A Common Story
It is a typical scene as I walk into the examination room. There on the exam table sits Roger, a 7-year-old young man with whom I am all too familiar.
Roger is doing what he usually does when I see him in my office: struggling to breathe. As I watch his chest heave up and down, I am struck by his loud wheezing and the exhausted face of his mother, who has been up all night with him. As you might guess, Roger is a frequent visitor both to my office and to the Emergency Room. He has been hospitalized several times. Despite what I think is good management on my part, Roger does not seem to get well.
Upon my persistent questioning, I find that his mom really hasn't been giving him his medicine regularly, despite my instructions. Whenever he does get well, she stops it, because she doesn't want him on medicine all the time...
The above story represents many of the difficult problems in treating asthma in children. Despite a growing understanding of the disease in the medical community, and the development of many new treatments, asthma continues to take a heavy toll on the health of millions of children.
The Basis Of Asthma Treatment
Before I can tell you about the specifics of treating childhood asthma, you must learn a few basics about the disease.
The two stages of asthma
There are really two parts to an asthma attack. The first, called the early phase, begins in minutes and can last for hours. It is caused by a clamping down of the muscles that surround the airways. When these muscles contract, they narrow the breathing tubes, making it harder to move air in and out of the lungs. This process is called bronchospasm. The second part of the attack is called the late phase. It begins in hours and can last for weeks. The cause of the late phase is the over-reaction of the "defense systems" in the lungs. When triggered, these defense systems call up an immune system response causing inflammation.
The makings of an inflammatory response in the lungs
Special cells in the lungs, called mast cells, release chemicals that call up this inflammatory response. One such chemical, histamine, makes the lining of the lungs leak, just like it does to lining of the nose in hay fever.
Another set of chemicals, called leukotrienes, call in more white blood cells, even when they are not really needed. So many of these inflammatory chemicals are released into your airways, already made smaller by bronchospasm, get clogged up with mucus plugs, fluids, and cellular debris. The end result is further narrowing of the breathing tubes and increasing difficulty breathing. What's more, there is increasing evidence that all of this inflammation may cause permanent changes in the structure of the airways, making them more prone to future illness. Therefore, managing the inflammatory response at a young age takes on even greater importance.
The take-home message of this rather complex process is that asthma is an inflammatory disease. If one treats only the first part, the bronchospasm, and does not adequately treat the inflammation, then treatment will not be as effective. Inflammation is a slow and chronic process, and its presence may not be all that obvious once bronchospasm goes away. Its treatment must be a long and continuous process. It is quite natural to resist giving children medicine when symptoms are not obvious. Many parents and many doctors fall into this trap. As you will see later, it is absolutely critical to treat the inflammation in order to get asthma under control.