Expert Advice -- Asthma: Causes and Medications

My son is 18-months-old and was first diagnosed with asthma when he was 13-months-old. He just had another asthma attack and also has sinus, upper respiratory and ear infections. He was prescribed Pediazole, albuterol in inhaler form, to be used with a spacer and mask, and prelone syrup. Our doctor also mentioned that she may want to keep him on an anti-inflammatory drug, coupled with the albuterol. I am nervous about all these medicines going into his little body. He seems so hyper and his heart beats so fast. Are there other treatments available?

Question:

Your questions are quite common ones especially considering that up to five percent of the population may suffer from asthma. But to understand the rationale behind the medicines that are given for asthma, it is helpful to first understand what causes asthma in the first place.

Pretend that the normal air passages in the lungs are tubes the size of the cardboard tubing found at the center of a paper towel roll. Normally, the air going into and out of the lungs has no problem through these large passageways. But during an asthma attack, essentially three changes occur:

  1. The walls of the airways constrict making the passageway smaller. In other words, the paper towel tube becomes the size of a soda straw. This effect happens rather rapidly (within minutes) during an asthma attack and can be reversed rather rapidly with medications.
  2. The walls become inflamed and swollen. In other words, the soda straw remains the about same size in diameter, but walls become thickened toward the inside which makes the passageway smaller inside the tube. This effect takes a little longer to occur (minutes to hours), but reversing the process may take hours to days.
  3. The walls secrete a lot of mucous. What little space there is left inside the soda straw for air to go through may get plugged with thick mucous.

Basically, strategies for treating asthma attacks are directed at the first two steps. Other methods are used to try to identify and prevent the thing that seemed to initiate the asthma attack in the first place. In addition, medications may be given to make an attack less likely to occur or at least make the symptoms not as severe.


Let's take your 18-month-old as an example to understand why the medications he received were chosen:

Reversing Step #1

Albuterol -- This is the main medication used to reverse what occurs in step #1. When given as a liquid, it must be absorbed by the stomach, circulate through the body, and thus only a portion of the medication acts upon the lungs. This whole process takes about 30 minutes to occur, so you can see it is not very efficient. On the other hand, when albuterol is given by an inhaler and spacer, the medication goes immediately to where it is needed and works within minutes. You notice I underlined spacer. Even in children and adolescents old enough to operate the inhaler on their own, most of the spray usually gets deposited inside the mouth due to incorrect use. Therefore, I recommend that all inhalers be used with a spacer all the time. The spacer can come with a mask for those who can't breathe correctly through the mouthpiece (usually children under 6). However, when using the spacer with mask, the parent should remember to pinch the nose through the mask so that the medication does not get filtered through the nose.

There are other medications that seem to work at least in part by reversing step #1. These include one called ipratroprium which is being used more and more. However, I don't anticipate this will be used for children at home on a regular basis until more studies are done to show its effectiveness.

Reversing Step #2

Prelone -- This is the trade name for one of the common steroid medications called prednisolone. Another common steroid used in asthma is called prednisone. These steroids are not the same kind that some athletes illegally use. These two steroids are anti-inflammatory medications. They reduce the swelling that is such a large part of what occurs in an asthma attack. Because these medications are typically given in oral form, the same problem applies with this as it does with the albuterol in that it must go through the whole body before acting upon the lungs. This can cause side effects. With repeated use (usually considered more than five separate times per year) or chronic use, there can be loss of calcium from the bones as well as growth suppression.

Reversing Step #3

There aren't any good medications to get rid of the mucous problems that occur in asthma, but this step is usually taken care of by the coughing that in such a major part of an asthma attack.

Preventing the Asthma Attack

Although prevention may be the most labor intensive portion of taking care of a child with asthma, it is the part that can make the most difference in alleviating symptoms and avoiding side effects of medications that must be used when an attack occurs. Therefore, this is where most of a parent's energy should focus.

There are two areas that are important in preventing an asthma attack. The first is identifying those factors which seem to bring on the attack and take steps to make it less likely that the child will encounter them. The second is giving medications to the child so that if he does encounter an asthma-attack inducing situation, he will be much less likely to have symptoms.

Identifying/Avoiding The Causes Of The Asthma Attack

The most common instigator of an asthma attack is an upper respiratory infection, and most of these infections are caused by viruses. Therefore, the most common instigator is both virtually impossible to avoid (everybody gets colds) and has no medications specific for the infection (can't be treated). However, there are some infections which may be either the cause of the asthma attack or make an asthma attack worse. These include ear infections and sinusitis.

Next, it is important to notice what the child may be allergic to. Identification of the allergies is the first step and then being diligent to avoid these things is second.

Medications Given Everyday to Help Avoid Asthma Attacks

There are things in the environment that the child may be allergic to that are virtually impossible to avoid. In addition, there are some children who despite intensive efforts in environmental control, still have significant problems with asthma. These children should be placed on chronic anti-inflammatory medications. These medications taken with an inhaler do not work immediately, so they are useless in treating the immediate symptoms of an asthma attack. However, with diligent use everyday, they can decrease both the number of attacks as well as the severity of attacks when they occur. These medications include:

Inhaled steroids -- There are several of these to choose from including Beclovent, Vanceril, and Azmacort just name a few. They offer the advantage of getting anti-inflammatory power to the lungs without causing the side-effects you get when taking steroids by mouth.

Cromolyn sodium (Intal) -- This medication is extremely safe with few if any side effects. However, it may not be as effective as inhaled steroids.

Leukotriene Inhibitors -- There are new ones being introduced almost monthly. The newest ones include Accolate and Zileuton. Leukotrienes are molecules in the body that serve a large role in causing the inflammation associated with an asthma attack. These medications are very new to the market but hold promise in being another weapon against asthma.

I hope this gives you a reasonable overview as to what purpose these medications serve in fighting asthma. While your concern about your child taking so many medications is certainly understandable, asthma is a disease that should be treated aggressively to avoid its complications. However, as you can see, with careful preventative measures, the total number of medications can be kept at a minimum. I suggest you voice your concerns to your pediatrician, so that you and your son's doctor can devise a plan that is suitable for all three of you.

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