Asthma, an increasingly common disease, is often feared and misunderstood. Many parents respond with trepidation when the term "asthma" is used. We immediately recall a child who always seemed sick and was never allowed to play outside. The severity of even such severe cases can now be abated with the advent of newer medications. Asthma is often mild enough as to go unrecognized, even by the afflicted person. The most common forms of asthma, exercise induced asthma (EIA) and cough-variant asthma, are usually manifested by episodic coughing spells and brief sensation of tightness in the chest. Although mild and easily overlooked, these forms of asthma can interfere with your child’s enjoyment of life as much as can more obvious forms, such as overt wheezing. They are also amenable to treatment and prevention. Therefore, you should strive to control the asthma and not let it control you or your child!

Who has asthma? Almost 10 % of us have asthma. Many Olympic athletes have asthma. Many adults who were diagnosed with chronic or recurrent bronchitis as children probably had unrecognized asthma. Children who experience recurrent wheezing (noisy, difficult exhaling), longer lasting colds and coughs than those of their siblings, cough with exercise or being "winded" sooner than their teammates may well have asthma. Asthma is far more common in people with eczema, hayfever or allergies. Asthma often runs in families. However, not all wheezing is asthma. If you think you or your child has asthma, talk to your doctor. A pulmonary function test (PFT) –simple, painless breathing measurements -- can help diagnose asthma in people old enough to cooperate (about 5 or 6 years old). Once the diagnosis is made, appropriate therapy can be started.

What is asthma? Asthma has been variously defines as "twitching airways", "allergic" airways, recurrent wheezing, or a common, recurrent reversible hyper-responsive lung condition. Recently, the definition of asthma has changed! A panel of national experts met in 1991 and in 1997 to discuss the years of research on asthma. In their report, they stressed that asthma, whatever the severity, is a chronic inflammatory disorder of the airways. They noted that if one does not treat or prevent this chronic inflammation, the hyper-responsiveness might worsen and, with time, become irreversible.

The stimulus of an asthma attack may be exercise, cold air, a viral respiratory infection, allergens (such as cat dander, dust mites, pollens, etc.), irritants (such as smoke, air pollution, volatile chemicals in paints and fragrances, etc.), ozone on hot humid summer days or leaf molds on cold, damp fall evenings. The hyper-responsiveness results in constriction of the outer muscle surrounding the airway and inflammation of the inner lining (mucosa) with consequent narrowing. It may manifest as coughing fits, wheezing, excessive mucus, chest tightness, fatigue or shortness of breath. Even without treatment, symptoms can eventually subside after the offending stimulus disappears. Treatment reverses the symptoms more quickly. When symptoms are severe, treatment should be instituted immediately.

The goal of therapy: We recommend treatment so asthmatics can maintain normal activity levels uninhibited by chronic and troublesome symptoms, while experiencing minimal to no side effects from any necessary medicines.

Develop an asthma management plan. Everyone with asthma should have an individualized asthma management plan. The first steps in any plan are to identify triggers (stimuli) and to monitor symptoms, activity levels and exacerbations. If your symptoms are frequent or persistent, consider monitoring your pulmonary function with a peak flow meter. This simple, inexpensive device measures your peak rate of exhalation (peak expiratory flow, PEF). Peak flow measurements offer an accurate way of assessing severity of wheezing and success of treatment. Reduce your exposure to your "triggers" (see our article in the Princeton Online archives on allergy-proofing your home). Know when, how and which medicines you should take for your asthma, and especially understand the distinction between the "quick-relief" and "long-term-control" asthma medicines (see below). Finally, know when to contact your doctor, when to come in for routine care or acute episodes and when to go directly to the ER (emergency room). If your management is appropriate, you will be able to minimize the need for emergency care. Your doctor should help you design an asthma management plan to accomplish these goals.

Quick relief medicines: Depending on the pattern of your child’s asthma symptoms, you and your doctor will decide on the appropriate medicines, often adding them in a step-wise fashion. All children with asthma need a way to obtain quick relief, whether by using a hand-held meter dose inhaler (MDI), breathing nebulized medicine via an electric air compressor, or swallowing a liquid or pill. Inhaled medication usually acts more quickly, is more effective and has fewer side effects. This "quick relief" medicine is usually a bronchodilator, a.k.a. "short-acting beta-agonist", such as albuterol ("Proventil®" or "Ventolin®"). A bronchodilator relaxes the muscles surrounding the airway, thereby opening the airway and making breathing easier. These "short-acting beta-agonists" are the most common medicine that athletes with Exercise-Induced-Asthma take before exercising. Your child’s doctor will help you establish criteria regarding when to administer this medication. For most children, acute symptoms or a low peak flow are reasons to take "quick-relief" medication. This medication lasts about 6 hours. It is important to avoid extra dosing, since too much albuterol may have undesirable side effects. If adequate relief is not obtained, consult your child’s doctor regarding the next step. Your child may rarely need such medicines, but you and your child should always have some available (even at school or on vacations) and know when and how to use it!

Long-term control medicine is often necessary. If your child needs a quick-relief medicine more often than is acceptable (typically greater than 3 times per week, but check the individual asthma management plan you have devised with your physician) or if your child has unremitting symptoms despite "quick-relief" treatment, you should consider a "long –term- control" medicine. Long-term control medicines do not give quick relief, but can prevent an attack or augment the effectiveness of quick-relief preparations. Anti-inflammatory medications, usually corticosteroids (not to be confused with the androgenic steroids abused by body builders) suppress the airway inflammation. They are among the most frequently prescribed long-term medications for asthma. Studies suggest that early intervention with an anti-inflammatory medicine can improve asthma control, normalize lung function, and may prevent irreversible airway injury. The most potent corticosteroids are oral preparations, for example prednisone or prednisolone (Pediapred®, Prelone®) which are safe for short term use. Potential side effects with daily long-term use preclude prolonged administration in all but extreme circumstances. Inhaled corticosteroids, such as budesonide (Pulmicort®), fluticasone (Flovent®), triamcinolone (Azmacort®), or beclomethasone (Vanceril®, Beclovent®) are weaker than the oral but are thought safe even for prolong periods of use (years!).

Another type of inhaled anti-inflammatory medicine is mast cell inhibitors. These preparations, helpful in an estimated 80% of asthmatics, have little, if any, side effects, but are less effective than corticosteroids. They inhibit the release of asthma producing chemicals into our airways. Sodium cromolyn (Intal®) and nedocromil (Tilade®) are the 2 available inhalant preparations in this country. The leukotriene inhibitors, montelukast (Singulair®) and zafirlukast (Accolate®) are a more recent family of anti-inflammatory medicines. They inhibit the release of different asthma producing chemicals. Being chewed or swallowed instead of inhaled, they are more convenient. Hopefully, further experience with these drugs will prove them as useful for long-term asthma control as older medications.

Finally, some physicians recommend antihistamines to help control asthma induced by allergens. Care must be taken, however, to avoid this class of medication if the asthma attack is not due to allergies, since its mucus-drying effects might worsen the symptoms.

Which "long –term control" medicine, if any, is right for your child? You, your child and your child’s doctor should decide together. Symptom control, potential side effects, costs and convenience are all important to consider in making a treatment selection. Moreover, you, your child and your doctor should continually monitor and refine your child’s individual treatment plan for optimal care.

Supplemental information: Further information can be obtained from your doctor and/or the organizations listed below: