Asthma in Children · 2020. 10. 28. · Forward Dear Parent, This is the second edition of “Asthma in Children.” There are over 100,000 copies of the first edition in print, in

By: Tom Kovesi, M.D. F.R.C.P.(C), Pediatric Respirologist, Associate Professor of Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.

Asthma in Children

Tom Kovesi, MD, FRCPC, is a paediatricrespirologist at the Children’s Hospital of Eastern

Ontario in Ottawa, Canada, and associate professor

in the Department of Paediatrics, at the University

of Ottawa. He graduated from the University of Ot-

tawa School of Medicine, completed a residency in

Paediatrics at the children’s hospitals in Ottawa and

Halifax, and then subspecialty training in paediatric

respirology at the Hospital for Sick Children in

Toronto. He has been on staff at the Children’s Hos-

pital of Eastern Ontario since 1992. Dr. Kovesi has

been a member of the Canadian Paediatric Asthma

Consensus Guidelines Committee since 1996 and is

past chair of the Paediatric Assembly of the Canadian

Thoracic Society. He is a member of the Executive

of the Ontario Thoracic Society and is the medical

advisor for the Ontario Lung Association’s Asthma

Education Centre in Ottawa. Dr. Kovesi also has a

web site on asthma in children (located at

http://www.cheo.on.ca/english/9101.shtml).

Dr. Kovesi’s research interests include asthma, air

quality and lung health in Inuit children in Nunavut.

When not working, he enjoys cycling, downhill ski-

ing, and shuttling his kids to lessons.

Forward

Dear Parent,

This is the second edition of “Asthma in Children.” There are over 100,000 copies of the first edition

in print, in English, French, and Farsi. This booklet is designed to fill a particular need. There are

many pamphlets, booklets, and web sites that provide basic information about asthma in children,

but most are too vague to be really practical and helpful. This booklet is intended to be detailed

enough to be really helpful. The first time I tried writing this booklet, it read rather like an encyclo-

pedia. I went back and redid it by writing down what I’d actually tell the parent of a child just diag-

nosed with asthma about asthma in my own clinic at the Children’s Hospital of Eastern Ontario. It’s

hard for a health care professional to tell you all about asthma in a busy clinic, emergency department,

or hospital ward, and this booklet is intended to supplement the information you get from your health

care provider. This book cannot replace medical advice from a qualified health care provider. How-

ever, you can, and should, use this booklet to determine whether your child’s asthma is adequately

controlled. If it isn’t, you should discuss with your health care provider methods of improving your

child’s level of asthma control.

Asthma is the most common chronic disease in children. Children with asthma may cough, wheeze,

and have difficulty breathing, which can prevent children from participating in sports, lead to missed

school, and lead to frightening, sometimes severe, asthma attacks. To control asthma effectively, fam-

ilies need information. They need to know what asthma is, the symptoms to watch for, common trig-

gers to avoid, and how to treat asthma. Every child should have well-controlled asthma, and with

avoidance of appropriate triggers and use of modern medications, this can nearly always be achieved.

I hope this book helps you and your child achieve this goal.

Tom Kovesi, M.D. F.R.C.P.(C),

Pediatric Respirologist,

Associate Professor of Medicine,

Children’s Hospital of Eastern Ontario,

University of Ottawa,

Ottawa, Ontario, Canada.

This booklet is provided for the information of

parents of children with asthma. The authors do

not assume responsibility for inaccuracies or

omissions contained in this booklet. New infor-

mation about asthma and new treatments are

constantly becoming available, and this booklet

cannot include all the latest information.

This booklet can not be used to make or confirm

a diagnosis of asthma, or to treat people with

asthma. This booklet can not be used as a sub-

stitute for obtaining medical advice or for seek-

ing treatment from a qualified physician. You

should not rely on the information contained in

it for advice in particular cases.

This booklet may help you identify when your

child is having an asthma attack. If your child is

having an asthma attack please contact your

doctor, bring your child to an emergency room,

or, in the case of an extremely severe attack, call

911, if 911 service is available in your area.

Disclaimer

Additional copies of Asthma in Children

may be obtained by calling

The Lung Association’s Asthma Action Helpline

at 1-888-344-LUNG (5864).

Table of Contents

INTRODUCTION ............................................................................................................................ 1

TELL ME ABOUT ASTHMA ........................................................................................................... 2

Symptoms of asthma in children .......................................................................................... 3

ASTHMA TRIGGERS ..................................................................................................................... 5

Allergic asthma triggers ...................................................................................................... 5

Other important asthma triggers .......................................................................................... 9

CAN YOU PREVENT ASTHMA? .................................................................................................... 10

ASTHMA: RISK FACTORS AND OUTCOMES .................................................................................. 12

PATTERNS OF ASTHMA IN CHILDREN ......................................................................................... 13

MONITORING YOUR CHILD’S ASTHMA SYMPTOMS ...................................................................... 16

Developing a written asthma action plan for your child ........................................................ 17

How do doctors determine the level of asthma control? ....................................................... 19

What are the signs of a severe asthma attack? .................................................................... 20

ASTHMA MEDICATIONS .............................................................................................................. 21

Reliever medications .......................................................................................................... 22

Controller medications ....................................................................................................... 24

Other asthma medications .................................................................................................. 31

Other forms of treatment .................................................................................................... 33

ASTHMA INHALERS & OTHER DEVICES ....................................................................................... 35

The metered-dose inhaler (mdi) ......................................................................................... 35

Spacer devices ................................................................................................................... 36

Dry powder inhaler devices ................................................................................................. 40

Wet nebulizer for aerosol treatment .................................................................................... 43

The peak flow meter ........................................................................................................... 48

SOURCES OF INFORMATION ON ASTHMA .................................................................................... 50

MY ASTHMA ACTION PLAN (Tear-Out) ....................................................................................... 51

MY ASTHMA DIARY CARD (Tear-Out) ......................................................................................... 52

1

Asthma triggers

2

Asthma is the most common chronic disease inchildren. Not only does one Canadian child in10 have asthma, but asthma in children is be-coming more common – especially in veryyoung children. Many children - especiallyyoung children who have asthma symptomsonly with ‘colds’ – eventually outgrow asthma.In other children – particularly those who alsohave allergies – asthma may persist for long pe-riods of time. Asthma can impair a child’s abilityto participate in activities, lead to absences fromschool, and lead to frightening and potentiallydangerous, asthma attacks. To control asthma,you will need to know what asthma is, whatsymptoms to watch for, and what are the com-mon triggers to watch for and how to avoid

them. You also need to know how to use asthmamedications effectively and safely. You need tobe able to recognize when your child’s asthmacontrol is not as good as it should be. Likeeverything in medicine, an “ounce of preventionis worth a pound of cure.” Recognizing poorcontrol early, before things get out of hand, willlet you take steps at home to improve the levelof asthma control, or will let you notify yourchild’s physician so you can discuss ways of im-proving your child’s asthma control. The pur-pose of modern asthma management is tocontrol your child’s asthma so the asthmadoesn’t control his or her life. The informationin this booklet is designed to help you achievethis.

To understand asthma, you have to know a littleabout the structure of the lungs. This section willtell you about how the lungs are constructed andwork, and how this changes during an asthmaattack.

The lungs are made up of airways (also knownas bronchial tubes or bronchi) and air sacs (alsoknown as alveoli). The purpose of the airwaysis to allow fresh air to travel into the air sacs andto allow spent or stale air to travel out of thelungs. In the alveoli, fresh oxygen is moved intothe blood and waste gas (carbon dioxide) istaken out of the blood so it can be exhaled intothe atmosphere. The bronchial tubes have tinybands of muscle encircling them.

Imagine a situation where you had to breathenoxious air – for example, if you were in a burn-ing house. The muscles around your bronchialtubes would tighten up, trying to keep smoke outof your lungs, and the inner linings of yourbronchial tubes would start to produce mucus totry to trap any soot and ash you inhaled. Then,you’d start to cough – your body’s way of remov-ing all these irritants out of your lungs. These arethe normal reactions we would all have.

The lungs of a child with asthma produce thesereactions when they’re not supposed to – in re-

sponse to things that shouldn’t cause problems,for example, exposure to pollens or animal dander,or during viral respiratory infections such as colds.

Tell me about asthma

3

Why do bands of muscle surroundbronchial tubes?

Tell me about asthma

Inflammation is the body’s natural way of deal-ing with potentially harmful exposures or in-juries. For example, your skin becomes red,irritated, hot, and inflamed after it’s burned, dur-ing a skin infection, or after you’ve had a sliverfor a while. The body relies on special cells,called inflammatory cells, which release chem-icals after exposure to irritants. The chemicalsreleased by these cells cause inflammation.

The inner lining of the bronchial tube containsinflammatory cells too. In the airways, releaseof chemicals causing inflammation leads to nar-rowing of the small muscles encircling thebronchial tubes, promotes mucus secretion bythe airways, and causes swelling of the inner lin-ing of the bronchial tubes. All of this leads tonarrowing of the bronchial tubes, making it hardto breathe and causing coughing and wheezing.Some of these chemicals also tell the body tosend more inflammatory cells to the area. Inpeople with asthma, the linings of the bronchialtubes contain more inflammatory cells than nor-mal, and the inflammatory cells both releasetheir chemicals more easily than normal and inresponse to more exposures than normal, suchas things the person is allergic to, for example,dogs, cats or ragweed.

People with ‘classic’ or adult-type asthma de-velop cough, wheezing and/or shortness ofbreath or chest tightness following exposure tothings to which the individual is allergic. Theusual culprits that can cause allergies andasthma are dust, pollens, animals, and mold. Themajority of people with typical asthma that isnot under control also have symptoms during orafter exercise – especially in cold or dry air andduring colds.

Younger children most often get asthma symp-toms only when they have a “cold” or “flu”(upper respiratory tract infections caused byviruses). During colds, they cough more thanother children, and usually have wheezingand/or difficulty breathing. Between colds,they’re fine. Asthma symptoms typically startabout two or three days after they begin havinga runny nose. Symptoms often continue forweeks after the cold has gone away. Like most

Symptoms of asthma

4

What causes these reactions? Symptoms of asthmain children

Classic asthma

Asthma with colds

things in pediatrics, symptoms (especially thecough) tend to be worse at night!

Since people with classic asthma can also haveattacks triggered by colds, in all, about 90 per-cent of asthma attacks in children (and many at-tacks in adults) are caused by colds.

The excess mucus production caused by asthmaleads to chest congestion. Asthma should beconsidered as a possible diagnosis in any childwhose colds ‘always seem to settle in the chest,’or who wheezes with colds. When a doctor lis-tens to the chest, mucus rattling around in thebronchial tubes can produce the same noises aspneumonia, and mucus clogging up a bronchialtube can also mimic the way pneumonia lookson a chest x-ray. Research studies have shownthat many children who are diagnosed with “re-current bronchitis” or “recurrent pneumonia”actually have asthma.

A few people with asthma never wheeze or havetrouble breathing, and their only symptom is ex-cessive coughing. This is called ‘cough-variant

asthma.’ Children with this type of asthma mayhave a persistent cough at night, cough with ex-ercise and/or prolonged or excessive coughingduring and after colds. The cough improves withasthma therapy.

Many doctors feel uncomfortable diagnosingasthma before the age of six-to-12 months. Invery young infants other conditions, sometimesmore serious, can cause asthma-like symptoms.If you have a small infant with asthma-likesymptoms, your doctor will evaluate your childfor these other conditions.

Many normal babies have noisy breathing dueto secretions rattling around in the back of thethroat that the baby hasn’t yet learned to swal-low. The noisy breathing is also worse duringcolds as there are more secretions. This “noisybreathing” sounds a bit like a motorcycle, andparents often feel a “rattle” when they feel thebaby’s chest. These sounds are different fromwheezing, which is a whistling sound comingfrom the chest. Rattly breathing is generally nota sign of asthma.

Symptoms of asthma

5

Cough-variant asthma

Can babies have asthma?

The more you can avoid things that can trigger yourchild’s asthma, the less your child will need asthmamedication(s). This section will help you recognizewhat your child’s asthma triggers are and ways inwhich you can learn to help your child avoid them.Things that people can get allergic to are often calledallergens.

Dust mite allergy is probably the most commonallergy leading to asthma in Canadian children.Dust mites are extremely tiny little animals thatlive in dust, feeding off bits of shed human skinand other appetizing little morsels. As the insu-lation in modern homes gets better and better(and air ventilation gets worse), house dust anddust mite accumulation has become an increas-ing problem. In children with dust mite allergy,exposure to high concentrations of dust cancause asthma attacks, and long-term exposurecan increase airway inflammation, increasing the

severity of the reaction to other asthma triggers. Dust mites grow best in high humidity (as domolds), so, contrary to popular belief, keeping

your house reasonably dry (humidity under50%) is preferable for children with asthma. Hu-midifiers in the bedroom are sometimes helpfulduring colds but should be used for as short atime as possible to avoid promoting dust mitegrowth. Humidifiers should also be kept ex-tremely clean as mold can easily grow in the hu-midifier and then get blown around the room. People spend more time in their bedroom thanin any other single location, so for people withdust mite allergy, reducing dust in the bedroomis especially important. Dust mites grow espe-cially well in mattresses, pillows and bedding.Some ways of reducing dust mites in yourchild’s bedroom include:

Asthma triggers

6

Allergic asthma triggersDust Mites

• Use a hardwood floor and remove upholstered furniture.

• Plastic-covered mattresses (the type used for cribs and toddler’s beds) are ideal for reducing dust mites in your child’s crib or bed — the most important source of dust mites for small children. When your child moves to a regular mattress, enclose the mattress, box spring, and foam pillows with dust-proof covers. These covers are available in medical-supply stores. Vinyl covers are less expensive, but also less comfortable.

• Wash sheets and blankets every 2 - 4 weeks.

• Wash blinds regularly; mop the floor with a damp mop each week.

• Avoid excess clutter (excess toys, books, etc.) in the child’s bedroom.

• Keep the household humidity level at 50% or less.

Furry animals (and less commonly birds) cancause quite serious asthma in people who are al-lergic to them. For people who are animal-aller-gic, not only can exposure lead to asthmaattacks but long-term exposure to a pet can in-crease airway inflammation, increasing theseverity of asthma attacks in reaction to othertriggers. If you have a pet and aren’t surewhether your child is allergic to it, you maywish to ask your doctor about allergy tests. Ifyou don’t have a pet but your child has animalallergies, you should avoid visiting homes withthat type of animal and not purchase that typeof animal as a pet. Children with a lot of aller-gies tend to develop more allergies over time,so if your child has several allergies, it’s wisenot to get a pet even if your child’s not allergicto that type of animal right now. It’s much, mucheasier to avoid getting a pet than to try removinga pet after your child’s become allergic to it!

Cats tend to cause more severe allergies thandogs, but dogs, horses and other animals can

also cause problems. People who react to ani-mals are actually allergic to the animal’s dan-druff or dander - if the animal has hair, it’s goingto have dandruff. For this reason, a ‘hypo-aller-genic’ dog can cause allergies.

To remove all traces of pet after a pet is removedfrom the house, it is important to get the heatingducts cleaned and the carpets and upholsterysteam-cleaned. This whole process should be re-peated about four months later. If your child ispet-allergic and removing the pet is not an op-tion, excluding it from the child’s bedroom andbathing the pet weekly might be helpful. Thechild should minimize contact with the animal.

Asthma triggers

7

Animals

Outdoor plants and pollens often cause seasonalallergies and asthma at particular times of theyear. In Ontario, trees (such as elm, poplar andspruce) generally cause problems between Apriland June. Grasses (such as timothy grass andbluegrass) generally cause problems betweenmid-May and mid-July. Ragweed causes prob-lems between August and October. You cancheck the level of pollens in your area on TheWeather Network Pollen Report web site(http://www.theweathernetwork.com/pollenfx/canpollen_en/).

Pollens can effectively be kept out of your houseby keeping your doors and windows closed dur-ing pollen season. An air conditioner is helpfulto keep your house comfortable while you dothis. If your child is grass-allergic, theyshouldn’t mow the lawn. You might wish to re-member that your child probably isn’t allergicto washing the dishes!

Outdoor and indoor molds are another importantgroup of allergens. Outdoor molds are a prob-lem in Ontario between March and Novemberas they tend to release their spores in dampweather which travel better on windy days. Thisis probably the reason why many people’sasthma gets worse in miserable, damp weather.During the fall, children with outdoor mold al-lergies (particularly allergy to a mold called Al-ternaria) should avoid playing in forests andother areas where there are a lot of damp, de-caying leaves.

Indoor molds grow especially well in dampplaces like poorly ventilated bathrooms. Theyalso like damp basements — especially if thereare open pools of water. Indoor molds can be aproblem year-round. Humidifiers should beused sparingly and cleaned often, as they can becontaminated by molds. Reducing dampness inbathrooms and the basement can reduce indoormolds. Areas in the home contaminated by moldshould be cleaned thoroughly. A de-humidifieris sometimes helpful. The Canada Mortgage andHousing Corporation (CMHC) has many usefulresources to help deal with home dampness andmold; these are available at: http://www.cmhc-schl.gc.ca/en/co/maho/yohoyohe/momo/.

Asthma triggers

8

Plants & Pollens Molds

Foods are actually a pretty unusual cause ofasthma. Unless your child wheezes or has otherasthma symptoms shortly after ingesting a food,it most likely isn’t a problem. One food you should be especially aware of ispeanut, if your asthmatic child has a peanut al-lergy. Studies have shown that children whohave asthma and severe, life-threatening reac-tions to peanut are more likely to die after eatingpeanut than children who have severe peanut al-lergy but who don’t have asthma. If your childhas severe peanut allergy, you should speak toyour doctor about getting a MedicAlert®bracelet and having an adrenaline syringe(Epipen®, Twinject®) with you at all times. Inaddition to watching ingredient lists (as in-structed by your doctor), you need to be on thelookout for unexpected things — like the friendwho makes a plate of peanut butter sandwichesand a plate of cheese sandwiches and then usesthe same knife to cut all the sandwiches.

Cigarette smoke makes asthma worse and cancause asthma attacks in children. Childrenshould not be exposed to cigarette smoke. Be-cause Canadian houses are so air-tight, cigarettesmoke readily re-circulates in houses, and peo-

ple who smoke should smoke completely out-side. While marijuana smoke is somewhat lessirritating to the lungs than tobacco smoke, it cancause increased cough and production of mucusby the bronchial tubes.

Polluted air may contain several substances thatcan worsen asthma, including nitrogen dioxide,low-level ozone in the atmosphere, and smallairborne particles (or particulates). Sulfur diox-ide is sometimes released by pulp and paperplants, and can cause exercise-induced asthmain people with asthma exercising outdoors inhot, polluted weather. It is advisable for peoplewith asthma to avoid excess time outdoors (es-pecially exercising outdoors) when pollutionwarnings are in effect. Air pollution levels canbe checked on several Internet web sites, includ-ing Air Quality Ontario (for people living in On-tario, at: http://www.airqualityontario.com/reports/forecast_today.cfm) and The WeatherNetwork Air Quality web site, available at:http://www.theweathernetwork.com/airquality/canairquality_en/.

Some children with asthma react to strongodours, like paints and hairspray, and shouldavoid exposure to these odours.

Asthma triggers

9

Foods

Cigarettes

Air Pollution

Strong Odours

About 90 percent of asthma attacks in childrenare triggered by viral upper respiratory tract in-fections, known commonly as ‘colds’ and ‘theflu.’ Asthma symptoms usually start about threedays after the child starts the runny nose andmild cough typical of a ‘cold.’ Some of theviruses that are common triggers of asthma at-tacks are: rhinovirus (the cause of the common“cold”), Influenza virus, and Respiratory Syn-cytial Virus (or RSV). RSV also causes bronchi-olitis in babies, a respiratory tract infectioninvolving the tiniest bronchial tubes. About halfof babies who have bronchiolitis will developasthma later in life. The commonest time of theyear for asthma attacks is September. This is be-cause kids returning to school in September startsharing colds, which leads to asthma attacks inkids with asthma, and in family members whohave asthma. Bacterial infections (bacteria aremore complicated bugs that are treated with an-tibiotics) are uncommon causes of asthma attacks.

There are a few things you can do to preventcolds. You can avoid having friends visit whenthey’ve got colds. You can try to keep your childwith asthma from using towels used by brothersand sisters with colds. You may wish to speak

to your doctor about having your child get the‘flu shot’ in the fall, to prevent “the flu”. Youcan try training older family members to re-member to wash their hands before and aftertouching their nose or mouth.

During quiet breathing, air is breathed in mainlythrough the nose, to be warmed and humidifiedbefore reaching the lungs. During exercise, mostair is breathed in through the mouth. In manyasthmatics, this relatively cold and dry air cancause inflammatory cells in the bronchial tubesto release the chemicals that cause an asthma at-

Other important asthma triggers

10

Other important asthmatriggersColds

Exercise

tack. As one might expect, this effect is morelikely to occur when someone with asthma ex-ercises in cold, dry air.

Exercise is important for good health, and asth-matics should be encouraged to exercise, justlike everyone else. A warm-up period some-times helps reduce exercise-induced asthma.Good asthma control, through effective asthmatreatment, can reduce or prevent exercise-in-duced asthma in many people with asthma. Forchildren with asthma who are pretty well con-trolled except during exercise, inhaling their re-liever (bronchodilator) medication just beforeexercise can help prevent exercise-inducedasthma symptoms. While regular exercise willnot prevent exercise-induced asthma attacks, itwill certainly improve fitness.

The rate of asthma in children is increasing inCanada and many other parts of the world. Findingout the reasons for this is an area of very active sci-entific research.

Dust mite allergy appears to be the most impor-tant reason for the increasing rate of asthma inchildren. As houses become increasingly air-

tight, the amount of dust mites trapped insidehouses rises. The more dust mites that are pres-ent in the home (especially the child’s bed-room), the higher the risk that children willdevelop dust mite allergy and asthma. Please seethe section entitled Dust Mites on page ?? tofind things you can do to reduce the amount ofdust mites in your home and particularly in yourchild’s bedroom.

Cigarette smoke is probably the second mostimportant contributing factor for rising asthmarates in children. You should not allow yourchild to be exposed to cigarette smoke. If yousmoke you should quit, if at all possible, for thesake of your children’s health, your spouse’shealth, and last but not least, your own health.

Your doctor can advise you of techniques avail-able to help you quit smoking — includingcounseling, community support groups, andmedications. If someone in your house cannotquit they should smoke completely outside (notin the basement, bathroom, etc. as smoke re-cir-

Can you prevent asthma?

11

Can you prevent asthma?

Exercise

Cigarette Smoke

culates in air-tight Canadian houses) and theyshouldn’t smoke in the car if the child is in thecar with them.

Some resources to help people quit smoking thatare available in Canada include:

Recent research from several countries suggeststhat if the immune system of infants under sixmonths of age is very busy fighting off infec-tions, it may be too preoccupied to develop thekinds of inflammatory cells needed to develop

allergic reactions. There is some evidence thatchildren who are exposed to more germs —such as children with several older siblings, chil-dren in day care before six months of age andchildren who live on farms or who are exposedto animals in early infancy, are less likely to de-velop allergies and allergic-type diseases suchas asthma. Letting kids get dirty in the play-ground may be a good thing!

The effects of breastfeeding on the preventionof asthma are controversial. Some studies sug-gest that breastfeeding reduces the risk ofasthma; others suggest that because breastfeed-ing reduces the risk of infection in infants, itmight increase the risk of asthma (see “Dirt,”above). Breastfeeding has numerous benefits forinfants and is recommended, whenever possible,for all babies.

Asthma triggers

12

• Making Quit Happen booklet – available by calling the Asthma Action Helpline at 1-888-344-LUNG (5864).

• Smoker’s Helpline – a toll free support service offered by The Canadian Cancer Society – 1-877-513-5333

Dirt

Breast feeding

The most important risk factor for asthma isprobably whether allergic diseases run in thechild’s family. Children can inherit an increasedlikelihood of having an allergic disease fromparents who have allergic diseases or whosefamilies have allergic diseases such as asthma,hay fever (or allergic rhinitis), eczema, and cer-tain food allergies. Any combination of these al-lergic diseases can run in families (for example,a parent could have eczema and the child couldhave asthma). Individuals in families with aller-gic diseases are more prone to have cells that re-lease chemicals causing local inflammation andallergic reactions in response to allergic and ir-ritant triggers.

Smoking in the home increases the risk ofasthma. This is important to note because pro-hibiting smoking in the house is a simple wayto reduce the risk of a child developing asthma.

Recent studies have suggested that asthma ismore common in children exposed to very largeamounts of house dust.

Asthma is more frequent in children who wereborn prematurely (before 36 weeks gestationalage). This is true even if the premature baby did-n’t have breathing difficulties due to under-de-veloped lungs at birth. Asthma is also morecommon in children who had bronchiolitis as ababy – probably because the types of inflamma-tory cells present in the lungs of some childrenmake them prone to both conditions.

Even though asthma is a potentially dangerousdisease, with good treatment, most Canadianchildren with asthma do well. About two-thirdsof children with asthma outgrow it — sometimebefore or around puberty. In a small number ofthese patients, asthma comes back later in adultlife. In most of the remaining one-third of pa-tients, their asthma improves as they grow older.Only about 10 percent of children with asthmawill continue to experience asthma as a majorproblem as adults.

Asthma: Risk Factors and Outcomes

13

Asthma: Risk Factors andOutcomes

Are there any risk factors forasthma?

Can a child with asthma outgrow it?

Recent asthma research suggests that there maybe two different forms of asthma in young chil-dren:

In children, asthma symptoms tend to followthree different patterns. Knowing the pattern yourchild’s asthma follows may help you and yourchild’s doctor develop a plan to keep the asthmaunder control. Sometimes the pattern of a child’sasthma changes as they get older. To recognizeyour child’s asthma pattern, you need to keeptrack of how often your child has asthma symp-toms or an asthma attack, what the triggers seemto be, and whether there are certain seasons whenyour child is more prone to asthma symptomsand/or asthma attacks. An asthma attack can bethought of as the presence of moderate or severeasthma symptoms which last for a day or longer.

Asthma: Risk Factors and Outcomes

14

• In one type, children are born with relatively small airways. When these airways are further narrowed by swelling of the linings of the air ways due to viral respiratory infections, wheezing can result. This is a more common problem in boys, and children whose mothers smoked during pregnancy. As the child grows, the airways become bigger and viral infections are less likely to cause enough airway narrowing to lead to asthma symptoms. Thus, children with this form of asthma tend to have symptoms during viral infections such as colds and are otherwise well. They usually don’t have other signs of allergies, and usually out grow their asthma later in childhood.

• In the other type of childhood asthma, children tend to have allergic diseases such as asthma, hay fever and eczema. These children have asthma symptoms when exposed to substances they are allergic to, such as pollens and animals, as well as having asthma symptoms during viral respiratory infections. These children have probably inherited their tendency to have allergic diseases from their parents. They are more likely to continue having allergic diseases such as asthma and hay fever as they grow older, and they are less likely to outgrow their asthma.

This pattern is called mild intermittent asthma.Children with mild intermittent asthma havefairly mild attacks (more often than not, startinga couple days after colds) and have few or no

asthma symptoms between these attacks. Doc-tors often treat this type of asthma with relievermedications used on an ‘as needed’ basis. Somedoctors recommend taking the reliever medica-tion regularly, for a few days, beginning at thestart of colds to help prevent the muscles aroundthe bronchial tubes from tightening up. The re-liever medication can then be stopped when thecold is over.

This pattern is called severe intermittent asthma.Patients with severe intermittent asthma gener-ally have infrequent attacks, but when attackshappen, they are often severe and may need avisit to the emergency department or even ad-mission to the hospital. As in mild intermittentasthma, colds are the most common trigger inchildren. Doctors may recommend using a con-troller medication — year-round or just duringthe seasons when asthma attacks are most likelyto happen.

Pattern of asthma in children

15

Mild Intermittent Asthma Severe Intermittent Asthma

Pattern of asthma in children

16

This pattern is called chronic asthma. Childrenwith chronic asthma have symptoms many ormost days. They have asthma attacks (whichmay be mild or severe), and often have asthmasymptoms even when they’re not having an at-tack. Current Canadian Asthma Consensus

Chronic Asthma

Guidelines recommend that children withchronic asthma receive regular daily treatmentwith a controller medication and also have a re-liever medication available to use, on an asneeded basis.

17

For most children, you can assess their asthmaby keeping an eye on their symptoms of cough,wheeze, and/or trouble breathing. Older childrenand adolescents can gradually learn to do thisthemselves, and then report to you if they’rehaving problems. For a few children who are six years or older, when it’s hard to tell whethertheir symptoms are due to asthma, or if theyhave few symptoms during asthma attacks, apeak flow meter can help you and your childmonitor their asthma. Keeping an asthma diary(either of symptoms, peak flows, or both) canhelp you track severity over time, and help yousee whether symptoms are related to exposures.

Your doctor will work with you and your childto monitor your child’s asthma. He or she willdo this by asking about how your child’s beendoing and by examining your child. If your childis old enough your doctor may order Pulmonary

Function Tests (or PFTs), which measure howwell air is getting in and out of your child’slungs. These are usually available for children6 years and older. Your doctor will also give youadvice on how to monitor your child’s asthmabetween doctor’s appointments.

If your child has signs of a severe asthma attack,and/or needs treatments with his or her relievermedication every four hours (or even more oftenthan this, or more often than your doctor recom-mends), you should have your child assessed bya doctor. You should also see or talk to a doctorif you are worried about your child’s asthma.

A peak flow meter lets you keep track of yourchild’s asthma, using an easy-to-use machine. Itmeasures the highest flow rate of air your child

Monitoring your child’s asthma symptoms

Monitoring your child’s asthmasymptoms

Assessing asthma control

What is good asthma control?

• Cough at night, or waking up at night because of coughing or chest tightness. • Increased cough, wheezing and/or trouble breathing with exercise or reduced ability to exercise because of asthma. • Cough or wheeze at rest (such as while doing homework or watching TV). • More frequent or severe attacks, such as visits to the Emergency Department.

Monitoring using a peak flow meter

Monitoring means ‘keeping track of the situa-tion.’ It’s important to monitor your child both forsudden increases in asthma symptoms, whichmay represent an asthma attack, and gradual in-creases or decreases in symptoms, which will tellyou and your doctor about your child’s overalllevel of asthma control.

18

can blow out of his or her lungs. Most childrensix years or older can learn to use a peak flowmeter. Recent studies suggest that many chil-dren can notice their asthma symptoms beforepeak flow meter readings begin to drop much.This suggests that peak flow meters may bemost useful for those children who have diffi-culty telling when their asthma has worsened.This includes children who have difficultynoticing when they’re having quite severe diffi-culties breathing or those who are perhapsoverly aware of their chest and may worry aboutminimal changes in their lung’s function.

If you use a peak flow meter, you should recordthe results in a diary card or on a calendar. Aftera few weeks you will be able to find out yourchild’s personal best peak flow reading. Yourdoctor can use this number when creating anasthma action plan for your child. Ideally yourchild should check peak flows in the morning,at night, and if you are wondering whether yourchild might be having an asthma attack. Yourchild might want to check his or her peak flowsbefore and after vigorous exercise. It is recom-mended that whenever peak flows are checked,the child should repeat the measurement threetimes, and you should use the best measurementfor your assessment and for record keeping. Youmay even want to record the peak flow readingsin a computer spreadsheet that should let youmake graphs to track trends!

Peak flow meters, like all-season radials, don’tlast forever. In most peak flow meters, the littleneedle (that slides up to give you a reading)eventually loosens making the meter’s readingsa bit too generous. After a couple years of regu-lar use, you should check your peak flow meteragainst a hospital’s or buy a new one.

When a doctor prescribes a peak flow meter,he/she usually will provide you with a writtenasthma action plan to go with it. The action planis usually based on the stoplight scheme. Thiswill allow you to guide therapy and judge theimportance of changes in your child’s peak flowmeter readings. In addition to checking wherereadings lie within your action plan, you shouldlook for trends — are the peak flows graduallygoing up after you start a new treatment, or arethey gradually going down (for example, in thespring as the trees start to blossom)?

It’s a very good idea to ask your doctor to writeout an asthma action plan for your child (youmay even want to offer them the blank one inthe back of this book). This will tell you whento give your child’s asthma medications, how totell when your child’s asthma control has wors-

Monitoring your child’s asthma symptoms

Developing a written asthma actionplan for your child

19

ened, what to do when this happens, and whatto do in case of an asthma emergency. Actionplans are particularly useful in the middle of thenight, when it’s hard to remember everythingyour doctor told you. The asthma action planusually uses the “stoplight” system based onyour child’s symptoms, peak flow measure-ments, or both. Many action plans include:

GREEN ZONE: Your child

has no asthma symptoms,

and/or the peak flow read-

ing is between 80-100% of

your child’s personal best.

This is the “All Clear” zone

— your child should con-

tinue his or her usual treat-

ments.

YELLOW ZONE: Asthma

symptoms are starting or

your child has been ex-

posed to a trigger such as a

cold, and/or the peak flow

reading is between 70-79%

of your child’s Personal

Best. This is the “Caution”

zone — your child’s

asthma may be getting

worse. You should change your child’s treat-

ment as recommended by your doctor.

RED ZONE: Your child

has severe asthma symp-

toms and/or the peak flow

reading is less than 70% of

your child’s personal best.

This is an asthma emer-

gency. You should take a

reliever medication as rec-

ommended by your doctor.

Your doctor may recom-

mend that you then call him/her right away.

You should call 911 or go to the hospital right

away if your child is struggling to breathe,

has blue lips or fingers, is becoming tired

from working so hard at breathing, and/or

has a peak flow still in the Red Zone 15 min-

utes later despite treatment with his/her re-

liever medication.

Monitoring your child’s asthma symptoms

The Canadian Asthma Consensus Guidelinesgive precise definitions of asthma control forCanadian doctors to use. This table gives the

definitions of good and adequate asthma controlas described in the Canadian Asthma ConsensusGuidelines used by Canadian physicians. If yourchild’s asthma doesn’t seem adequately con-trolled, you should inform your child’s doctorand you should discuss together what you cando to better control your child’s asthma.

20

Monitoring your child’s asthma symptoms

How do doctors determine the levelof asthma control?

21

WHAT ARE THE SIGNS OFA SEVERE ASTHMA ATTACK?

Severe shortness of breath, rapid or shallow breathing, laboured breathing and/or sucking in of the skin between the ribs or at the base of the neck.Blueness anywhereSevere cough or wheezing that returns within four hours after a treatment with the child’s reliever medication. Inability to speak in fullsentences.Sleepiness due to asthma.Fainting because of an asthma attack.

22

NOTE: All medications have both a commercialname and a chemical name. Generic products oftenuse the chemical name. In the following, the chemi-cal names are given in brackets. There are too manyasthma medications to list them all. In this section,we will discuss the preparations most commonlyused in Ontario.

Controlling asthma involves a couple of impor-tant steps. The first step is reducing contact withthe child’s asthma triggers and the second stepis drug therapy. As most medications for asthmaare inhaled, an understanding of how to use thechild’s inhaler(s) is absolutely essential.

These are the main types of medications used inasthma:

• RELIEVER medications (fast-acting bronchodilators) temporarily relax the muscle bands that surround the bronchial tubes whenthey tighten up (or bronchoconstrict) during an asthma attack. These medications areessential for making certain that enough air gets in and out of the lungs during an asthmaattack. Virtually everyone with asthma shouldhave a reliever medication available.

• CONTROLLER medications are important for long term control of asthma.

These include:

As the name suggests, controller medicationscontrol asthma symptoms to reduce the chanceof asthma attacks and reduce the severity of thechild’s asthma. In general, these medicationsmust be used regularly to be effective. Anti-in-flammatory medications make inflammatorycells in the lungs less likely to release the chem-icals that cause asthmatic reactions in the lungs.This makes the lungs less sensitive to the vari-ous factors that trigger a given child’s asthma,even when the child is exposed to these factors.Some controller medications even decrease thenumber of inflammatory cells in the lungs. In-haled corticosteroids are the most effective con-troller medication.

• OTHER asthma medications. Although less commonly used, these can sometimes be helpful:

Inhaled medications are popular, as relativelylarge amounts of medication can be delivereddirectly to the lungs, and quite little medicationreaches other parts of the body where it can po-

Asthma medications

The types of medications usedin asthma

• Inhaled Corticosteroids • Anti-Leukotriene Medications • Long-Acting Beta-2-Agonists

• Zaditen® (ketotifen) (controller) • Theophyllines (have reliever and controller properties) • Anti-IgE Therapy (controller)

23

tentially cause side effects. The disadvantage ofinhaled medications is that the inhaler must beused properly and the inhaler must be in goodworking order for the medication to reach thelungs. Some asthma medications are taken aspills or syrups.

The main reliever medication for asthma is thebeta-2-agonist. Occasionally your doctor mayprescribe an anti-cholinergic medication (seePage 29).

Beta-2-agonists are related to adrenaline, but arechemically altered so they have much less effecton the heart and the blood pressure. They are themost powerful and most rapidly-acting type ofreliever medication. There are two main typesof beta-2-agonists: short-acting and long-acting.

Short-acting beta-2-agonists, when given by in-haler, start working in about five minutes, reachpeak effect in about 30 minutes, and finishworking in about four-to-six hours. Common in-haled forms of short-acting beta-2-agonists in-clude Ventolin® (salbutamol), Airomir™(salbutamol), Bricanyl® (terbutaline), andBerotec® (fenoterol). These medications comein metered-dose inhalers (“puffers”), dry pow-

der inhalers, and for use in wet nebulizers; Ven-tolin® is also available as a syrup. Beta-2-agonists are more effective and have fewer sideeffects when given by inhaler. If your child ishaving an asthma attack and you have a beta-2-agonist syrup and a beta-2-agonist inhaler avail-able at home, using the beta-2-agonist inhaler ispreferable.

• Inhaled short-acting beta-2-agonists areusually given every four-to-six hours, as needed, for asthma symptoms such ascoughing, wheezing, chest tightness, or trouble breathing. Beta-2-agonist syrups can be given up to every six hours.

• If your child needs his/her beta-2-agonist inhaler more than every four hours, it is a signof a severe asthma attack. You should discusswith your doctor ahead of time what to do if this happens. Many doctors will recommend that you should talk to a doctor, bring your child to a doctor, or take your child toan emergency room.

• Treatment with a short-acting beta-2-agonist,three-to-four times a day, can be started at thefirst sign of a cold to help prevent the musclesaround the bronchial tubes from tightening up

Asthma medications

Reliever medications

Short-acting beta-2-agonists

There are several common ways short-acting beta-2 agonists are used:

24

(known as bronchospasm). The beta-2-agonistshould be stopped once the cold starts to go away, if no signs of asthma have developed.

• Beta-2-agonists can be used about tenminutes before exercise to prevent exercise-induced asthma.

• Because beta-2-agonists are related to adrenaline, even when they are used properly, they can cause a muscle tremor and a mild increase in the heart rate, and temporarily make children excessivelyactive.

• Very high doses can cause serious heart problems, which is why giving very frequent doses of beta-2-agonists should bedone in a hospital setting carefullysupervised by medical staff. If your child needs his/her inhaled beta-2-agonist more than every four hours, you should carry outyour doctor’s plan of action. If you don’t have a plan of action prepared in advance, or if you have any worries about your child,you should speak to or see a doctor, or takeyour child to an emergency room.

• Regular prolonged use of short-actingbeta-2-agonists can lead to worsening of asthma. The same is true for long-acting beta-2-agonists, if they are used regularly without regular use of an inhaled steroid controller medication. For this reason, current Canadian guidelines for the treatment of asthma suggest that people whoneed short acting beta-2-agonists four or more times per week do not have adequate asthma control and should receivea controller medication to improve their control. If your child needs his/her short-acting beta-2-agonist four or more times perweek, you should let your doctor know as you should discuss potential treatment options with your doctor.

Asthma medications

Side effects

Anti-cholinergic medications relax the musclesthat surround the bronchial tubes by usingchemical messages which are different from theones used by beta-2-agonists. One anti-cholin-ergic medication is presently available — Atro-vent® (ipratropium bromide). Atrovent® isavailable as a puffer (or metered-dose inhaler)and for use in a nebulizer. Anti-cholinergic med-ications cause gradual, fairly mild relaxation ofthe muscles that surround the bronchial tubes.However, because it works using messageswhich are different from the ones used by beta-2-agonists, doctors may use an anti-cholinergicmedication along with a beta-2-agonist toachieve more relaxation of tightened bronchialmuscles than you could achieve with a beta-2-agonist by itself.

Ipratropium is also available combined with theshort acting beta-2-agonist salbutamol in a neb-ulizer solution called Combivent®.

• An Anti-cholinergic medication can beused to help relieve asthma attacks thatusually don’t get relieved enough bya beta-2-agonist by itself.

• An Anti-cholinergic medication can beuseful as a reliever medication in children who can’t tolerate or use a beta-2-agonist, including children with heart conditions who have difficulty tolerating the increase in heart rate beta-2-agonists can cause, or are on medications called beta-blockers, that interfere with the action of beta-2-agonists.

• An Anti-cholinergic medication can be used before exercise to preventexercise-induced asthma.

Anti-cholinergic medications rarely cause sideeffects but can occasionally cause a dry throat.The medication should not be aimed towards theeyes.

There are three main types of controller medica-tions for asthma. They are: steroid-type medica-tions, anti-leukotriene medications, andlong-acting beta-2-agonists. Occasionally yourdoctor may also prescribe a theophylline (seepage 37).

25

Asthma medications

Anti-cholinergic medication

Common used of anti-cholinergic

Side effects

Controller medications

26

Steroids act directly on the inflammatory cellsthat cause asthmatic reactions in the lungs, mak-ing them less likely to release chemicals causingasthmatic reactions, and reducing the number ofinflammatory cells present. This helps preventasthma symptoms and attacks, and reduces theseverity of the disease. Steroid medications arethe most consistently effective preventer med-ications used to treat asthma.

The steroid medications used in asthma treat-ment are different from the anabolic steroidsthat have been misused by athletes, for example,in the Olympics. When steroid medications areused for the long-term prevention of asthma at-tacks, they are almost always given by inhaler.Inhaled steroids are more effective when

given on a consistent basis, during the season

or seasons when a child with asthma is most

likely to be having asthma symptoms and at-

tacks. During asthma attacks, oral steroidsgiven by pill or liquid may be used to preventthe worsening of a severe attack. A few very se-vere asthmatics need to take oral (pill or syrup)steroid medications on a regular basis.

Inhaled steroids are designed to go directly towhere they are needed (the lungs), with ex-tremely little of the drug reaching the rest of thebody. This lets inhaled steroids act as extremelyeffective controller medications, while markedlyreducing the risk of steroid-type side effects. In-haled steroids are used to prevent asthma at-tacks, and improve overall asthma control.Because inhaled steroids usually take one-to-sixweeks to start working, they generally work bestwhen taken on a regular basis, long-term, usingthem for a season at a time (or longer). Becauseinhaled steroids begin working relatively slowly,if your child is started on an inhaled steroid andisn’t better after a couple of weeks, youshouldn’t get discouraged. Obviously, if duringthis time your child gets worse, you should no-tify your doctor. Inhaled steroids available inCanada include Pulmicort® (budesonide),Flovent® (fluticasone), QVAR™ (beclometha-sone), and Alvesco® (ciclesonide). Inhaledsteroids are available, depending on the medica-tion, as puffers (metered-dose inhalers), drypowder inhalers, and for use in nebulizers. Somedoctors recommend that when asthma symp-toms or peak flows show signs of steady wors-ening, the inhaled steroid dose should beincreased. While some studies suggest that dou-bling the dose during attacks is not very effec-tive for many patients, quadrupling the dose

Asthma medications

Steroid-type controller medications Steroid-type controller medications

27

may be effective, although that’s fairly expen-sive. It’s generally better to find a dose of in-haled steroids that consistently prevents attacksfrom occurring in the first place. During a severeasthma attack, oral steroids are the most effec-tive medications for preventing the attack fromworsening.

Several inhalers containing a combination of in-haled steroid and long-acting beta-2-agonist arealso available. These are discussed under Long-Acting Beta-2-Agonists (page 35).

Most children using inhaled steroids experienceno side effects at all.

• A few people have dry mouth or throatirritation. This is usually minor.

• Inhaled steroids can cause thrush in the mouth (little white patches caused by a yeast infection). If this happens it isusually treated with a special anti-yeastantibiotic. Thrush can be prevented by:

• Very rarely, inhaled steroids can cause a hoarse voice. If your child develops a hoarse voice for no apparent reason (such as a cold) you should let your doctor know because the hoarseness can be animportant indicator of a problem with the vocal cords.

• Some children, especially on higher doses of inhaled steroids, may grow about 1 cm (1/2 inch) less during the first year oftreatment. With continued, long-termtherapy, the growth rate generally returns to normal. Final adult height is generally normal, particularly since children with asthma often begin puberty a little later than normal and will therefore keepgrowing for longer. It’s important toremember that many children on inhaled steroids grow just fine. Since severe, uncontrolled asthma affects growth, some children actually grow better on inhaled steroids. Others may be more sensitive to growth effects, and should have theinhaled steroid dose reduced, if possible. All children on inhaled steroids should have their growth carefully monitored. Alvesco® (ciclesonide) inhalers contain aninactive inhaled steroid, which is activated only in the lungs, so effects on the rest of the body are minimal; studies to date have not found that this drug affects growth or hormone levels (see below).

Asthma medications

Side effects

• Rinsing the mouth with some water (and ideally spitting the water out) after using the inhaled steroid inhaler;

• Using a spacer device (like the Aerochamber® spacer), so the heavier medicine particles released by the inhaler land in the spacer, rather than in the mouth.

28

• Inhaled steroids may cause minor changes in the balance of natural steroid hormones that are produced by the body’s adrenal glands. This does not seem to be of any clinical significance. Children with severe asthma may frequently need oral steroids. By reducing the severity of asthma, inhaled steroids generally reduce the need for oral steroids. Studies have shown that being on an inhaled steroid all year long has less effect on natural steroid hormone balance than four courses of oral (or intravenous) steroids in a year. Because of this, it is safer for a child to take inhaled steroids all year round than use oral steroids frequently. Children on extremelyhigh doses of inhaled steroids (generally over 1000 micrograms per day of fluticasone, for example) may be at risk of suppression of the adrenal glands’ function,which can lead to growth failure, severefatigue, nausea, low blood sugar, and/or low blood pressure. Children on such very high doses of inhaled steroids should be followed by an asthma specialist, possibly have their morning blood cortisol levels checked, and see a doctor if theyexperience these types of symptoms. Note that if your child’s doctor recommends a course of oral steroid to control a serious asthma attack, your child should still take the oral steroid because it can keep the asthma attack from becoming severe.

Oral steroids can be given by mouth or, in a hos-pital setting, injected (either through an intra-venous or into the muscle). When given in suchways they powerfully reduce inflammation andare effective in helping control severe asthmaattacks. Oral steroids are usually given for threeto seven day periods; when used for a week ormore the dose is usually slowly tapered downover a varying period of time. Oral steroidsrarely have serious side effects when given forthree-to-seven day periods.

In a few very severe cases, oral steroids are usedfor months at a time, or even longer. This shouldbe done under the careful supervision of a doc-tor. When oral steroids are used for months at atime (or longer), there is a potential for a numberof serious side effects.

In Canada, commonly used oral steroids includePrednisone, PediaPred® (Prednisolone), andDecadron® (Dexamethasone).

• When used for short (three-to-seven day) periods, oral steroids can cause mood changes, increased appetite, acne and weight gain. Serious side effects, such as damage to the hip joint, are uncommon.

Asthma medications

Oral steroids

Side effects

• When used for long periods (many monthsor more), oral steroids can cause reduced growth, thinning of the bones, cataracts, high blood pressure, difficulties dealingwith stresses (like surgery), reduced abilityto handle infections (especially chickenpox)and weight gain. Because of the potentialfor these kinds of side effects, patients on long-term treatment with oral steroids are monitored closely by a doctor.

Singulair™ (montelukast) and Accolate® (zafir-lukast) interfere with chemicals that cause in-flammatory reactions in the airways calledleukotrienes. These are oral medications, so in-haler devices are not needed, making it conven-ient for many people. Anti-leukotrienemedications are given on a long-term, regularbasis to prevent asthma attacks and improveasthma control. They work in many, but not allchildren with asthma. Children with asthma trig-gered by colds produce more leukotrienes thannormal, and Singulair™ (or montelukast) issometimes used only during colds, especiallyaround September when colds are most fre-quent. These medications take about one-to-seven days to start working, and reachmaximum effectiveness in about three weeks.This means that if your child is started on Sin-gulair™ or Accolate® and doesn’t improve

right away, you shouldn’t get discouraged. Ifduring this time your child gets worse or isn’tbetter within about three weeks of using this typeof medication, you should notify your doctor.

In Canada, Singulair™ is licensed for use inchildren two years of age and older. It’s avail-able as a chewable tablet and a sprinkle, whichcan be mixed with applesauce or pudding. It isgiven as a single dose at bedtime. In Canada Ac-colate® is licensed for use in children twelveyears of age and older. It’s a tablet that’s takentwice a day and each dose should be taken onehour before or two hours after meals.

Given alone, these medications reduce asthmasymptoms, including symptoms of exercise-in-duced asthma, and the frequency of asthma at-tacks. Children with more severe chronic orintermittent asthma (including people with at-tacks severe enough to need visits to an emer-gency room or admission to hospital, and/orpeople with frequent and severe symptoms) willgenerally have better asthma control using aninhaled steroid.

Patients with more severe asthma may benefitfrom regular therapy with both an anti-leukotriene medication and an inhaled steroidmedication. This may reduce symptoms morethan using the inhaled steroid alone, and it mayallow the doctor to reduce the amount of inhaledsteroid needed by the child. If your child is tak-

Asthma medications

Anti-leukotriene medications

ing an inhaled steroid and your doctor adds ananti-leukotriene medication, the inhaled steroidshould not be stopped abruptly and the doseshould not be reduced without your doctor’s ad-vice. In a child who needs an inhaled steroid toprevent severe asthma attacks, decreasing theinhaled steroid dose too much (or stopping theinhaled steroid) could put the child at risk for asevere attack.

Accolate® may interact with several medica-tions, including erythromycin (a common an-tibiotic), Aspirin® (acetylsalicylic acid),theophylline (another asthma medication whichis taken by mouth), Coumadin® (or warfarin, ablood-thinner), Dilantin® (phenytoin, an anti-seizure or Epilepsy medication) and Tegretol®(or carbamazepine, an anti-seizure or Epilepsymedication). Speak to your doctor or pharmacistif your child is taking Accolate® and other med-ications which are not inhalers.

• Anti-leukotriene medications are used as controller medications, on a long-term, regular basis.

• Anti-leukotriene medications are sometimesused to reduce asthma symptoms during colds.

• Anti-leukotriene medications may be used on their own or together with an inhaled steroid.

In general, side effects with anti-leukotrienemedications are rare.

• These medications occasionally cause headaches and stomach aches.

• A few children may experience insomnia, nightmares, mood changes, and/orbehaviour problems.

• Rarely, patients on Accolate® havedeveloped liver problems, and patients on this medication should have blood tests to check the liver regularly. Liver problems are extremely uncommon withSingulair™.

• There have been a couple very rare cases of patients developing a rare disease calledChurg Strauss Syndrome. Churg Strauss Syndrome involves inflammation of blood vessels in the lungs, heart, and otherorgans. Recent studies suggest that there is no true link between anti-leukotrienemedications and Churg Strauss Syndrome.

30

Asthma medications

Common uses of anti-leukotrienemedications:

Side effects

31

The long-acting beta-2-agonists available inCanada are Serevent® (salmeterol), Oxeze®(formoterol) and Foradil™ (formoterol). Theseare only available as metered dose and dry pow-der inhalers. A long-acting beta-2-agonist can beuseful for reducing asthma symptoms in peoplewho still have symptoms despite use of an in-haled steroid controller medication. In Canada,salmeterol is licensed for use in children fouryears of age and older, and formoterol is li-censed for use in children six years of age andolder.

Both long-acting beta-2-agonists are also avail-able in inhalers combined with an inhaledsteroid medication. Salmeterol (Serevent®) isavailable combined with the inhaled steroidFlovent® (fluticasone), and called Advair™.Pulmicort® (budesonide) is available combinedwith the long-acting beta-2-agonist Oxeze®(formoterol), called Symbicort®. One advan-tage of these combination inhalers is conven-ience for people requiring both inhaled steroidand long-acting beta-2-agonist medications. Inaddition, for adolescents, the combination prod-uct will prevent them from using only the long-acting beta-2-agonist inhaler (which providesfairly rapid symptom relief) and ensures theyalso receive their anti-inflammatory controller

medication. Advair™ is licensed in Canada forindividuals four years of age and older as aDiskus® dry powder inhaler, and for individuals12 years of age and older as a puffer (metered-dose inhaler). Symbicort® is licensed in Canadafor individuals 12 years of age and older andcomes in a Turbuhaler® dry powder inhaler.

• Long-acting beta-2-agonists can be useful for prolonged protection againstexercise-induced asthma in older children who are endurance athletes (e.g. cross-country skiers). Serevent® should be takena half-hour before exercise and Oxeze® or Foradil™ should be taken 15 minutesbefore exercise. Both can provide up to 12 hours of protection. People taking long-acting beta-2-agonists should also receive regular treatment with an inhaled steroid controller medication.

• In people who have asthma symptomsdespite optimal treatment with preventer medications, taking a long-acting beta-2-agonist regularly (on a long-term basis)reduces symptoms, improves lungfunction, and possibly even reduces the risk of asthma attacks.

Asthma medications

Long-acting beta-2-agonists

There are several common wayslong-acting beta-2-agonists are used:

32

• If you have taken a long-acting beta-2-agonist and are still having asthmasymptoms, you can take a short-acting beta-2-agonist. You should contact a doctorif the asthma symptoms are severe.

• Because the combination inhalerSymbicort® contains a long-acting beta-2-agonist that starts working as fast as short-acting beta-2-agonists, it can both be takenregularly, and have additional doses taken as needed for asthma symptoms(to a maximum total dose of 8 inhalations per day). The additional “as needed” doses will provide extra inhaled steroidcontroller therapy, which appears to reducethe risk of asthma attacks. This strategy is sometimes called the “SMART” protocol, which means Symbicort® Maintenance And Reliever Therapy.

• Because beta-2-agonists are related to adrenaline, even when they are usedproperly, they can cause a muscle tremor and a mild increase in the heart rate, and temporarily make children excessivelyactive.

• Regular use of long-acting beta-2-agonists may lead to a slight reduction in theirability to prevent exercise-induced asthma.

• Many recent studies suggest that regular prolonged use of long-acting beta-2-agonists without the regular use of aninhaled steroid controller medication can lead to worsening asthma. If a long-acting beta-2-agonist is used without an inhaled steroid more than three-to-four times per week, you should speak to your physician about using a combination long-acting beta-2-agonist and inhaled steroid inhaler instead, or adding an inhaled steroidcontroller medication.

Zaditen® (ketotifen) interferes with a chemicalcalled Platelet Activating Factor. It is usuallygiven on a long-term, regular basis to preventasthma attacks and improve asthma control. Ke-totifen also has some anti-histamine effects. Ke-totifen is given as a pill or syrup and takesone-to-two months to start working. It works insome patients with mild asthma. This meansthat if your child is started on ketotifen and isn’tbetter after a couple weeks, you shouldn’t getdiscouraged. If during this time your child getsworse, you should notify your doctor.

Other asthma medications

Side effects

Other asthmamedications

Ketotifen

33

• Ketotifen is used as a controller medication,on a long-term, regular basis.

Side effects are relatively common with keto-tifen.

• Ketotifen may cause weight gain.• A few children get sleepy on ketotifen. As

can happen when they take anti-histamines,a few children get overly active instead of sleepy. Both of these reactions are usually temporary.

Theophyllines are available as pills and syrups.They produce fairly mild relaxation of the mus-cles around the bronchial tubes and commonlycause side effects. For these reasons they aren’tcurrently used that often to treat asthma in chil-dren in Canada. Theophylline appears to alsohave some anti-inflammatory controller effectswhich may help inhaled steroids work better.Theophylline drugs available in Canada includeTheolairTM and Uniphyl®. Theophyllines haveto build up a certain level in the blood to be ef-fective. If the blood level is too low, the med-

ication may not work. If the blood level is toohigh serious side effects can happen. People ontheophyllines should have their blood levelschecked periodically by their doctors.

• In Canada theophyllines are used most often in severe asthmatics who need additional medication despite treatment with other drugs.

Antibodies are proteins people make to fight in-fections. IgE is a very special type of antibodymade by people with allergies. When peoplewith allergies are exposed to their allergic trig-gers, the substances they’re allergic to combinewith IgE to trigger an allergic reaction. Part ofthe allergic reaction involves creating airway in-flammation, which can lead to asthma symp-toms or attacks (see page 1).

Xolair™ (or omalizumab) is a medication de-signed to block IgE antibodies. It is currently li-censed in Canada for individuals 12 years of ageand older. It is given by injection, every 2 to 4weeks (rather like allergy shots). However, byblocking all human IgE antibodies, it can helpprevent most types of allergic reactions fromleading to worsening asthma. Studies have

Other asthma medications

Common uses of ketotifen

Side effects

Theophyllines

Common uses of theophyllines

Anti-IgE therapy

34

shown that treatment with Xolair™ leads tomoderate improvements in asthma severity.

Xolair™ can only be used in patients with mild-moderately increased blood levels of IgE, be-cause patients with too high blood IgE levelsneed a dose of Xolair™ that is generally toohigh to administer. Thus, some patients withvery severe allergies have blood IgE levelswhich are too high to benefit from Xolair™.Side effects of this medication are infrequent. Afew patients develop swelling or other local re-actions occurring where the medication is in-jected. Extremely rarely, people may haveallergic reactions to this medication.

Xolair™ is currently very expensive, and is gen-erally used only in patients with quite severeasthma, who have mild-moderately increasedblood IgE levels.

Allergy shots (or immunotherapy) are a seriesof injections which contain very tiny amountsof a substance a person is allergic to. Givingthese injections, in slightly increasing amountsover a long period of time may gradually makethe person less likely to have an allergic reactionwhen exposed to a larger amount of this sub-

stance. Allergy shots can be helpful in peoplewith hay fever (or allergic rhinitis) who are al-lergic to a particular pollen which is present acertain time of the year, such as ragweed. Un-fortunately, most people with asthma triggered byallergies are allergic to many different things, andmaking these people less sensitive to one or twoparticular allergens usually has little impact ontheir overall asthma control. In addition, peoplewith asthma are more likely to have severe reac-tions to allergy shots than people who have aller-gies alone. Allergy shots can be helpful in somechildren with asthma. However, because of thesereasons, most children with asthma do not receiveallergy shots. If allergy shots are used, theyshould be given very carefully and are usuallyonly used in particular situations, such as thechild who really seems to be only allergic to oneor two things, and who has no other triggers.

Conventional asthma therapy can improveasthma control and prevent potentially danger-ous asthma attacks in virtually all children withasthma. While some families may wish to con-sider alternative treatments, it must be empha-sized that these treatments, when used, shouldbe used in addition to conventional therapy,rather than instead of conventional therapy, toavoid the possibility of a severe asthma attack.

Other form of treatment

Other forms of treatment

Allergy shots

Complementary (alternative) therapies and asthma

35

You must remember to keep your doctor in-formed of any alternate treatments and reme-dies. Relaxation therapy, such as massagetherapy, has been shown to be helpful in chil-dren with asthma.

Twenty-minute massage therapy sessions(stroking and kneading motions of the face,head, neck and shoulders, arms, hands, legs, feetand back) taught by a trained massage therapisthave been shown in a carefully-performed med-ical research study to reduce anxiety in childrenfour-to-14 years of age and modestly improvepulmonary function.

A carefully performed study of chiropractic ma-nipulation showed no benefit when added to con-ventional medical therapy in children with asthma.

Some herbal remedies for asthma contain com-pounds closely related to medications com-monly used in the conventional treatment ofasthma. Tea contains caffeine, which is closelyrelated to theophylline, a mild bronchodilator.Ma Huang (Ephedra) is related to beta-2-agonist

relievers (bronchodilators). However as dosagesmay not be standardized or may vary, there isno discernible advantage to their use over con-ventional drug preparations. Mixing herbalremedies with conventional medications couldbe a dangerous combination. Remember to keepyour doctor and pharmacist informed of everytreatment you or your child take.

Many other alternative therapies for asthma arebeing promoted. In general, these treatmentshave not been carefully evaluated for their effi-cacy and their potential side effects are often un-known. Some of these therapies rely onnon-conventional allergy testing. Conventionalallergy tests usually apply extracts of substanceswhich are common causes of allergies to skinwhich has been pricked with a needle or, lessoften, injected with a needle into the skin. Theresults of these tests have been shown to beclosely related to allergy-causing antibodiesagainst these substances. Non-conventional al-lergy tests, using electrical, magnetic or othermethods, have not been shown to be related toantibodies and their clinical significance has notbeen demonstrated. If your child is having al-lergy tests performed by someone who is not atrained allergist you should ask whether yourchild is getting a conventional allergy test or anon-conventional allergy test.

Other form of treatment

Massage therapy

Chiropractic therapy

Herbal remedies

Other methods

36

Inhaled asthma medication will not work unlessit reaches your child’s lungs. This section willhelp remind you how to use the various types ofasthma inhalers. However, a health care profes-sional experienced in teaching the use of asthmainhalers (such as a doctor, nurse, pharmacist, orrespiratory therapist) should also teach you andyour child how to use the inhalers, and double-check your child’s inhaler technique from timeto time. If you have questions or concerns re-garding the use of your child’s inhaler device(s),speak to your doctor as soon as possible.

Of course, as with all asthma medications, in-haled medications also won’t work unless yourchild takes them. Particularly with teenagers,check from time to time that they are takingtheir medications as prescribed. Many inhalershave dose counters, which you can use to checkwhether the medication is being taken too fre-quently, or not often enough. Some parents trustquite young children to take their controllermedications alone. This may not be a good idea,and it may be better to have your child take theirmedication(s) at meal times, when you can ver-ify that they’re being used the way they’re sup-posed to be.

This is a metal canister placed in a plasticholder. Most children under the age of nine cannot use an MDI properly. For these children aspacer device (see page xx) should be used withthe MDI. Regardless of the child’s age, spacersare recommended when a steroid inhaler is usedto reduce the risk of developing a yeast infectionin the mouth or throat.

Asthma Inhalers & Other Devices

The metered-dose inhaler (mdi)Asthma Inhalers &Other Devices

1. Make sure that the metal canister is placedfirmly in the plastic holder.

2. Remove the cap and shake the MDI well.

3. Ask your child to breathe out, emptying his/her lungs.

4. Have your child tilt his/her head back slightly and place his or her mouth aroundthe mouthpiece.

5. Have your child start breathing in slowly and deeply through the mouth. About one-third of the way into the breath, have yourchild depress the metal canister to release one puff of the medication, while continuing to breathe in steadily and deeply all the way. Once your child has breathed in fully, have your child hold his/her breath in for five-to-ten seconds oras long as possible before breathing out.

6. If your child requires more than one puff of the medication, wait 30 seconds, shake the MDI again, and then repeat stepsthree-to-five.

1. If you see a mist escaping from the mouthduring the inhalation, you will need toimprove your child’s technique.

2. Rinse the plastic holder of MDI regularly with warm tap water. Remove canisterfrom plastic holder before rinsing. Let drythoroughly before replacing the canister.

3. To check the level of medication.

4. remaining in your MDI, remove the metalcanister from the plastic holder. Placing a finger on the top of the canister, gently shake, feeling for liquid moving within the canister. When little liquid movement can be felt, the MDI is almost empty.

Spacer devices allow medication released froma metered-dose inhaler to form a cloud insidethe holding chamber, allowing people withasthma to inhale the medication without havingto precisely coordinate releasing the medicationfrom the inhaler and breathing it in. The bestspacer devices contain a one-way valve, toallow the medication cloud in the holding cham-ber to be inhaled when the child breathes in, butprevents the medication cloud from being di-

Asthma Inhalers & Other Devices

Instructions Hints

Spacer devices

38

luted by exhaled breath when the child breathesout. There are several very good quality spacerdevices available in Canada, and some othersthat may not be as effective. Your health careprofessional can help you choose the appropri-ate device for your child. In the past, some pro-fessionals have suggested using coffee cups ortwo litre plastic soft drink bottles as spacer de-vices. However, these do not contain valves, andare not nearly as effective as devices designedespecially for delivering asthma medications tothe lungs. This booklet will discuss the Ae-rochamber®, one of the high-quality spacer de-vices which are commonly used in Ontario.

A spacer with mask is a holding device whichhelps to deliver medication in young children(usually under five years of age) who cannot co-ordinate their breathing well enough to use ametered-dose inhaler (MDI) alone and who aretoo immature to be able to keep their lips tightaround the mouthpiece of a spacer with mouth-piece. The spacer with mask is used togetherwith an MDI. They come in different sizes, forchildren of varying ages. For example:

1. Prepare the MDI by removing the cap, shaking the canister well and placing it upright in the rubber opening of the spacer.

2. Place the device’s mask over your child’s face firmly, making a good seal over the nose and mouth.

3. Press down on the canister, releasing one puff of medication into the spacer.

4. Hold the mask in place until your child hastaken at least six breaths. You can generallywatch a valve behind or above the mask move to help you count the breaths.

Asthma Inhalers

The spacer with mask

• The orange AeroChamber® with Mask is used for infants less than one year of age.

• The yellow AeroChamber® with Mask is used in children approximately one-to-five years of age.

Instructions

5. If your child requires more than one puff ofmedication, wait at least 30 seconds, and then repeat steps one-to-four. Remember toshake the canister well before giving another puff. Do not spray more than one puff at a time into the device.

1. If your child struggles when using this device, try to persist, as most children willeventually get used to it. Your child will get some medication into the lungs even ifhe/she cries.

2. At about five-to-six years of age your child should be switched to a spacer with mouthpiece, as this will prevent loss of medication in the nose.

3. If your child is using inhaled steroids, you may want to consider having your child drink or rinse his/her mouth with water if able after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.

4. The device should be replaced when the valve is cracked, hard, or gets permanentlycurled, if the rubber holder for the MDI becomes cracked or torn, if the device gets

very worn, or if the mask is damaged or has a hole in it.

5. To avoid dust accumulation, keep thedevice in its plastic container when not in use.

6. Rinse the device in warm tap water every few days and clean weekly with a mild detergent. Let dry thoroughly before using.

The spacer with mouthpiece is a holding devicethat helps to deliver medication in children (usu-ally five years of age or older) who cannot co-ordinate their breathing well enough to use ametered-dose inhaler (MDI) alone.

The spacer is used together with an MDI. Thespacer with mouthpiece is appropriate for chil-dren old enough to keep their lips tight aroundthe spacer mouthpiece. Because the nose trapsparticles, children who use the spacer with maskwill lose some of the medication in the nose andit is therefore preferable to use a spacer withmouthpiece when the child is able to keep theirlips tight around the adult spacer mouthpiece.This is usually around five or six years of age. Regardless of the child’s age, spacers are rec

Asthma inhalers

Hints

The spacer with mounthpiece

40

ommended when a steroid inhaler is used inorder to reduce the risk of developing a yeast in-fection in the mouth or throat.

1. Prepare the metered-dose inhaler by removing the cap, shaking the canister well and placing it upright in the rubber opening of the spacer.

2. Ask your child to breathe out, emptying his/her lungs.

3. Place the mouthpiece of the spacer into your child’s mouth and have your child close his/her lips tightly around the mouthpiece.

4. Press down on the canister, releasing one puff of medication into the spacer.

5. Ask your child to take one breath in through the mouth as deeply as possible, and hold the breath in for five-to-tenseconds. If he/she is unable to do so, ask your child to breathe in and out deeply and slowly for three-to-four breaths instead, while keeping the lips closed aroundthe mouthpiece.

6. If your child requires more than one puff of medication, wait at least 30 seconds, and then repeat steps one-to-five. Remember toshake the canister well before givinganother puff. Do not spray more than one puff at a time into the spacer.

1. If your child is breathing through the (blue) Adult AeroChamber® too quickly, you will hear a musical sound. If thishappens ask your child to breathe in and out more slowly when using theAeroChamber®.

Asthma inhalers

Instructions Hints

2. If your child is using inhaled steroids, have your child rinse his/her mouth with water after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.

3. The device should be replaced when the valve is cracked, hard, or getspermanently curled, the device is worn, orif the rubber holder for the MDI becomes cracked or torn.

4. Rinse the device in warm tap water every few days and clean weekly with a mild detergent. Let dry thoroughly before using.

5. To avoid dust accumulation, keep cap on mouthpiece when not in use.

Many children enjoy using dry powder inhalers,as they avoid the need for a bulky spacer device.Most children can learn to use a dry powder in-haler between four and six years of age. A fewchildren are bothered by the powder containedin a dry powder inhaler and prefer a metered-dose inhaler with or without a spacer device.

The Turbuhaler® is a bullet-shaped device thatcontains finely powdered medication in pre-measured doses. Most children five years of ageor older can use this device.

Pulmicort® (budesonide), an inhaled steroid(brown base); Bricanyl® (terbutaline), a short-

Asthma inhalers

Dry powder inhaler devices

The Turbuhaler®

Medications that are available inTurbuhaler include:

42

acting beta-2-agonist reliever medication (bluebase); Oxeze® (formoterol), a rapid-acting,long-acting beta-2-agonist reliever medication(green base); and Symbicort® (budesonidecombined with formoterol), a combined inhaledsteroid controller and a long-acting beta-2-agonist medication (red base).

1. Unscrew the cover and lift it off.

2. Holding the inhaler upright, turn the coloured base to the right as far as it will go and then back to the left until you hear a click. This releases a measured dose of medication.

3. Ask your child to breathe out, emptying his/her lungs.

4. Then, have your child close his/her lips tightly around the mouthpiece then ask him/her