Asthma in Children - Everything You Need to Know - Prof. Benjamin Volovitz

Asthma Video Transcript

To Know More About Asthma - Prof. Benjamin Volovitz

Introduction Structure of the Airways What Happens to the Airways in a Child with Asthma? Symptoms of an Asthma Attack Role of the Parents in Identifying an Asthma Attack Age-Dependence of Asthma Controlling Asthma Can Damage to the Cells Be Prevented? Triggers that Induce Asthma Medical Treatment of Asthma Treating Asthma Attacks Prophylactic (long-term) treatment Proper Use of Inhalers and Spacers Food allergies

Introduction

Today, children with asthma can stay healthy and active despite their breathing problems. Proper and timely treatment can not only overcome asthma attacks within a day or two of the first appearance of symptoms, it can also prevent future attacks, with no symptoms at all. The aim of this presentation is to guide you, the parents, in attaining these goals and to provide you with the right tools to help you make the proper decisions.

To help you control you child's asthma, I will first describe where the airway passages are located, how they work, how asthma affects the way your child breathes, and how to recognize the first signs of an asthma attack. I will discuss the different triggers that can penetrate the airways and cause an asthma attack. This will be followed by an explanation of exactly what you should do when your child is having an attack – when to administer treatment, which drug to use, when to stop the drug, and when to seek medical attention. Finally, I will discuss what we can do to strengthen the airways in order to prevent attacks in the future.

Structure of the Airways

All people have two lungs, one on each side. During breathing, air entering the mouth and nose is conveyed through the trachea, or windpipe, and then to the bronchus (the major airway leading to the lungs). The bronchus divides at a certain point into two smaller bronchi, and each of these further divides into still smaller ones, and this process is repeated about 23 times until we have a veritable "tree" of airway passages. The first 15 such divisions yield almost 30,000 airways.

The branches continue to split until we get to the tiniest ones, the bronchioles. Each bronchiole is surrounded by 100 air spaces, called alveoli. The air enters the capillaries that surround each alveolus and from there the blood carries the oxygen throughout the body. In return, the blood carries the carbon dioxide out of the body back to the lungs, from where it is expelled.

Bronchitis, bronchiolitis, spastic bronchitis, asthma, allergy, shortness of breath all these are diseases of the airways. Pneumonia is a disease of the air spaces, the alveoli. If we correctly treat bronchitis, bronchiolitis, spastic bronchitis, and asthma, the illness will not progress to the alveoli and cause pneumonia.

What Happens to the Airways in a Child with Asthma?

Asthma is a disease of the bronchial airways. Specifically, it is a disease of the epithelial cells situated in the lining, or mucosa, of the small airways. In children with asthma, these epithelial cells are very sensitive to various types of stimuli. Exposure to these stimuli or "triggers" damages the walls of the airways, and substances (mediators) within the epithelial cells spill out. The mediators affect the muscles around the airway, causing them to contract. At the same time, the mucosal lining of the airways becomes inflamed and swollen, leading to the overproduction of mucus. It is the accumulation of mucus in the already constricted respiratory bronchi that makes it difficult for the child to breathe during an asthma attack. Thus, asthma is an inflammatory disease, not an infectious disease.

Symptoms of an Asthma Attack

Parents may detect the onset of an asthma attack when they see their child's chest rising and falling in his attempt to breathe. They can hear whistling sounds caused by air flowing through the narrowed, inflamed passages, and snorting sounds (rhonchi, rales) caused by air flowing thought the mucus-filled passages. The child may complain of chest tightness and shortness of breath. When the mucus accumulates, the child may cough in an effort to expel it. Sometimes children swallow the mucus, which causes them to vomit.

This is the process of an asthma attack. Shortness of breath, wheezing, rhonchi, and coughing. All this occurs almost simultaneously, when an airway that was normal becomes abnormal.

Role of the Parents in Identifying an Asthma Attack

When you seek medical attention for your child's cold, in the first day or two of the disease, the doctor won't be able to detect abnormal lung sounds, such as whistling, rales, or crackling noises. Usually by the third or fourth day of illness the doctor will detect abnormal lung sounds; however, at this time the airways are almost completely constricted. At this point, because the doctor can't be sure that one side is not completely blocked, he may prescribe antibiotics to prevent pneumonia, although the risk is low. If the symptoms don't respond to treatment, the doctor may send the child for an x-ray. The radiologist may see patchy white areas on both sides of the lungs, but he still cannot definitely rule out pneumonia. Therefore, the physician may feel justified in erring on the side of caution and keep prescribing antibiotics.

It is not only your doctor who doesn’t know. No doctor can be sure if pneumonia will not occur. Therefore, the person who must decide if your child has an asthma attack is you, the parent. You know your child better than anyone. The minute you notice the child doesn't look well and is starting to cough, and you hear the same wheezing breaths as in the previous attack or the coughing goes on and on – or both - you start treating your child for asthma.

If you start treating early, enough of the airway will still be open for the medication to penetrate easily. The child will respond quickly, and within a day or two, the attack will be over. However, if you wait two or three days, the airways will be almost completely blocked (at this time the radiologist will suspect pneumonia). It will now be very difficult for the medication to penetrate the airways, making it necessary to use higher doses for a longer time… and sometimes we won't be able to stop the downhill road to pneumonia.

Age-Dependence of Asthma

Bronchial reactivity changes with age, and there are several mileposts along the course of the disease that may signify "exit points" for different children.

In a large proportion of very young children with a diagnosis of asthma, the symptoms are alleviated by age 2 or 3 years. We assume that these children probably did not have true asthma at all, but simply small airways that were easily blocked. As they grew, their bronchi enlarged more and more, and consequently, the external triggers no longer caused significant obstructions of the bronchial walls.

Nevertheless, until age 3 years, we have to manage all children with suspected asthma alike – using the same medications and the same approach -- because we can't know ahead of time who will be asthmatic at a later age and who won't. We do know, though, that if both parents were asthmatic, the likelihood is high that their child is asthmatic as well. The next exit point from asthma is age 5 years (what was once called spastic bronchitis); the next is age 10 years; and the final one is adolescence.

By adolescence, most children who ever had a diagnosis of asthma have recovered. Only in the most severe cases can the disease recur later. If you ask parents, only small percentage of the children who were once ill are still ill in their teens. Thus, the disease usually passes with age, and this, at least, provides much room for optimism.

Controlling Asthma

There are several possible directions from which asthma can be managed:

By controlling the process whereby the epithelial cells acquire oversensitivity to certain stimuli.
By preventing exposure of the asthmatic child to the external triggers that cause his or her asthma attacks.
By helping the child overcome asthma attacks, once they occur, quickly and easily.
By strengthening the membranes of the sensitive cells to prevent their destruction.

Can Damage to the Cells Be Prevented?

Some asthmatic children have extremely sensitive epithelial cells. Many triggers set them off, and the child is always ill. Others, however, have only mildly sensitive cells, and only certain triggers, or triggers in large amounts, set them off. In some children, healthy cells are produced as well, and during these periods, the children stay healthy.

The human body contains mechanisms to detect and fix these sensitive cells. If the defect is mild, the body will rapidly correct it. If the defect is more severe, the illness lasts longer. Nonetheless, even children with severe disease will ultimately recover. We cannot stop the process whereby the body produces sensitive cells. However, with the help of our experience and understanding of the natural course of the dieses, we can estimate its severity and duration. Our job is to help the child pass the time until total recovery from asthma without suffering from asthma symptoms and with as few attacks as possible.

Triggers that Induce Asthma

The many triggers that can cause an asthma attack may be divided into five general groups:

Changes in the weather

The entry of cold air or dry air into the lungs can cause an asthma attack. Therefore, to protect your child, do not let him run around outside on a cold day. Do not allow him into an cold-air-conditioned room, especially not directly from a warm bath, or into an cold-air-conditioned car, especially from the beach. Air conditioning (both cold and warm) not only cools or worms the air, it also dries it. If your house is heated, you need to ensure that the air remains damp by using a humidifier, placing damp towels on the radiator, leaving an electric kettle with boiling water, or leaving the door of the bath open.

Cold viruses

The common cold is a very important trigger of asthma attack. Every infection of an asthmatic child with a cold virus will cause an asthma attack. After the first time a cold induces an attack in the child, the child will never have a cold without an attack. Thus, you must exert the greatest efforts in preventing your child from catching cold.

In very young children, the biggest danger is daycare. Take a 1 1/2-year-old child to a daycare center of 40 children, the child will have a cold up to 40 times a year; take the child to a daycare center of 20 children, the child will have a cold up to 20 times a year. In any daycare center or kindergarten with 20-30 children, at any one time, there will be at least 2 or 3 children with a cold. All it takes is one sneeze, and every child within 4 meters could catch a cold, too. The smaller the child entering a daycare, the smaller are his airways, and the higher is the risk of him to acquire a severe illness. Therefore, if the child starts daycare or kindergarten later – after at least age 2–3 years – the airways will be larger, and the child will be ill less often.

Besides daycare, it is important to make ensure that your child does not visit friends with a cold, and that friends with a cold don't come to play with him. If there's a sibling in the house with a cold, don't let him share a room with your young asthmatic child. Send one of them to a grandparent, if possible, or to another part of the house. Keep the child with a cold in a well-ventilated room so the viruses won't spread through the house. Do everything you can to keep your child from being exposed to cold viruses. This is very important, and very worthwhile. If your child wakes up with a cold, keep him home. Don't send the sick child to daycare or kindergarten. You need to start treating the child immediately with asthma drugs, according to the protocol given to you by your doctor or your lung specialist.

It should be emphasized that 80-90% of asthma attacks in children under 3 are caused by viruses of the common cold. Things get a bit better as the children get older, though the rate remains relatively high.

We have to do our best. We probably can't eliminate all colds, no matter how hard we try. To do so would mean closing the child in a hermetically sealed, sterile room, until he's ready for college!

Physical exertion or exercise

The third group of triggers is physical activity. This category probably relates more to older children. Intensive physical activity over time causes shortness of breath. What does this mean for your child?

The child runs around the school twice in gym class: by the third round, he can't breathe.
The child runs up four flights of stairs because he is late for class: by the fifth floor, he can't breathe.
The child runs around outside during recess on a chilly day: after a few minutes, he has difficulties breathing.

We want your child to be able to engage in normal physical activity, and to feel good and stay healthy at the same time. This goal can be achieved if you, the parents, and the child, follow a few general rules.

The child with asthma can participate in physical activities at school. However:

If your child wants to run the 2000-meter course, he must take the bronchodilator medication before starting. Then he can complete the course without breathing difficulties.
If your child wants to run only the 500-meter course, he should have the bronchodilator medication at hand for immediate use after the run, if necessary, to stop possible asthma.
The older child with asthma may participate in school trips, under three conditions:

He should have the bronchodilator/inhaler handy at all times and know how to use it.
The trip guide and accompanying teacher should be aware that the child has asthma and may exhibit breathing problems in certain circumstances. If the child claims to have breathing difficulties, the guide or teacher must make sure that the child takes his asthma medication. They should allow him to stop the activity and then consult the parents or seek medical help.
The child or the guide/teacher should have a cell-phone within reach at all times in order to be able to call the parents for instructions or to answer questions, as necessary.

It is important to emphasize that the combination of physical activity in cold air is a very strong trigger of asthma attacks. Asthmatic children can swim in regular outdoor pools, but not in indoor pools which contain chlorine. All activities inside the gym room are fine.

Dust and Allergens

All kinds of substances in the environment can enter the airways and interact with the sensitive cells, causing an asthma attack. You have to try to keep your child from being exposed to these triggers. Some are found inside the house, and others, outside the house. In the house, the main trigger of asthma attacks is house dust mite. The greatest danger in this respect is posed by bedding, because sheets, covers, pillowcases, and mattresses all harbor dust mites.

Dust mites are tiny insects - invisible to the naked eye. If you magnify them 500 times, they look like lice or ants; meaning, they're 500 times smaller than an ant. A single mite – or even the feces (excrement) of a single mite - that enters the airway can cause an asthma attack. Unfortunately, there is not a house or a bed or a mattress in the world that is completely free of dust mites. You cannot eliminate them completely. All you can try to do is keep them to a bare minimum. How can you lower the presence of dust mites? Dust mites need humidity and an organic environment to grow. For nutrition, they eat mold and scales that falls from human skin. So to significantly lower the risk of exposure to mites, replace all cotton and woolen bedding with synthetic materials (allergy pillow and mattress encasements) that provide the mites with less suitable living conditions, and keep the bedding dry and clean at all times.

Inside the house, attention should also be addressed to two more important factors:

Don't smoke near an asthmatic child! Cigarette smoke can irritate or block the small airways.
Once the diagnosis of asthma is established, don't bring cats or dogs into the house. After an already sensitive child spends, say, 50-60 hours in the company of the dog or a cat, he may develop sensitivity to the animal's hair. Thereafter, every time the child is in the proximity of a cat or a dog, he may have an asthma attack. Likewise, make sure the child avoids close contact with birds – because of their feathers – and any other animals with fur. That, I'm afraid, leaves you with a choice of "Tamaguchis" or computer games. Unfortunately, pets are a real problem.

Within the house, substances with sharp smells, such as paint and perfume, are also best avoided.

Outside the house, children with asthma are affected by smoke from bonfires. In addition, tree, grass, and flower pollens are major triggers. It is not wise for an asthmatic child to sit or play under trees - cypress, tamarisk, olive trees, nut trees, etc. - when they're blooming, because the pollen will penetrate his lungs. The child will then develop sensitivity to the pollen, and the following year, at his first exposure to that tree, the child will have an allergic reaction. This may take the form of an eye inflammation, a runny nose, or an asthma attack.

Identifying the substances to which your child is sensitive may be very difficult. Normally, allergies are tested by performing a skin prick test. However, testing children younger than 3 years to the common allergens usually yields negative results. In older children, the test may uncover sensitivity to some allergens, though it does not rule out sensitivity to others that were not tested. Furthermore, the child's skin reaction to certain substances does not necessarily indicate the sensitivity of his lungs. To identify the specific triggers of airway obstruction, we would have to have the child inhale many potential substances – and possibly cause an asthma attack. At the same time, the intradermal test itself may pose a risk in asthmatic children, in whom exposure to high enough amounts of certain allergens may induce a general allergic reaction in the body.

It should be mentioned here that children with asthma can eat everything, even milk and peanuts. Milk does not cause mucus accumulation. Some children, of course, may be allergic to cow milk, and they should not have it. If they do, they will have symptoms of milk allergy—vomiting, swelling, skin rash and so on. Children with milk allergy who are also asthmatic may have an asthma attack when exposed to the milk.

Psychosomatic factors

Anger, crying, laughter, irritability – all these can lead to an attack of shortness of breath. You, as parents, must try, to the extent possible, to prevent your child from unnecessary, extreme, anger, bouts of crying, and tantrums in order to avoid the risk of an attack. I would, however, recommend that you let your child laugh as much as he wants, even if this causes the child to cough.

Changes in the weather.
Cold viruses.
Physical exertion or exercise.
Dust and allergens.
Psychosomatic factors.

Medical Treatment of Asthma

There are two approaches to the treatment of asthma: treatment only during the attacks, and long-term treatment.

Treating Asthma Attacks

Two types of drugs are used in the treatment of asthma attacks:

Drugs that open the airways (bronchodilators) - relievers.
Drugs that keep the airways open - controllers.

The drugs that open the airways include Ventolin (albuterol), Bricalin (terbutaline), Oxis (formoterol), and others. These are delivered by green or blue devices. The drugs that keep the airways open include Budicort (budesonide) and Flixotide (fluticasone) and others. These are delivered by brown or orange devices.

The drugs that open the airways offer symptomatic relief. We administer them when symptoms appear, and we stop them when symptoms pass. However, they don't cure the underlying illness. Their use is analogous to the administration of Acamol (paracetamol) for fever: the child's fever rises, you give him Acamol, the fever drops; the drug wears off, the fever rises, you repeat the Acamol…and so on, until the illness passes. Acamol relieves the fever, but it does not cure the underlying illness.

Similarly, during an asthma attack, treatment with Ventolin or Bricalin opens the airways, and more air penetrates the lungs; with time, the body neutralizes the drug, its effect wears of, and the airways again become constricted; treatment is repeated…and so on, until the body recovers from the attack.

Symptomatic treatment alone is amenable to children who respond rapidly and have asthma attacks only occasionally (at least one month between attacks) and are otherwise healthy. However, in children who are chronically ill, symptomatic treatment would need to be given for a long term – 3 days, 7 days, 14 days – until the body could cope with the "insult". During this time, complications might develop. The child may even acquire pneumonia. Therefore, in these cases, a combination of reliever drugs and controller drugs is recommended to first open the airways (Bricalin, Ventolin) and then to keep them open (Budicort, Flixotide). This will quickly and effectively stop the asthma attacks.

Combined treatment is also advantageous in that it prevents the side effects that occur when Bricalin or Ventolin accumulate in the body, such as hand tremors, rapid pulse, irritability, and others. With combined treatment, these drugs are given intermittently.

A potential treatment protocol may include the following steps: At the onset of an asthma attack, immediately give the child Ventolin or Bricalin, followed right after by Budicort or Flixotide. Repeat the Budicort or Flixotide so that the child receives 4 doses on day 1 and maybe for another day as well. Then reduce the frequency to 3 times a day, with dose adjustments accordingly, and so on for 4 or 6 days, depending on the severity of the illness and the individual child's schedule.

You, the parents, need to decide that an attack has started. You need to provide the treatment. If within a few days you find that the treatment is not successful, seek the advice of your doctor. He will check that you adhered properly to the schedule of drug administration, including frequency and dosage and will ensure that there were no errors in the technique used or a malfunction of the drug delivery device.

Prophylactic (long-term) treatment

Long-term treatment to prevent asthma symptoms and asthma attacks, also called prophylactic or maintenance treatment, is given to children who have asthma symptoms most of the time: the child who's not over one illness and is already coming down with the next one; the child who seems to have been sick more often than healthy in the past three months. Prophylactic treatment is usually administered more in winter.

How does prophylactic treatment work?

Prophylactic treatment is designed to "coat" the sensitive cells in the airway walls to protect them from being activated by triggers until the body begins to produce healthy cells. It works like an umbrella: If it rains once a month, you don't need an umbrella. Accordingly, if your child gets sick once a month or less, you need to treat him only during attacks. However, if it rains every single day, and you don't use an umbrella, you'll get wet, dry off, get wet, dry off, get wet, and dry off. This situation is impossible. So you take an umbrella. Hold the umbrella over your head all day – you won't feel even a drop of rain. Take it only in the morning or once in a while – chances are you're going to get wet at least some of the time. Hold it upside down – you'll get wet again. In the same way, the child who does not follow the schedule, or uses his device incorrectly, or forgets to take his medication… will be sick. But the child, who faithfully adheres to his schedule of treatment day in and day out and never forgets, will stay healthy. The child who takes care of his inhaler device, uses it correctly, and ensures that all the medicine gets into the lungs… will stay healthy.

Types of prophylactic drugs

At present, there are only two groups of drugs (umbrellas) available:

Inhaled corticosteroids (Budicort or Flixotide).
Singulair (montelukast sodium) tablets.

Singulair is a relatively new non-corticosteroid drug that has been on the market about 10 years. It has been used so far by more than 5 million people. Singulair is recommended for use by children with borderline to mild asthma. However, it is mainly used as add on therapy to other prophylactic drugs. That is, if treatment Budicort doesn't seem to be sufficiently alleviating the child's symptoms, adding Singulair will help the Budicort do its job more effectively. Singulair can also benefit children who have exercise-induced asthma to perform physical activities. A child who takes Singulair doubles the length of time he can exercise.

Inhaled corticosteroids: Budicort and Flixotide are derivatives of cortisone; a hormone secreted naturally by the body by two small glands situated on the kidney, each the size of a fingernail. Cortisone is sometimes called the "hormone of life" because it maintains the integrity of the cell walls. It therefore plays an important role in the process of inflammation. The body has a certain amount of natural cortisone. If we take oral drugs that contain corticosteroids (such as betnesol, betapred, bentalen, prednisone, or danalone), we significantly increase the amount of cortisone already in the blood. This can cause side effects, such as irritability, facial swelling, and changes in appetite. Large amounts taken over a long term can lead to more severe side effects, such as thrush, cataracts (in adults) and skin and bone reactions. In children, corticosteroids can interfere with growth.

Oral intake of corticosteroids causes many adverse effects Inhaled budesonide is metabolized in the liver. Ninety percent of the drug is neutralized in the liver during the first passage of blood, and 90% of the remaining 10% is destroyed by the liver during the second passage. Given that the blood passes through the liver 90 times a minute, we need to put a very large amount of steroids in each pill for enough to be left for treatment by the time the medication reaches the lungs.

Therefore, instead of oral corticosteroids, we use inhaled corticosteroids. Inhaled steroids are administered via special devices, either metered dose inhalers, powder inhalers, or nebulizers, which deliver 98% of the dose directly to the lungs, and only 2% – a negligible amount- actually reaches the bloodstream (mainly by absorption through the mouth and the saliva). You need to press an inhaler holding 50 mg of Budicort 100 times, or an inhaler holding 200 mg of Budicort 25 times, to get the amount of cortisone contained in a single pill of prednisone. To manage an asthma attack, a young child would need 2 tablets of oral steroids twice daily for 3-5 days. With an inhaler, however, pressing twice on the device provides the child with 2% of 1/25th the amount of cortisone in one tablet – enough to stop the attack. The amount of steroids in one three-to-five-day treatment with oral steroids is equal to about one whole year's worth of treatment with inhaled corticosteroids.

I began to administer Budicort for asthma in children at my clinic in 1983. Thousands of children have since used it. Initially, I treated a group of 2-to-5-year-olds for five years. I found that it provided excellent protection, with zero side effects. I checked the children periodically by clinical signs and chemical profile, including blood levels of the drug. There were no problems whatsoever. The results of this trial were reported in a world-renowned medical journal, The New England Journal of Medicine. On the basis of these findings, I was invited to join international groups that meet at regular intervals to set guidelines for the diagnosis and treatment of asthma on a global scale.

The use of Budicort during attacks, however, is not accepted by everyone and not written in all textbooks. The recommendations outlined here are based on my own long experience. My work over the last 30 years has shown that Budicort delivered by an inhaler device during an asthma attack can stop the attack in children. However, the drug must be used as directed. You need to carefully adhere to the instructions.

Stopping treatment

We cannot know for sure when to stop preventive treatment. Much like we don't know how long to hold that analogous umbrella: until the rain stops. We administer the medication for a while - say a month or two. If the child doesn't have an attack, we try to stop the medication and see if the child stays health. If he has another attack, we open the umbrella again. There are no tests or measurements available today that can tell us the optimal time.

Proper Use of Inhalers and Spacers

Inhaled corticosteroids are delivered to the lungs by a metered dose inhaler, or MDI, which works by vacuum, or a dry powder inhaler. The MDI is more difficult to use because the child has to coordinate the actuation of the device (pressing the inhaler) with his inhalation of the drug. The child removes all the air from the lungs, inserts the inhaler into his mouth, inhales very deeply to draw in the air containing the drug, holds it for a few seconds, and finally exhales, keeping the inhaler out of in his mouth. Children need to carefully learn the technique, because if the device is used wrongly, it will not work.

Younger children are encouraged to use Spacers with the MDI for more effective delivery of the drug. The Spacer is a container that holds the "puff" of medication after its release from the pressurized MDI canister so it can be inhaled more slowly, and more enters the lungs. A mask can be attached to the Spacer to maintain a good lip seal. However, application of the mask is difficult: the parent needs to hold the child down so that he doesn't move, place the mask on the child's face to create a vacuum, and make sure that the child inhales the drug. This requires a special skill that has to be learned. If used incorrectly, none of these devices will be effective.

Food allergies

The last thing I'd like to talk about is food. Children with asthma can eat everything, even milk and peanuts. Milk does not cause mucus. Some children, of course, may be allergic to cow milk, and they should not have it. If they do, they will have symptoms of milk allergy: vomiting, swelling, skin rash and other symptoms. Children with milk allergy who are also asthmatic may have an asthma attack when they drink milk. Children who are not allergic to milk can drink as much milk as they want, with no effect on their asthma.
The same goes for peanuts. Asthmatic children can eat as much "Bamba" (A popular snack made of peanut flavor) as they want - unless they also have a peanut allergy. In Israel, peanut allergy is rare because every newborn is met by a dad or grandparent holding a bag of "Bamba" the minute he's out of the hospital, and he continues to eat it the rest of his life.