Pediatric Asthma FAQs: Overview of the Disease Process

What is ASTHMA?

Asthma is a chronic (long-term) lung condition that causes inflammation and narrowing of the airways. Airways become irritated, swollen, and overly sensitive to breathing in certain substances like pollen (NIH, 2013). When triggered, muscles in the airway react by tightening, and this causes the airway to become narrower, limiting the amount of air that can get to the lungs and making it hard to breath (NIH, 2013). The cells in the airway that make mucus also overreact and begin making excessive amounts sticky, thick liquid that narrows the airway even more (NIH, 2013). This chain reaction in the airways results in the four main symptom of asthma, including:

Wheezing
Shortness of breath
Coughing (Most commonly at night or in the morning and in the absence of an infection)
Chest tightness

(Hockenberry and Wilson, 2006)

Symptoms in children may also include:

Itching on the front of the neck or upper back (early symptom)
Acting uncomfortable, irritable, apprehensive, or increasingly restless
Complaints of headache or tiredness
Paleness with plum-red cheek and ears
Blue lips, nail beds, and skin
Sweating
Short, panting speech
Infants tend to have less obvious symptoms because their chests are more flexible, but you may be able to see chest retractions (you may be able to see the outline of their ribs as they try hard to breath) (Hockenberry and Wilson, 2006). They may feed slowly or get short of breath while feeding (Mayo, 2014). Older children may sit in the Tripod Position (leaning forwards with hands on their knees) or upright with shoulders hunched and arms outstretched on a bed or chair, and they may have a decreased desire to run and play (Mayo, 2014).

(Hockenberry and Wilson, 2006)

Asthma Triggers:

An asthma trigger is something that causes an asthma attack. Common asthma triggers include:

Allergies
Changes in weather (such as from mild to cold temperature)
Exercise
Hormonal changes (such as a period or pregnancy)
Humidity
Infections (such as a cold or bronchitis)
Pollutants
Smoking

What is an Asthma Attack?

Sometimes, symptoms can be mild and disappear on their own, but sometimes symptoms are more severe and require treatment. If symptoms worsen, intensify, or new symptoms occur, this is called an asthma attack (NIH, 2013). The best way to prevent an asthma attack is to treat symptoms immediately because this can help them from worsening (NIH, 2013). Parents and older children can learn the early signs of an asthma attack so that they can control symptoms before they worsen (NIH, 2013). A severe asthma attack can require emergency medical care and can even lead to death (NIH, 2013).

Video:
What Causes an Asthma Flare?

The first asthma attack usually happens between age 3 and 8 years, but they can happen in infancy, when an asthma attack will often follow an upper respiratory infection (Hockenberry and Wilson, 2006). An attack can develop gradually or may come on very suddenly and may be followed by a second wave of symptoms 6-8 hours later (Hockenberry and Wilson, 2006). Although deaths from asthma attacks are relatively uncommon (with a peak between age 10-14), asthma attacks should be taken very seriously (Hockenberry and Wilson, 2006).

This picture shows what lungs looked like normally. The airways are wide open, and air can easy pass through (UVA Pediatrics, 2010):

Source: http://www.medicine.virginia.edu/clinical/departments/pediatrics/clinical-services/tutorials/asthma/attacks

When you have an asthma attack, your airway muscles tighten, or "SPASM,” and your airway lining swells (EDEMA) and clogs up with thick mucus (UVA Pediatrics, 2010). Air gets trapped inside the lungs, and this is what makes it so hard to breathe! This picture shows what lungs looked like during an asthma attack (UVA Pediatrics, 2010):

Source: http://www.medicine.virginia.edu/clinical/departments/pediatrics/clinical-services/tutorials/asthma/attacks

Just for fun, go HERE to HEAR the difference between breathing normally and breathing during an asthma attack:

http://www.medicine.virginia.edu/clinical/departments/pediatrics/clinical-services/tutorials/asthma/attacks

Does MY CHILD have Asthma?

The DIAGNOSIS of ASTHMA has traditionally been based on guideline recommendations (Busse, 2011). Diagnosis is based on clinical information combined with objective criteria (Busse, 2011). Determining that a child has a diagnosis of asthma involves taking a history of symptoms, doing a physical exam, and performing various diagnostic studies to rule out other causes of symptoms (Sawicki and Haver, 2014). Once the diagnosis has been made, the severity of the asthma (mild intermittent, mild persistent, moderate persistent, or severe persistent) will also be assessed. This will assist the doctor in prescribing treatment.

Diagnostic Studies used to diagnose asthma include:

Spirometry: Test that will likely be preformed to assess for evidence of airway obstruction. If there is airway obstruction, particularly if it is reversible with certain meditations, this is likely asthma. This test is recommended for those children 5 year of age and older. In children under 5, the spirometry may not be able to be performed, so asthma medications may be tried on a trial basis to diagnose the disease instead.
Bronchoprovocation: Test to measure lung function after exposure to asthma triggers. Triggers commonly used include a drug called methacholine, cold air, or exercise.
Peak Flow Meter: Handheld device used to measure peak expiratory flow, or how well air moves in and out of your lungs. It is most useful for monitoring symptoms over time.
Other tests, such as allergy testing, chest x-ray, sweat chloride test, or a barium swallow may also be conduced in order to rule out other cause of symptoms.

(Sawicki and Haver, 2014)

Treatment of Asthma:

Treatment of asthma depends on the severity of your disease and how well your asthma action plan is controlling symptoms and preventing attacks (NIH, 2013). Most people with asthma can manage the disease, experience few (or no) symptoms, and live active lives (NIH, 2013). Good asthma control will prevent troublesome symptoms, decrease the need for quick relief medicines, preserve lung function, allow you to sleep through the night and maintain normal activities, and prevent asthma attacks and hospitalization (NIH, 2013). Asthma can’t be cured, but it can be managed by:

Controlling asthma triggers
Monitoring asthma symptoms
Monitoring lung function
Understanding how/when to use asthma medications

(Sawicki and Haver, 2014)

There are two main types of asthma medications:

1. Long-term control medicines

2. Quick relief “rescue” medicines

1. Long-term control medicines are also called maintenance mediations and are taken every day to reduce inflammation and prevent symptoms (NIH, 2013). There are several types of long-term control medicines, including:

Inhaled Corticosteroids: These anti-inflammatory drugs are commonly prescribed and tend to work best in young children.
Leukotriene Modifiers: These drugs block the chemicals released after coming in contact with an allergen and are prescribed in addition to inhaled corticosteroids.
Cromolyn
Theophylline: A bronchodilator, this medication opens the airways by relaxing the muscles around the airway, but it is less frequently prescribed today.
Combination Inhalers: Inhaled corticosteroid AND a long-acting beta agonist (LABA) together

(Mayo, 2013)

2. Quick relief medicines, also called short-acting bronchodilators, relieve asthma symptoms once they are already present (Sawicki and Haver, 2014). Bronchodilators relax the airway muscles (UVA Pediatrics, 2011). The effects of a bronchodilator last approximately 6 hours, and Albuterol is the most common kind for asthma patients (Mayo, 2013). A child who uses a quick-relief medicine OFTEN has asthma that is NOT under control (Mayo, 2013). You should track how often your child uses this type of medication and share this with your doctor at EVERY visit (Mayo, 2013).

Once a patient’s asthma has been classifies by severity, the provider will likely use the STEPWISE APPROACH, which means that he will increase the amount of medication(s) if symptoms are NOT under control and slowly decrease the medications if a patient’s asthma is well controlled for a period of time. Here are three the stepwise charts commonly used for children: