Asthma: A New Generation of Care

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One moment health-care professionals in pediatrics face with trepidation is when a former patient returns – as a parent! Jill had severe asthma as a child, and had many admissions, emergency and outpatient visits to the Children’s Hospital of Eastern Ontario. She was visiting Ottawa, when her two-month-old son, Matthew developed the unmistakable signs of wheezing and difficulty breathing that she had experienced as a child.

There are many sources of information for people with asthma:

The Lung Association provides a toll-free Asthma Action Line, for information about asthma, staffed by CAEs. 1-800-668-7682.

Some local Lung Associations have Asthma Educators on staff for counseling, by appointment.

The Ontario Lung Association has produced a 32-page colour booklet by CHEO respirologist, Dr. Tom Kovesi, called, “Asthma in Children”. For more information, call 1-800-668-7682.

The Internet has many websites for parents to learn about asthma. A few recommended sites are:

Websites designed especially for children with asthma are:

Information cannot be used as a substitute for obtaining medical advice or for seeking treatment from a qualified physician.

Asthma is a variable disease, so one can expect symptoms from time to time. In children, symptoms of asthma are most often precipitated by a cold. Parents are encouraged to use physician directed self-management plans or “action plans” for the treatment of asthma. If treatment adjustments are made early, when symptoms of asthma first appear, then serious attacks can often be prevented. An individualized action plan outlines what medications should be used daily, and how and when treatment should be increased should symptoms occur. A sample of the Asthma Action Plan developed at the Children’s Hospital of Eastern Ontario can be downloaded from www.cheo.on.ca. (Fig. 1)

It is a privilege to have been involved in both Jill and Matthew’s care. It is most gratifying to know that should Matthew develop asthma there are many treatments to offer and it is unlikely that he would suffer the interference with daily activities due to asthma that Jill did as a youth.

Matthew was brought to the Children’s Hospital of Eastern Ontario, where he was diagnosed with bronchiolitis. Bronchiolitis is an inflammation of the tiny air passages (called “bronchioles”), and is usually caused by a viral illness. Jill’s concerns about Matthew developing asthma were valid. He had three risk factors – bronchiolitis during infancy, a positive family history of asthma and he is male.

In asthma, the airways (bronchi) become inflamed, producing excess mucous, and the muscles surrounding the airways become irritated and constrict, further narrowing the airway. The characteristic symptoms are cough, wheeze and shortness of breath.

Asthma is the most common childhood disease, and a significant cause of school absenteeism, Emergency Room visits, and admission to hospital. Asthma affects about 10% of all children in Canada.

As a child, Jill’s treatment consisted of oral and inhaled bronchodilator therapy. Theophylline was the oral drug of choice (not that there was much choice in the 1970s). Theophylline is metabolized rapidly in children, so doses were high relative to those given to adults. The side effects were significant – poor bronchodilation if the levels were too low, and irritability, headache, nausea and vomiting if the levels became too high.

Adolescence was particularly troublesome for Jill. She disliked the regimented dosing schedules and frequent blood tests required to maintain safe, yet effective dosing of theophylline. She also hated the weight gain associated with prolonged treatment with oral corticosteroids required to control her asthma.

The advent of inhaled steroids in the mid-1970s heralded a new era in asthma management. For the first time, the underlying inflammatory component of asthma could be treated with inhaled medication, hence symptoms more effectively controlled with little steroid side effect. Over the years, more effective steroids have further improved asthma management. However, inconsistent use of inhaled steroids remains a common cause of poor asthma control.

Recently, other controller medications such as leukotriene receptor anatagonists and long acting bronchodilators have become available. The most recent advance is combination therapies, which combine an inhaled steroid with a long acting bronchodilator in the convenience of a single inhaler.

The “Canadian Asthma Consensus Guidelines” (CACG) – evidence-based guidelines for the treatment and control of asthma were published in 1996 and updated in 1999 and 2001. It is expected that with optimal treatment, most patients can achieve good asthma control.

According to the CACG, asthma is under good control if:

  • Daytime symptoms less than 4 days/week
  • Night-time symptoms less than one night/week
  • Normal physical activity
  • Mild, infrequent exacerbations
  • No absenteeism from school or work due to asthma

Fewer than 4 doses/week of short acting bronchodilator needed (apart from one dose/day before exercise) (Adapted from the Canadian Respiratory Journal 2001 Volume 8 Suppl A).

Jill recognizes, according to the criteria for good asthma control, that she spent many years with uncontrolled asthma.

Asthma education is a key component to its effective control. Avoiding triggers which are known to cause symptoms of asthma, the appropriate use of medications and inhaler devices and how to initiate treatment for symptom relief are key to improved quality of life for people with asthma. The Canadian Network for Asthma care has established a program to train health-care professionals to become Certified Asthma Educators (CAE). Presently, there are 456 CAEs in Canada. To learn more about becoming a CAE or upcoming events visit www.cnac.net.