ASTHMA

Asthma in children is a chronic condition that inflames and narrows the airways, causing breathing difficulties. Symptoms include wheezing, coughing, chest tightness, and shortness of breath, often worsening at night or early morning. These symptoms can disrupt everyday activities like playing or participating in sports.

Asthma may be triggered by factors such as viral infections, allergens (e.g. pollen or dust mites), cold air, exercise, air pollution, tobacco smoke, and stress. Exposure to these triggers can swell the airways and tighten surrounding muscles, reducing airflow to the lungs. Effective management is crucial since asthma involves breathing and is a long-term condition. The treatment of asthma can help children lead active, healthy lives.

Children with a family history of asthma, nasal allergies, allergic conjunctivitis, eosinophilic esophagitis, or eczema (atopic dermatitis) are at higher risk. These conditions are interrelated allergic diseases and collectively known as atopic diseases. Other risk factors for developing asthma include premature birth, low birth weight, and early severe respiratory infections like RSV bronchiolitis.



Asthma is one of the most prevalent chronic illnesses in children, affecting about 5.5 million in the U.S. with symptoms often starting before age five. Asthma can lead to frequent emergency visits, hospitalizations, and missed school days, impacting children’s education and social lives. Early recognition and effective treatment is important.

Description of Asthma, an atopic condition

Asthma is a chronic inflammatory disease affecting the small airways in the lungs. In children with asthma, the immune system releases chemicals that cause several problematic changes leading to airway obstruction. First, the airway lining becomes swollen and inflamed, narrowing the air passageways. Next, the mucous glands produce excess mucus, leading to coughing as the child tries to clear the mucus. Lastly, the muscles surrounding the airways tighten, further constricting them and increasing the effort needed to breathe. These changes make it difficult for air to move in and out of the lungs, causing labored breathing, chest tightness, and shortness of breath. Children experiencing an asthma attack might describe the sensation as chest pain.

An asthma attack typically begins with a cough, as the child attempts to expel mucus. This is followed by wheezing—a high-pitched sound from air passing through swollen, constricted airways—then rapid breathing, and retractions, which are depressions of the skin around the chest. As the attack progresses, it can lead to severe breathing difficulties. Early treatment of an asthma attack is crucial to prevent severe symptoms. It’s essential to recognize the signs of an impending attack and respond promptly to manage the condition effectively.

Diagnosis of Asthma

Diagnosing asthma in children can be challenging, as symptoms often overlap with other respiratory conditions such as infections with RSV bronchiolitis. Pediatricians typically start by reviewing the child’s medical history and conducting a physical examination to identify patterns of wheezing, coughing, difficulty breathing, or chest tightness—particularly if these occur during exercise, at night, or with exposure to specific triggers. A family history of asthma or allergies is also considered, as it can support an asthma diagnosis.

Spirometry is a common lung function test performed in children over the age of five. It measures airflow obstruction and its reversibility after using a bronchodilator. We offer spirometry in our office and can also refer patients to Arkansas Children’s Hospital pulmonary laboratory for this test.

For very young children who may have difficulty performing the test, a trial of asthma medication that results in symptom improvement can help support an asthma diagnosis. Other specific tests may be ordered to confirm the diagnosis, rule out alternative conditions, and identify specific allergens. Referrals to allergists can help with testing for specific antigens, while pulmonologists can assist in distinguishing between asthma and recurrent viral respiratory infections that cause wheezing, mimicking asthma. Overall, diagnosing asthma in children requires a careful, comprehensive approach that combines clinical observation, medical history, and testing to differentiate it from other respiratory issues and ensure appropriate management.

Prevention: 

If your child has been diagnosed with asthma, preventing asthma attacks is crucial for effective management. Asthma is a chronic condition that requires ongoing attention to keep your child safe and healthy. Regular office visits, at least every six months, are recommended to create, implement, and adjust an asthma action plan. The primary goal is to prevent lung damage and its long-term complications. According to the National Asthma Education and Prevention Program (NAEPP) Guidelines, classifying asthma severity is essential in determining the appropriate treatment. Severity is assessed based on the frequency and intensity of symptoms and lung function measures. Asthma is classified into four categories to account for persistent symptoms and their severity. Treatment is based on this classification of asthma persistence and severity. These are:

Mild Intermittent Asthma

• Symptoms of cough, wheeze, chest tightness or difficulty breathing happen less than twice a week
• No interference in daily activities
• Flare ups are brief, but intensity may vary
• Minimal night-time symptoms
• No symptoms are present between flare-ups
• Normal lung function

Mild Persistent Asthma

• Symptoms of cough, wheeze, chest tightness or difficulty breathing more than twice per week but not daily
• Flare ups may cause minor interference in activities
• Nighttime symptoms occur three to four times a month
• Rescue inhaler use: There is a requirement for short-acting beta-agonists (SABAs) for asthma symptom relief which occurs more than twice a week, but not daily and not more than once on any day.
• Lung function: The forced expiratory volume in one second (FEV1) or peak expiratory flow (PEF) is ≥80% of the predicted value.

Moderate Persistent Asthma

• Symptoms of cough, wheeze, chest tightness or difficulty breathing occur daily
• There is some moderate limitation in normal daily activities and physical activities.
• Nighttime symptoms are frequent, more than once or twice per week
• Rescue inhaler use: There is a daily requirement for short-acting beta-agonists (SABAs) for symptom relief, but not continuous.
• Lung function tests often show reduced airflow that can respond to bronchodilator medication. FEV1 is more than 60% but less than 80% of the predicted value.

Severe Persistent Asthma

• Symptoms of cough, wheeze, chest tightness or difficulty breathing are continual, present throughout the day.
• Activity level is affected significantly with limited physical activity.
• Nighttime awakenings often occur, sometimes nightly, affecting sleep quality.
• Rescue inhaler use: The need for a short-acting beta-agonist (SABA) for symptom relief is typically several times per day.
• Lung function tests show the FEV1 is less than or equal to 60% of the predicted value, indicating significantly impaired lung function.

Classifying asthma severity is needed for customizing treatment plans and monitoring their effectiveness. Children with asthma should have regular check-ups, typically every six months if their condition is well-controlled, and more often if it is not. Asthma control can vary over time, so ongoing assessments and revisions to treatment plans are crucial. This classification helps guide the intensity of treatment and informs necessary adjustments to improve patient outcomes and quality of life.

Asthma Action Plan:

Compliance with an asthma preventative plan that is developed for your child is essential to keep your child healthy and out of the hospital. The following can be helpful in preventing asthma:

Avoidance of asthma triggers: Once a child develops sensitive, over-reactive airways, there are many factors which can trigger an asthma attack. These “triggers” should be identified in your child and when possible strictly avoided. Failure to avoid a trigger for your child’s asthma can cause an attack of breathing difficulty.

To avoid an attack of asthma you should do the following to avoid asthma triggers:

• There should be no exposure to cigarette smoke or fireplace smoke whatsoever.
• Avoid strong odors and sprays. This includes perfumes, cleaning agents, etc.
• Avoid exposure to people with respiratory infections like colds and flu.
• Avoid exposure to mold.
• If your child wheezes with exercise, consult us about how to prevent this.
• Avoid other triggers for your child as you identify them. We can do an allergy test in our office, or an allergist can help you identify these.

To mitigate certain identified known environmental triggers, such as house dust and house dust mite, you should do the following:

• Bedding: Encase mattresses, pillows, and box springs in allergen-proof, zippered covers. These covers prevent dust mites from penetrating. Wash all bedding, including sheets, pillowcases, and blankets, in hot water at least once a week. Hot water should be at least 130°F (54°C) to effectively kill dust mites.
• Flooring: Use a vacuum cleaner with a high-efficiency particulate air (HEPA) filter or double-layered microfilter bags to reduce dust emissions. Vacuum carpets, rugs, and upholstered furniture regularly. Consider replacing wall-to-wall carpets with hardwood or tile floors, which are easier to clean.
• Furniture and Decor: Choose furniture with non-fabric surfaces like wood, leather, or vinyl, which don’t harbor dust mites as much as upholstery.
• Minimize the number of plush toys or wash them frequently in hot water. Store them in a covered container when not in use.
• Humidity Control: Maintain indoor humidity between 30% and 50%. Dust mites thrive in humid environments, so using a dehumidifier or air conditioner can help. Fix any leaks or sources of water accumulation to prevent dampness.
• Clutter and Storage: Reduce clutter where dust can accumulate, especially in bedrooms. Store items in closed cabinets or drawers to limit dust exposure.
• Air Filtration: Use a central air filtration system or portable air purifier equipped with a HEPA filter to reduce airborne allergens. Change HVAC filters regularly and consider using high-efficiency filters designed to trap allergens.
• Curtains and Window Treatments: Use washable curtains or shades, and wash them frequently. Avoid mini-blinds, which can collect dust. By implementing these strategies, you can effectively reduce dust and dust mite allergens in your home, which may help to control allergy and asthma symptoms more effectively.

Remember, managing your environment is just one part of a comprehensive asthma and allergy management plan. Sometimes work up by an allergist is indicated to help identify and treat the role that different allergens may be playing in your child’s asthma. Consult us for a referral to an allergist should this become necessary.

Immunizations:

Make sure that your child has received all their needed immunizations, including a yearly Flu Shot.

Medications to treat asthma:

In addition to the above asthma preventative measures that are needed for all children with asthma, children with persistent asthma need daily medicines to control their symptoms.

Asthma Treatment with medications

There are two classes of medications used to treat asthma. Controller medications are used to prevent asthma. Quick relief medications are used to help a child improve their breathing during an asthma flare up.

Controller medications for asthma include:

-Inhaled Corticosteroids (ICS): These are the most effective long-term control medications for persistent asthma in children. They reduce inflammation in the airways. Examples include:

1. Budesonide (e.g., Pulmicort)
2. Fluticasone propionate
3. Beclomethasone (e.g., QVAR)
4. Mometasone (e.g., Asmanex)
5. Ciclesonide (e.g., Alvesco)

-Long-Acting Beta-Agonists (LABAs): These bronchodilators are used in combination with ICS for moderate to severe asthma. They help open airways by relaxing the muscles around them.

Examples include:

Salmeterol (often combined with fluticasone as Advair)

Formoterol (often combined with budesonide as Symbicort or with mometasone as Dulera)

-Leukotriene Modifiers such as Montelukast (Singulair): Montelukast helps directly block certain chemicals called leukotrienes that cause airway inflammation and constrict airways which are made by certain white blood cells.

A black box warning given by the FDA in 2020 states that Montelukast may increase the risk of serious neuropsychiatric events, including: suicidal thoughts or actions, aggression, agitation, depression, disturbed sleep (e.g., insomnia, nightmares), anxiety, hallucinations, restlessness and tremor. Due to these potential mental health risks, healthcare providers were advised to consider prescribing montelukast only when other treatments are not appropriate. Children who have tolerated montelukast in the past without side effects should remain on the medication as side effects are unlikely.

-Long-acting muscarinic antagonists (LAMAs) are a class of bronchodilators primarily used as controller medications rather than quick-relief options. They help to manage and reduce asthma symptoms over time by relaxing and widening the airways. An example of a LAMA agent used for asthma is: • Tiotropium- This is commonly available under the brand name Spiriva Respimat. It is approved for controller management of asthma in certain older patients.

Biologic Agents: These medications are used for cases of severe asthma. They are typically delivered as injections or infusions. Examples include:

1. Omalizumab (Xolair): is approved for patients aged 6 years and older and is indicated for individuals with moderate to severe persistent allergic asthma who experience frequent exacerbations despite regular treatment with inhaled corticosteroids.
2. Mepolizumab (Nucala): is indicated as and add on treatment of patients aged 6 years and older with severe eosinophilic asthma.
3. Benralizumab (Fasenra) is indicated as an add on treatment for patients aged 12 years and older with severe eosinophilic asthma. It is used in patients whose asthma is inadequately controlled with high doses of inhaled corticosteroids plus other asthma medications.
4. Dupilumab (Dupixent): is indicated as an add on treatment for patients aged 6 years and older with moderate-to-severe asthma characterized by an eosinophilic phenotype or dependence on oral corticosteroids.

Cromolyn Sodium: This medication is less commonly used but can be prescribed as a controlled for asthma. It works by stabilizing mast cells which can prevent allergic reactions and asthma symptoms.

Theophylline: An older oral medication sometimes used for older children with asthma. However, it requires monitoring of blood levels due to its potential side effects.

Quick-relief, or “rescue,” medications are used to treat acute asthma symptoms and exacerbations. The primary quick-relief medications include:

Short-acting beta-agonists (SABAs): These are the most common quick-relief medications used for child asthma attacks. They work rapidly to relax tightened muscles around the airways, providing quick relief of asthma symptoms like wheezing, coughing, and shortness of breath.

Common SABAs include:

1. Albuterol
2. Levalbuterol
3.  Pirbuterol (Maxair, age 12 and up)

Anticholinergics: Ipratropium bromide, sometimes used in conjunction with SABAs for more severe asthma exacerbations, particularly in emergency department settings.

Systemic corticosteroids: Although inhaled corticosteroids are primarily used as a longer-term controller, systemic corticosteroids may be used in a burst (short course) to manage more severe exacerbations when there is inadequate response to SABAs. They reduce inflammation in the airways over a period of a few hours to days. Examples include:

1. Prednisone
2. Prednisolone
3. Methylprednisolone
4. Dexamethasone

These medications provide rapid relief of acute symptoms and are essential in helping manage more severe asthma exacerbations. It’s important for caregivers and patients to follow their asthma action plan as recommended by us, which includes knowing when and how to use both controller and quick-relief medications properly.

Stepwise Approach for the Management of Asthma

The National Asthma Education and Prevention Program (NAEPP) provides a structured, stepwise approach for managing asthma, which requires regular medical treatment to control symptoms and prevent exacerbations. These guidelines categorize treatment into steps based on symptom severity and the level of control achieved. Treatment for persistent asthma ranges from lower-step therapies, like Step 2, to higher-step therapies, like Step 6, depending on how well the asthma is controlled and the severity of the patient’s condition.

Step 1:  addresses individuals with intermittent asthma. This stage emphasizes environmental control, patient education, and minimal use of medication. Intermittent asthma is characterized by symptoms occurring no more than two days per week, nighttime awakenings up to twice a month, no interference with normal activity, and normal lung function between episodes. Patients are advised to use a short-acting beta-agonist (SABA) as a quick-relief medication for symptoms or before exposure to triggers. In certain patients, it is recommended that a short course of an intermittent inhaled corticosteroid (ICS) may be introduced to reduce inflammation during respiratory tract infections (RTIs). Patients are encouraged to monitor their symptoms, avoid triggers, and follow a personalized action plan. If symptoms become more frequent or severe, re-evaluation for a step-up in treatment may be necessary.

Step 2: recommends treatment that includes a low-dose inhaled corticosteroid (ICS) as the primary controller medication to reduce inflammation and prevent symptoms. 

Step 3:  as asthma severity increases, the treatment progresses which may involve higher doses of ICS or the addition of other long-term control medications, such as long-acting beta2-agonists (LABAs), leukotriene modifiers, or LAMA agents (long-acting muscarinic antagonists). 

Steps 4 and 5:  might require additional medications mentioned in step 3 or higher doses of ICS to achieve better control. Specialists are consulted.

Stepping down therapy:

After a three month period of time during which a patient experiences well-controlled asthma with minimal or no symptoms, we consider stepping down the level of asthma management to find the lowest effective dose of medication possible. This process involves a careful and systematic reduction of medication, such as decreasing the dose of an inhaled corticosteroid (ICS) or potentially withdrawing a long-term controller medication that was added to manage more severe symptoms. The decision to step down is taken after evaluating the patient’s symptom frequency, exacerbations, and lung function measurements to ensure that control can be maintained. 



At all steps, it is crucial to maintain regular monitoring and follow-up visits, while also considering potential triggers and environmental controls. The goal of the stepwise approach is to achieve and maintain asthma control by adjusting therapy upward or downward as needed, guided by the patient’s symptom frequency, exacerbations, and lung function measurements. It is our responsibility to thoughtfully manage these decisions to optimize patient outcomes.

SMART Asthma Care:

SMART (Single Maintenance And Reliever Therapy) represents an effective approach to asthma management in children, allowing for both maintenance of control and on-demand quick relief within a single inhaler. This therapy typically combines a low-dose inhaled corticosteroid (ICS) with a long-acting beta-agonist (LABA).

Young children with moderate to severe persistent asthma, who experience frequent symptoms or exacerbations, may particularly benefit from SMART therapy. It simplifies asthma management, reducing the burden of multiple inhalers for pediatric patients and their caregivers.

The administration of SMART therapy involves children using the combination inhaler daily for maintenance, with instructions to also use it as needed for quick relief during acute asthma episodes. This dual action not only helps maintain control over chronic inflammation but also provides rapid relief from bronchoconstriction during asthma attacks. This approach eliminates the need for separate rescue inhalers, streamlining the treatment process and making it easier for children and their families to manage asthma effectively. Consult us regarding this type of therapy for children with moderate or severe persistant asthma.

Overall, SMART therapy serves as a promising option for managing asthma in children, supporting better disease control and enhancing overall quality of life through simplified treatment regimens.

Specialty Allergy care: Some children with persistent asthma may need an allergy workup by an allergist or a visit with a pediatric pulmonologist. Please consult us about this if your child has had several episodes of wheezing or a particularly severe episode of wheezing requiring hospitalization. We also refer when patients need multiple medications to control asthma as in steps 3-5.

Asthma Attack Management: Should your child develop an attack of asthma with breathing difficulty, you should institute your asthma attack management plan. These plans are developed during a visit to our office concerning asthma for use when an attack of asthma occurs in your child.

Typically, a quick relief medication, which is also called a rescue inhaler, is prescribed for your child for these situations. If you are in a situation in which your child is having an attack of asthma with no quick relief medication to treat it, you should contact us immediately or go to an emergency room.

Repeated trips to the emergency room may indicate that the preventative plan is not effective enough and requires modification.

Our asthma attack management plans include three possible situations:

GREEN ZONE: Your child is doing well.

• No cough, wheeze, chest tightness or shortness of breath during the day or night,
• Your child can do usual activities,

What to do: Take preventative medications as usual.

YELLOW ZONE: Your child’s asthma is getting worse.

• Your child may be experiencing cough, wheezing, chest tightness or shortness of breath, or waking at night due to asthma,
• Your child can do some but not all usual activities,

What to do: Take preventative medications as usual and take your quick relief medications.

RED ZONE: Alert! Emergency! Your child isn’t breathing well.

• Your child is very short of breath with wheezing, retractions and difficulty breathing.
• Quick-relief medicines have not helped,
• Your child cannot do usual activities,
• OR Symptoms are same or get worse after 24 hours in Yellow Zone.

What to do: Take preventative medications as usual and take your quick relief medications. If no better after the administration of quick relief medications, go to the Emergency Room or our office.

DANGER SIGNS: Call 911 or go to the Emergency Room immediately if:

• Your child has trouble walking and talking due to shortness of breath.
• Lips or fingernails are blue.

How to use a Metered-Dose Inhaler with an AeroChamber® with Mask:

This type of spacer is for the child who is too young to be able to breathe in through their mouth at the right time to inhale their asthma medications when using a metered dose inhaler. Usually this is someone 6 years of age or under. Instructions:

1. Remove the plastic protective cap from the MDI.
2. Insert the metered dose inhaler (MDI) into the plastic holder on the rubber end of the AeroChamber®.
3. Shake the AeroChamber® and the MDI.
4. Sit the child on your lap. The back of your child’s head should be against your chest.
5. Apply the mask to your child’s face so that the nose and mouth are covered.
6. Spray 1 puff from the metered-dose inhaler into the AeroChamber®.
7. Keep the mask in place for 6 breaths. Have your child breathe through his or her mouth, if possible. Watch the child’s chest to count breaths. If your child objects to the treatment and cries, this only increases how deeply your child is breathing. This will actually help deposit the medication deeper into the lungs. So, don’t let the objections of your child stop you from giving him or her the needed treatment.
8. Rest and repeat according to the our directions.
9. At least once a week, take the AeroChamber® end off and rinse with warm tap water.