Asthma Health Article

Treatment

Once asthma is diagnosed, a treatment plan should be initiated as quickly as possible to manage asthma symptoms.

In most cases, asthma treatment is managed by the child's pediatrician. Referral to an asthma specialist should be considered if:

• There has been a life-threatening asthma attack or severe, persistent asthma.
• Treatment for three to six months has not met its goals.
• Some other condition, such as nasal polyps or chronic lung disease, complicates the asthma.
• Special tests, such as allergy skin testing or an allergen challenge, are needed.
• Intensive steroid therapy has been necessary.

The first step in bringing asthma under control is to reduce or avoid exposure to known allergens or triggers as much as possible. Treatment goals for all patients with asthma are to prevent troublesome symptoms, maintain lung function as close to normal as possible, avoid emergency room visits or hospitalizations, allow participation in normal activities—including exercise and those requiring exertion—and improve the quality of life.

Medications

The best drug treatment plan will control asthmatic symptoms while causing few or no side effects. The child's doctor will work with the parent to determine the drugs that are most appropriate and may be the most effective, based on the severity of symptoms. Age and the presence of other medical conditions may affect the drugs selected.

Two types of asthma medications include short-acting, quick relief, medications and long-acting, controller, medications. Quick relief medications are used to treat asthma symptoms when they occur. They relieve symptoms rapidly and are usually taken only when needed. Long-acting medications are preventative and are taken daily to help a patient achieve and maintain control of asthma symptoms.

Asthma treatment guidelines may be based on these symptom classifications:

• Mild intermittent: No daily medication is needed but a short-acting beta2 agonist may be used when needed to treat symptoms.
• Mild persistent: Daily long-term medication may be prescribed.
• Moderate persistent: Two medications may be prescribed, including a long-term medication to control inflammation and a short-acting medication to use when symptoms are more severe.
• Severe persistent: Multiple long-term control medications are required.

When asthma symptoms worsen, medication is increased. When asthma symptoms are controlled, less medication is needed. It is very important to discuss any desired changes to the medication schedule with the doctor. The medication dose should never be changed without the doctor's approval. The condition can worsen if certain medications are not taken.

Inhaled medications have a special inhaler that meters the dose. The inhaler may have a spacer that holds the burst of medication until it is inhaled. Patients will be instructed on how to properly use an inhaler to ensure that it will deliver the right amount of medication.

A home nebulizer, also known as a breathing machine, may be used to deliver asthma medications at home. The nebulizer changes medication from liquid form to a mist. The child wears a face mask to breathe in the medications. Nebulizer treatments generally take seven to 10 minutes.

Quick relief medications include short-acting, inhaled beta2 agonists and anticholinergics. Long-acting medications include leukotriene modifiers, mast cell stabilizers, inhaled and oral corticosteroids, long-acting beta2 agonists, and methylxanthines.

SHORT-ACTING BETA-2 AGONISTS These drugs, which are bronchodilators, open the airways by relaxing the muscles around the airways that have tightened (bronchospasm). The short-acting forms of beta-receptor agonists are the best choice for relieving sudden attacks of asthma and for preventing attacks triggered by exercise. These drugs generally start acting within minutes, but their effects last only four to six hours (although longer-acting forms are being developed). They may be taken by mouth, inhaled, or injected.

ANTICHOLINERGICS Anticholinergics are medications that open the airways by relaxing the muscle bands that tighten around the airways. They also suppress mucus production. They do not provide immediate relief, but can be used to control severe attacks when added to an inhaled beta-receptor agonist.

LEUKOTRIENE MODIFIERS Leukotriene modifiers, also called antileukotrienes, can be used in place of steroids for older children who have a mild degree of asthma that persists. They work by counteracting leukotrienes, substances released by white blood cells in the lung that cause the air passages to constrict and promote mucus secretion.

MAST CELL STABILIZERS Available only in inhaled form, mast cell stabilizers, such as cromolyn and nedocromil, prevent asthma symptoms. These anti-inflammatory drugs are often given to children as the initial treatment to prevent asthmatic attacks over the long term. They can also prevent attacks when given before exercise or when exposure to an allergen cannot be avoided. They are not effective until three to four weeks after therapy is started. These medications need to be taken two to four times a day.

STEROIDS These drugs, which resemble natural body hormones, block inflammation. Steroids are extremely effective in relieving asthma symptoms and can control even severe cases over the long term while maintaining good lung function. When steroids are taken by inhalation for a long period, asthma attacks become less frequent as the airways become less sensitive to allergens. Besides being inhaled, steroids may be taken by mouth or injected, to rapidly control severe asthma. Steroids are the strongest class of asthma medications and can cause numerous side-effects, including bleeding from the stomach, loss of calcium from bones, cataracts in the eye, and a diabetes-like state. Patients using steroids for lengthy periods also may have problems with wound healing, weight gain, and mental disorders. In children, growth may be slowed. To prevent serious side effects, the child will have periodic monitoring tests.

LONG-ACTING BETA-2 AGONISTS Long-acting beta-2 agonists are used for better control—not relief—of asthma symptoms. The medications take longer to work and the effects last longer, up to 12 hours.

METHYLXANTHINES Theophylline is the chief methylxanthine drug. It may exert some anti-inflammatory effect, and is especially helpful in controlling nighttime symptoms of asthma. If a patient cannot use an inhaler to maintain long-term control, sustained-release theophylline is a good alternative. The blood levels of the drug must be measured periodically, as too high of a dose can cause an abnormal heart rhythm or convulsions.

OTHER DRUGS Some inhalers contain a combination of two different medications that can be delivered together to shorten treatment times and decrease the number of inhalers that need to be purchased. Clinical trials are continuously evaluating new asthma medications.

IMMUNOTHERAPY If a patient's asthma is caused by an allergen that cannot be avoided, or if medications have not been effective in controlling symptoms, immunotherapy (also called allergy shots) may be considered. Immunotherapy is helpful when symptoms tend to occur throughout all or most of the year. Typically, increasing amounts of the allergen are injected over a period of three to five years, so that the body can build up an effective immune response. There is a risk that this treatment may cause the airways to become narrowed and bring on an asthmatic attack.

An international conference, Immunotherapy in Allergic Asthma, hosted by the American College of Allergy, Asthma, and Immunology (ACAII) in 2000 concluded that immunotherapy is an effective treatment for allergic asthma and can prevent the onset of asthma in children with allergic rhinitis. The Preventive Allergy Treatment study, published in 2002, confirmed the ACAII conference conclusions, documenting that immunotherapy reduces the risk of developing asthma and reduces lung airway inflammation in children with hay fever, a condition that predisposes them to asthma.