage over the MDI is their ease of use. They also do not use CFCs as propellants. In comparison studies, patients have been very successful with the breath-actuated inhalers. They are not recommended for children under 8 years old.

Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. Such devices include Rotahaler, Spinhaler, Turbohaler, Clickhaler, Easyhaler, Diskhaler, Discus, Twisthaler, Spiros, and others. DPIs are as effective as the older devices, and generally have a better taste and are easier to manage. They may differ, however, in their ability to deliver drugs into the airways. In one study, for example, the Turbohaler was easier to use than the Diskhaler, and it achieved better delivery.

Humidity or extreme temperatures can affect DPIs' performance, so they should not be stored in humid places (bathroom cabinets) or locations subject to high temperatures (glove compartments during summer months).

Dry-powder may cause tooth erosion. Children are advised to rinse their mouths out right after using these inhalers and to brush twice a day with a fluoride toothpaste.

Other Hand-Held Inhalers. Respimat delivers a fine-mist spray that is created by forcing the liquid medication through nozzles. It does not use any propellant.

Nebulizers. A nebulizer is a machine that delivers a fine spray of medication-containing liquid. Nebulizers are often used for children younger than 3 years and sometimes for older children who have difficulty using the MDI. It takes 5 - 10 minutes to administer medication using a nebulizer. Because the spray is less targeted than with the inhaler, it must deliver large amounts of the drug. This increases the risk for toxicity and severe side effects.

Children who can manage an inhaler should not use nebulizers. Their use has been associated with a higher rate of hospitalizations and longer duration of symptoms than inhalers. The misuse of home nebulizers may be an important factor in asthma deaths in children and young adults. If children must use an albuterol nebulizer, parents should be sure that it does not contain the preservative benzalkonium, which actually narrows the airways. Recent studies suggest spacers may be better than nebulizers for children, and they shorten the time spent in emergency rooms. Studies also indicate that with the use of a face mask and a spacer, the MDI works well even for infants in the emergency room and may prove to be useable at home.

Non-Medical Treatment Strategies

Asthma triggers a vicious emotional-physical cycle:

• Breathlessness and wheezing incite a fear of suffocation and death, even in very small children.
• This anxiety produces further constriction on the muscles surrounding the airways, which makes breathing even more difficult.

Caregivers must first focus on alleviating their own anxiety, which can heighten a child's own fears. The next step is to help the child relax. One method for this is as follows:

• The child sits comfortably, bending slight forward with the eyes closed.
• The hands are placed gently over the navel.
• The child is then told to pretend the stomach is a balloon.
• The "balloon" must be "blown up" by inhalation, not exhalation. The child can tell if this working because the hands will move slightly apart.
• When the child breathes out, the "balloon" will be made flat.

This exercise both relaxes the child and discourages shallow, oxygen-poor breathing. Massaging the child in gentle circles on the chest is relaxing and may also loosen mucus.

Other recommendations include:

• A child may also find relief by lying stomach-down on several pillows so that the head is slightly lower than the chest while the caregiver gently pats the back between the shoulder blades.
• Warm liquids, such as soup or hot cider, are effective in loosening mucus and may also relax bronchial muscles. Cold fluids, like cold air, should be avoided.
• Overhydration (too much liquid) can be harmful, however, so these drinks should not be forced on the child.
• Warm, moist air from vaporizers can greatly ease and moderate asthma attacks.

Visits by home health care nurses or social workers may help if the family is having trouble managing the asthma and following prescribed treatments. Often, having the home evaluated for triggers can be very helpful.