by Warren P. Silberstein, M.D.
07/07/97
Even though asthma is caused by inflammation in the airways, not all asthmatics need to take anti-inflammatory medications. Children who have mild or occasional symptoms can control their symptoms just by using bronchodilator medications such as albuterol (spray, nebulizer, syrup, tablets). A good general rule to follow is that asthmatics who require rescue medications three times a week or more over a long period of time should be on some form of maintenance medication which usually includes an inhaled anti-inflammatory. Patients whose symptoms and use of rescue medications are infrequent don't require maintenance medications. It is likely that these patients or their parents would be reluctant to use maintenance medications including anti-inflammatory sprays since they need to be used long term to be beneficial.
Some patients only have symptoms when they run or play sports. This is known as exercise induced bronchospasm or exercise induced asthma. These symptoms can be treated by using a rescue medication like albuterol spray. Albuterol spray provides 4 to 6 hours of bronchodilation so it can be taken before sports to prevent wheezing. Anti-inflammatory sprays such as Intal (cromolyn), Tilade (nedocrimil), or an inhaled steroid can be taken before sports to prevent wheezing as well. The only situation for which it is useful to take anti-inflammatory sprays on an as needed basis is for the prevention of exercise induced asthma. Sprays should be taken one half hour before sports to prevent wheezing.
Upper respiratory infections (URIs) such as colds tend to aggravate asthma in both the mild and severe asthmatics. Some patients who rarely have symptoms may have a significant increase in asthma symptoms when they have a URI. They may go from no use or occasional use of rescue medication to using their inhalers every 4 hours to control symptoms. If the symptoms are mild that may be sufficient treatment until the cold resolves; however, if the symptoms persist, there is always a risk that they may get worse. While a few days of increased wheezing may not always require institution of anti-inflammatory medicine, a good general rule to follow, whether a child is regularly on medication to control asthma or only uses medication occasionally, is that for any significant increase in asthma symptoms, you should seek medical attention or at least medical advice. The best way to avoid a serious increase in asthma symptoms or a hospitalization is to recognize increased asthma symptoms early and treat vigorously.
Patients who have chronic symptoms should monitor their status by checking their peak flow rates regularly. It is important to know a patient's personal best peak flow rate reading when he is well in order to use readings to monitor increasing symptoms. A drop in peak flow rate below 80% of the personal best is an early sign of increased symptoms. A drop below 50% is a clear sign of trouble and a need for medical evaluation. Unfortunately, young children cannot use peak flow meters. Often, a parent's only clue that asthma is starting to flare up is increased coughing. If the parents are unsure whether a young child's symptoms are asthma related, the best thing to do is call the doctor.
Asthmatics who have occasional symptoms, as well as those who have more severe or persistent symptoms should keep in mind the following danger signs that indicate a need for more aggressive therapy and therefore a visit to the doctor:
In an effort to decrease asthma symptoms, asthmatics and their parents should learn to identify and avoid triggers. Triggers are those things that provoke asthma symptoms when an asthmatic is exposed to them. Keep in mind that triggers may not always cause symptoms immediately but chronic exposure may lead to an increase in the baseline inflammation of the airways resulting in chronic low-grade symptoms and greater susceptibility to increased symptoms and asthma attacks.
The most common triggers are dust mites, tobacco smoke, dander from furry animals like cats and dogs, cockroach, pollen, mold, smoke from wood-burning stoves, upper respiratory infections, physical activity, and cold air. Some triggers like tobacco smoke and animal dander are best dealt with by complete avoidance when possible. Other triggers like dust mite and cockroach require control measures to limit exposure. Exercise, should not be avoided. Asthmatics should use appropriate medication before sports to allow them active participation. None the less, some will have to be excused from long runs and all should be permitted to self limit physical activity in gym class. For more complete information on controlling and avoiding triggers see Asthma Management and Prevention - a Practical Guide.
Since many of the triggers that provoke asthmatic symptoms do so because the asthmatic is allergic to them, any asthmatic with chronic or recurrent symptoms should have a complete allergy evaluation. Not only can the evaluation help direct the efforts at control measures, but for those situations where avoidance of allergen triggers is difficult or impossible, immunotherapy (allergy shots) may help.
For more information on the management of asthma see
Asthma Management and Prevention - a Practical Guide - a complete and erudite treatise on asthma.
Stepwise Approach for Managing Asthma in Adults and Children Over 5 Years Old
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