Apprehending Asthma

“We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right – one after the other, no slipups, no goofs, everyone pitching in.” – Atul Gawande, surgeon and journalist

Since I have talked of colds and allergies I guess it is natural to feel compelled to discuss the challenges a paediatrician faces with managing asthma. My moment of truth came when a close friend of mine broke down as I was nebulizing her nephew. I knew that she had outgrown wheezing episodes as a child and I expected her to be reassuring by virtue of her experience. When I asked her to explain herself she said, “The fear you feel when it becomes increasingly difficult to breathe, it’s horrible… I know what the child must be going through, can’t help feeling bad for him.” That’s when I guessed that it’s this panic that actuates so much of absurd behaviour and decision making. So let me share some facts to allay some of it.

First of all being asthmatic means you have airways that are hypersensitive and prone to becoming narrowed because the surrounding tissues get bloated as a part of the rabble rousing response of the immune system when it encounters some triggers. Asthma attacks come and go, with wide variation in the symptoms at different times. Many people with asthma have problems only occasionally but others struggle with it every day. There is no cure, the focus should be on control, and it can be achieved. What we aim for when we say control, is generally

An ability to live an active, normal life (which means performing daily activities, play, and participation in sports without difficulty)

Prevention of chronic and troublesome symptoms

Zero school absenteeism because of asthma related symptoms

Avoidance of symptoms during the night

Stopping the need for urgent visits to the doctor, emergency department, or hospital

Prescription and adjustment of medications to control asthma with little or no side effects

Secondly, not all wheezing is asthma. About half of infants and toddlers with repeated episodes of wheezing with shortness of breath or cough (even though these illnesses usually respond to asthma medications) will not have asthma by the age of six. Because of this, many paediatricians use terms like “reactive airways disease” or “bronchiolitis” when describing such children instead of labelling them as asthmatic.

No one really knows the exact reasons why more and more children are developing asthma in recent times. Some experts suggest that children spend too much time indoors and are exposed to more and more dust, air pollution, and second-hand smoke. Some suspect that children are not exposed to enough childhood illnesses to direct the attention of their immune system to bacteria and viruses and therefore, develop allergies (the so called “hygiene hypothesis”).

We also find many parents hesitant to give inhaled asthma drugs or liquid medications delivered with an asthma nebulizer, also known as a breathing machine. I wish parents would take the time to educate themselves (the resources being so accessible) and have clear concepts in their minds because only then can they motivate children to be regular with medications and not feel self-conscious while taking them. This is very crucial.

Asthma in children is handled using very specific guidelines, depending on the severity and duration of symptoms. The medications given fall into two categories. One category includes drugs taken daily that are meant to control asthma in the long term and reduce the frequency of asthma attacks (controller or maintenance medications). The other category is medications that provide instant relief from symptoms (rescue medications). Steroids are a vital part of the list too. Very short oral courses (three or five days) or long term inhaled preparations seldom cause alarming side effects and there is no need for trepidation. In general, doctors start with a high level of therapy during an asthma attack and then decrease treatment to the lowest possible level that still prevents asthma flare-ups and allows your child to have a normal life. Every child needs to follow a customized asthma management plan based on the severity and triggering factors so do not compare it with another.

So the essential parts to managing your child’s asthma are Identifying and Controlling Asthma Triggers, knowing when to anticipate flare ups and having a clear plan of action to handle it, being regular with medicines and periodically updating your knowledge with your doctor.