It can be very confusing for parents of asthmatics reading or talking to other parents about this topic. Indeed, it can even be confusing if they go to more than one doctor about it. This is because the medical profession as a whole has undergone something of a revolution in the way it thinks about and treats Asthma over the past 10 to 15 years. Several different changes have occurred. One of the biggest is that we make the diagnosis much more readily (at a lower "threshold ") than we did in the past. Prior to the late 1970's a patient had to have what today we would call moderate to severe Asthma to even be given the diagnosis. What we call mild Asthma today (which is the majority of Asthmatics) prior to the 1980's tended to get called "chronic bronchitis", "recurrent chest colds", or simply "allergies". The belief among physicians in that era was that mild Asthma did not pose any danger, and therefore did not need to be treated with Asthma medications. Since no treatment was necessary, there was no point in "scaring the family" by using the term "Asthma" at all. The problem with this approach was that it allowed a certain subset of those mild asthmatics to progress and become worse. Indeed, around 1980, data started to come out which suggested that both hospitalization and death rates from Asthma had been increasing in the United States since about 1950. After much analysis by many experts, ultimately the conclusion was drawn that the relative "neglect" of its mild form was at least partly to blame for Asthma's increasing severity over the middle part of this century. Because of this, the "standard of care" shifted - we started to call any illness, no matter how mild, "Asthma" if it shared the same basic mechanism or "physiology". We started treating such cases rather aggressively with Asthma medications as well.

Another big change in the way think about Asthma has to do with our understanding of its mechanism. Today, physicians think of Asthma as a chronic inflammatory disease of the lungs. This simply means an asthmatic has "sensitive lungs". It takes less to irritate an asthmatic's lungs than it would to irritate the lungs of a normal person. In fact, even normal people can experience episodes which are physiologically identical to Asthma IF their lungs are subjected to a severe enough insult. Examples of this would be smoke inhalation from a fire, a near-drowning incident, or a bad case of pneumonia. In all of these circumstances a normal persons lungs can react just like an asthmatic's, and indeed they respond in such situations to Asthma medications! The difference is that they are not "prone" to recurrences of this phenomenon. An asthmatic, in contrast, experiences inflammation of the lungs at "a drop of a hat". Rather than smoke inhalation from a fire being what it takes to make their lungs "angry", an asthmatic's lungs get upset if they are in the same room with a cigarette smoker. Rather than it taking a bad case of pneumonia, an asthmatic's lungs get inflamed from a simple "cold". Many other things can trigger Asthma: Allergies to things in the air or in the diet; dust or air pollution; cold air or sudden changes in the weather (in any direction); exercise - even emotional distress can trigger it, especially in adolescents and young adults. It used to be that physicians focused too much on the exact trigger of a particular patient's Asthma rather than focusing on the fact that their lungs were more sensitive in general. Thus, in the era from 1950 - 1970, we tried to describe "allergic Asthma", "bronchitis" (or "infectious Asthma"), "exercise induced Asthma", or "psychogenic Asthma" as if all of these things were separate and distinct diseases. This distorted the truth. In reality, most patients with Asthma over the course of their lives will, at one time or another, be sensitive to all or most of the above triggers. A typical pattern is for an infant or toddler to react mostly to virus's, colds, and changes in the weather. As they get older, during the school-age years, allergies come to the fore. When they enter adolescence, exercise and emotional lability can become more and more of a problem. However, while this general pattern is very common, any of these triggers can cause problems for any asthmatic at any time.

Yet another change over the past ten years in how we think about Asthma is in our understanding of the process by which lungs become inflamed, irritated, or "angry". The lungs are made of a branching "tree" of air passageways which become steadily smaller and narrower until they end in small microscopic air sacs. The walls of these air-tubes contain circumferential muscles which, when they squeeze, narrow the airway. When the lungs are subjected to an irritating substance or stimulus, the most rapid response which is available to them is for these muscles to squeeze. You could imagine that the muscles are trying to keep the bad substance out. This process is called "bronchospasm" -- quite literally, spasming of the muscles of the bronchi or breathing tubes. Narrowed breathing tubes are harder to breath through. This leads to respiratory distress and wheezing - a whistling noise which is usually loudest during exhalation (breathing out). Prior to about 1980, bronchospasm was considered to be the primary mechanism by which Asthma occurred. Virtually all of our Asthma medicines in that era were directed at relaxing the muscles of the airways ("bronchodilation"). In the past decade, we have appreciated more and more that other mechanisms of lung inflammation play an equal and sometimes greater role in Asthma, however. While bronchospasm is the most rapid response of the lungs to an irritating stimulus, very soon after bronchospasm begins the walls of the breathing tubes themselves start to swell in much the same way that you might experience swelling in a sprained wrist or an infected finger. Swelling basically means that the tissues in the area accumulate more fluid and therefore grow in size. When this happens in the breathing tubes of the lungs once again they become narrower - just as with bronchospasm. Yet another thing that happens soon after a noxious stimulus to the lungs is that the lining of these breathing tubes starts to secrete fluid - phlegm, mucous - in much the same way that the lining of your nose secretes fluid when you have a cold. This fluid sits in the air passageway and has the effect of still further narrowing the space through which air must travel in order for you to breath. Moreover, this fluid can become a breeding ground for germs which can secondarily "take over", worsening the inflammation and keeping the whole inflammatory process going in a "viscious cycle". In sum, there are three natural mechanisms which come into play in an irritated lung - bronchospasm, swelling and mucous secretion. In any particular asthmatic at any particular time one or more of these may be playing a dominant role, OR all three may be equally at work.

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In general, we "rate" asthmatics into one of four categories:

"Mild" asthmatics get sick relatively infrequently and when they do get sick can be managed easily with medications on an outpatient basis. They do not need to be on medications all the time - only when they get sick.

"Moderate" asthmatics EITHER get sick fairly frequently but NOT so severely that they need to be hospitalized; OR relatively infrequently but severely enough for occasional hospitalization to be necessary. In general moderate asthmatics are best managed with chronic medications which they take all the time in order to prevent Asthma exacerbation's.

"Severe" asthmatics are children who, despite chronic management with appropriate medications, still require frequent hospitalization and miss a significant amount of school. These children often need to take multiple medications and see the doctor frequently.

"Unstable" asthmatics have a very dangerous form of Asthma. When they get hospitalized they often end up in the "Intensive Care Unit" and their life may be in danger. This kind of Asthma, while rare, requires the most diligent, aggressive, and careful medical attention.

"Mild" and "moderate" asthmatics make up more than 95% of all children with Asthma. Less than 1% of children with Asthma develop the "unstable" form.

When we think about treating Asthma we need to think separately about the acute situation at hand (How do we make this sick child better right now?) and about the more long-term chronic management (Should we be doing something to prevent this in the future, and if so, what?). In general, when dealing with the acutely ill child we use whatever medications seem to be needed to bring their symptoms under control as quickly as possible based upon the pattern of those symptoms, their severity, and what we believe to be the likely triggers. When making decisions about acute management, we do not think very much about side-effects, cost, or the effect on one's lifestyle. In contrast, decisions about chronic Asthma management rest more importantly on how frequently a child gets ill. It would not make sense to put a child on chronic medication they need to take every day to prevent an "attack" which only happens once a year - no matter how severe that yearly attack might be. In general, we start chronic medications when an asthmatic is getting sick more often then four times per year. When we do decide to start chronic management, we think very much about side effects, risks, cost, and the effect on lifestyle and we try to choose the medicine which will be safest and has the least deleterious effects on the child's day to day living. We then "step upward" in a gradual fashion from there until we achieve control. It is important to bear in mind this distinction between acute and chronic management when reading through the information about specific medications below.

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Then there are allergies..... I pause here because people too often confuse Asthma and allergies. THEY ARE NOT THE SAME THING! Asthma is a disease of the lungs ("sensitive lungs"). Allergies are a disease of the immune system. This is a bit of a simplification - but you could think of allergies as being an "overactive immune system" (or the opposite of an immune deficiency). What I mean is that while someone with an immune deficiency has a weakened immune system which cannot fight as effectively as it should, someone with allergies has an immune system "with an attitude" - "picking fights" with things when it would be better off to "turn the other cheek".

While allergies are not asthma - if you have both allergies and asthma the former will almost surely trigger the latter. This is a very common situation partly because both diseases are so widespread (Asthma occurring in 15% of children, allergies in up to 40%!!!). There is also some evidence that the two are associated with one another, i.e. both diseases often run in the same family. Exposure to an "allergen" may elicit asthma symptoms rapidly making the connection obvious, but the response may also be delayed for hours (or chronic/frequent exposure may cause persistent rather than acute symptoms) making it more difficult to identify the precipitating agent. Unfortunately, the most common things which children are allergic to (pollen, molds, house dust, cockroaches) are difficult if not impossible to avoid. Therefore testing to determine or "prove" that you are allergic to these substances is, practically speaking, of very limited value. On the other hand, sometimes children may be allergic to a household pet or a particular food in their diet which can be easily eliminated - identifying this kind of allergy can be quite helpful. It is therefore important that, as a parent, you "keep your eye out" for things in your child's environment which seem to bother him or her and let your pediatrician know if you suspect something. We can then consider if targeted allergy testing might be worthwhile in your child's case. We do not generally recommend "routine" allergy testing of all asthmatics, however.

One final word about infectious Asthma triggers. We very recently (in the last five years) have come to recognize a group of disorders which have been termed "mild" or "functional" immune deficiencies. Children with functional immune deficiencies are nowhere near as sick as children with AIDS or other serious immune problems. They do not get life-threatening or unusual infections. They simply are more prone to common childhood illnesses like colds and ear infections and it takes them longer to "shake" such illnesses. It turns out that, like allergy, functional immune deficiencies are statistically associated with Asthma. Indeed, up to 5-10% of asthmatics may turn out to have such deficiencies. Therefore, children who seem to have frequent infections as main trigger of their Asthma should probably be tested for functional immune deficiencies. Often such children will be helped greatly by long-term chronic antibiotics, and if this fails, other treatments aimed specifically at the immune system are also available.

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Steroids have an unfairly "bad reputation" among the general public. This is partly related to steroid abuse by athletes. It is important to understand that the kinds of steroids athletes abuse are not at all the same thing as what we use in Asthma care or other medical management. The kind of steroids abused by athletes are actually related to and mimic the action of the male sex hormone testosterone. The kinds of steroid used in most medical situations including Asthma are not related to testosterone at all, but instead to another hormone the body produces - Cortisol. Cortisol is a "chemical cousin" of testosterone but has a totally different biologic action modulating the immune system, not the sexual organs. As mentioned above, steroids related to Cortisol have some very serious long-term risks and side-effects and so a decision to use them on a chronic basis is something we take very seriously and try to avoid. On the other hand, short-term use is quite safe and is often the most effective thing we can do to help someone acutely ill with an Asthma attack.

While differing opinions exist within the medical community over the "threshold" at which one begins short-term steroids, the general trend over the last ten to twenty years has been very much towards increasing freedom in their use. It is important for you as a parent to know that when you are placed on steroids for between 5 and 7 days, they can be given in the full dose and then stopped immediately. Someone who is on steroids for longer than 7 days needs to be "tapered" rather than stopped abruptly. This is rarely necessary on an outpatient basis since we hardly ever use steroids for more than 5-7 days in non-hospitalized patients. However, sometimes a hospitalized patient will have spent 7-10 days already in the hospital getting intravenous steroids and we will want them to continue on steroids for several days after going home -- in this situation, they will need to stop the steroids by gradually reducing the dose over a course of 10-20 days on a schedule which will be worked out by their doctor. It is also important to keep track of how often short-term steroid use is being employed with a particular patient. While a single episode of short-term steroid use is perfectly safe, if you are needing to use short-term steroids more often than every 2-3 months you are approaching a situation where the patient is, for all practical purposes, on chronic steroids and some "re-thinking" of the overall plan at that point is probably appropriate.

Steroids are also available in inhaled forms (Flovent, Pulmicort, Vanceril, Beclovent, Aerobid, others). These are our newest "weapons" in the fight against asthma. The proper role of inhaled steroids in this battle is still evolving and has yet to be fully defined, however. Inhaled steroids essentially "compete" not with oral or injected steroids (they don't work as powerfully or as fast), but rather with Intal as a chronic preventative treatment. They can unquestionably be quite effective for certain patients in whom Cromolyn hasn't worked and, because they are not absorbed very much into the bloodstream, appear to be quite safe even for long term chronic use. Whether they are as safe as Intal, and whether they will ever come to replace it as a "first line" therapy, remains to be seen however

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Until relatively recently, theophylline was the "first line" drug of choice used for chronic Asthma management by most pediatricians, allergists, and pulmonologists. This was because it is available in a "long acting" form so, unlike a "ß-agonist", it was possible to maintain a steady level in the bloodstream with a two or three times daily dose. In recent years theophylline seems to have fallen out of favor, however. It is now used very little by "modern" Asthma specialists. When it is used, nowadays it tends to be for acute Asthma exacerbations and it is discontinued as soon as the child improves. The biggest reason for this change has been the increasing availability of drugs which are more effective and which have fewer side effects. The unpleasant need to periodically draw blood to monitor theophylline levels probably also contributed to its decline. Finally, concerns have been raised that theophylline may have certain long term side effects above and beyond the typical ones mentioned above. Specifically, long-term therapy with theophylline has been said to adversely affect learning ability and school performance. Several studies attempting to look critically at this "allegation" have tended NOT to support it, however. It is important to remember that theophylline can still be a very effective drug which may be quite useful for certain Asthma patients, especially if the use of inhaled medications is for some reason difficult or ineffective in a particular case.

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There are three ways to inhale medications: in powdered form (a "turbohaler" or "autohaler"), as a spray from a "metered dose inhaler" (MDI), or as a continuous mist created by a nebulizer machine. Of the three, nebulized mists are both the most effective and the easiest to take/deliver properly. However, they are also the most expensive and physically cumbersome because of all the "equipment" involved. Meter dose inhalers can be much more convenient from a "lifestyle" point of view. The danger of meter dose inhalers is twofold: first, unlike nebulizers which work the same no matter how ill a patient is, meter dose inhalers work progressively less well the sicker a patient gets. This is because the ability to breathe in the medication from the inhaler is impaired by the disease. Patients on inhalers can thus get into a vicious cycle - the sicker they get, the less well the medicine works regardless of how often it is taken, and the more prone they become to continue getting even sicker. Especially in teenagers (who always think they are immortal) this can be a dangerous combination because as they deteriorate they just take their inhaler more and more frequently and they do not come to the doctor as they should. The other problem with meter dose inhalers is they are quite difficult to take correctly. It requires just the right distance from the mouth and just the right "timing" of the breath with the spray. It can be very difficult to teach this technique to someone younger than about 13 years old. We try to get around this difficulty using different types of "spacer devices" - which are essentially chambers for holding the spray mist in the air so that the timing of the breath in is less crucial. These devices can be used successfully down to the early elementary school age, but even they can be difficult to use correctly. Ultimately, meter dose inhalers are not as reliable a way of getting medication into a child as nebulizers are. For that reason, nebulizers are always preferred in children less than 6 or 7 years old and in older children whose Asthma is more severe. Sometimes a combination of the two approaches can be useful - a nebulizer for use at home and meter dose inhalers (perhaps with a spacer device) for use in the school setting.

Powdered types of inhalers are the least commonly used form of inhaled medication. This is because many children find them unpleasant - the granular feeling in the back of the throat they create can lead to coughing in and of itself. However, for certain children who do not want to take a nebulizer and have difficulty taking a meter dose inhaler they are a good alternative.

Despite the advantages of the inhaled route, sometimes oral medications are necessary or even best. In a young child with mild asthma they are by far the most convenient and perfectly adequate for the job. Certain medications that may be necessary at times for more severe asthmatics do not come in an inhaled form. At other times a combination approach, using both inhaled and oral medications simultaneously, will be necessary to bring symptoms under control.

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Every Asthma patient should have an "Asthma plan". Your plan should consist of a specific list of treatments you give at different "levels" of illness. Level 1 is when your child seems completely well and could be thought of as your "baseline" care. Level 2 is the plan you "move up" to whenever the child gets sick with something that does not appear to be Asthma. In other words, if the child gets a cold or a sore throat or fever or vomiting or diarrhea, you want to increase their Asthma medications a little bit to prevent this illness from triggering an Asthma attack. You might also want to move to Level 2 when you know you are going to be exposed to certain triggers such as before exercise, before a big storm, or if you are going over to grandma's house where they all smoke cigarettes. Level 3 is the treatment plan you "move to" when the child clearly is starting to have problems with Asthma (wheezing, coughing, shortness of breath) BUT they do not seem severe enough to require a visit to the doctor yet. Always, you should call your pediatrician if you have moved to Level 3 and it does not seem to have helped the Asthma symptoms within a relatively short period of time. Also, it is appropriate to call your pediatrician if you have been at Level 3 for several days and the Asthma symptoms return every time you try to "move down" to Level 2. The specific plan at Levels 1, 2, and 3 for each individual patient will be different. Only your pediatrician can customize a plan that works just for you.

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