In this disease, airways are hyperreactive, which means that there is a narrowing of airways which leads to difficulty in breathing. By definition, Asthma is a chronic inflammatory disorder of the airways, characterized by recurrent, reversible, airway obstruction. Airway inflammation leads to airway hyperreactivity, which causes the airways to narrow in response to various stimuli, including allergens, exercise, and cold air. The most common symptom of Asthma is Wheezing but all asthmatic children do not wheeze. The most common symptoms of recurrent airflow obstructions are
- Recurrent wheeze (wheeze is heard by stethoscope but sometimes audible whistling sounds )
- Recurrent isolated cough
- Recurrent breathlessness
- Nocturnal cough
- Tightness of chest
Signs are (examination by a doctor):
- Generalized rhonchi (wheezing sounds heard with a stethoscope)
- Prolonged expiration
- Chest hyperinflation (on X-ray of Chest)
The Ten Commandments of Asthma
- Asthma is a chronic condition with episodic symptoms. There is a need for continuous preventer drugs for certain grades of asthma. The drugs used for asthma ‘control’ asthma but do not ‘cure’ asthma.
- A majority of children outgrow their symptoms as they grow older.
- There are lots of myths and misconceptions regarding inhaled therapy that need to be cleared. Medications given using inhaled route have their own merits and advantages.
- Discuss the selected regime and address concerns regarding the usage of medications with your doctor.
- Discuss the usage and maintenance of the inhaler device selected. Carry the inhaler device at each follow-up visit.
- It may take some time taken to note improvement and the need for compliance with the prescribed preventer drugs cannot be over-emphasized.
- Dealing with triggers/precipitants like dust, pollen, fur, smoke, exercise, etc can go a long way in controlling the symptoms, and preventing asthmatic attacks. Diet has a small role in the causation of symptoms.
- Maintain a diary of events and carry it at each follow-up visit. Record days that there are events such as daytime cough, nocturnal cough, wheeze, reliever medication use, doctor/hospital visits, school absenteeism due to symptoms, etc.
- Learn how to manage acute exacerbations/ sudden asthmatic attacks at home before doctor contact.
- Go for the follow-up visit 2-4 weeks after the institution of the preventer regime. Subsequent visits may be planned 2-8 weekly according to the severity or earlier in case of recurrences, or as your specialist plans.
The eleventh commandment (During follow up)
- Identify any lacunae in understanding and clarify all doubts in subsequent meetings.
- Advantages of the inhaled route (MDI pump and nebulizers) are Smaller dose: Contrast the milligram (mg) concentration of syrups and tablets with the microgram (mcg) concentration of the same drug in the inhaled form.
- ‘Target delivery’ – ‘Quicker action’: Drug is delivered directly to the site of action. Reliever drugs, therefore, act faster.
- ‘Safer’: Smaller dose and thus, much better safety profile than with oral therapy. This is particularly relevant for steroids.
Misconceptions that need to be cleared
- Is inhaled therapy addictive? I want to emphasize that addiction liability is a property of the drug rather than a device/route. An example is that alcohol, though oral, is still addictive. None of the asthma medications are known to cause dependence.
- Is inhaled therapy strong? No, as discussed earlier, a smaller dose is needed (microgram concentration) of drugs used.
- Is inhaled therapy expensive? The inhaler device is a one-time purchase. Only drugs need to be purchased subsequently. A few inhaled drugs may be slightly more expensive than oral drugs on a per-dose basis but these in the context of the child’s well-being, safety, and reduced doctor/hospital visits are a better option.
- Are inhalers easy enough for children to use? MDI pumps used with a spacer can be given to small children also with ease and the technique is very easy.
Typical features of this disease
- Afebrile episodes (most cases)
- Personal atopy or skin allergy
- Atopy / Asthma in a parent or sibling
- Exercise / Activity: In a smaller child, laughing or crying may provoke symptoms.
- Triggers: These are usually inhaled irritants or aeroallergens (page 10).
- Seasonality: Sudden temperature changes, flowering season, and harvesting time are risk situations. This feature can be judged only after observation over a sufficient period.
- Later onset of symptoms (usually around 3 years of age)
- Relief with a bronchodilator (asthalin )± short-course oral steroid
In children, asthma is a clinical diagnosis, made by evaluation over time, either retrospectively or prospectively. Investigations help in confirming or ruling out alternative diagnoses, rather than in diagnosing asthma.
By Dr. Rahul Varma
Child Specialist
