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Monday, December 9, 2013
Asthma in kids
I have an 8 year old son, who was just told that he had mild persistent asthma, and the doctor prescribed advair,however in the last 2 years that we have been trying to find out what his problem was, he has only had about 4 problems, most of these were made up of just chest pains and some of the episodes have wheezing and very short of breath, his doctor did give him a chest x-ray and an ekg to rule out heart issues and when he had the PFT test done is fef25-75 was 70% before the breathing treatment and 107 after but since his symtoms are not that frequent, would you suggest such stron steroidal medicine?
Asthma is a chronic (long-lasting) problem which involves irritation and swelling of the inside of the breathing tubes. This irritation is present even with the patient feels well. As long as it is present, the airways are likely to over-react to minor irritations (or things that wouldn't even bother healthy airways) like catching a cold, being around allergens, fast breathing during exercise, changes in the weather . . . plus more. When they over-react, the muscles around the airways squeeze down (bronchospasm), the inner lining swells even more, and it starts making more mucus. If mild, these changes may only cause a cough. If more severe, breathing becomes more difficult and a wheezing sound (a squeak from air squeezing through "tight spots") develops. Unhappily, in very severe reactions the blockage to air flow can become so severe that oxygen levels start to drop and, if this continues, the patient's life can be in danger. Diagnosing asthma involves consideration of whether the patient's symptoms are similar to asthma, occur repeatedly, respond to asthma therapy - in general "fit the asthma pattern." Breathing tests can sometimes detect that the airways are swollen enough - even on a "good day," that airflow is below normal rates. If giving an aerosol results in rapid improvement in these rates that further "proves" the patient has asthma - and further, shows that the asthma is fairly active. (The airways are "twitchy" on the day of testing.) It should be noted that some patients with asthma can have perfectly normal tests when they are well - this does not mean they DON'T have asthma, it just means their airways aren't terribly twitchy or swollen on the day tested. I gather that your child has had symptoms/ a pattern of illness that fit with asthma, and even further has had testing that shows the presence of "twitchy airways" - which further confirms the diagnosis of asthma. Treatment for asthma is very individual. All patients need a plan for what to do if symptoms flare up - this usually involves knowing when to start a "rescue" inhaler, when to call the doctor, when oral steroids might be needed. Many patients are going to be at their healthiest - and safest - if they also take daily medicine to help calm and sooth and stabilize the airways on a daily basis. These medications are generally called preventive or controller therapies. The decision regarding if (and how much) of this type of therapy would be best involves reviewing many factors. How often a patient is using rescue inhalers, how often they are having symptoms (even mild cough), whether they are having trouble breathing with exercise and other day-to-day issues are considered. How abnormal their breathing tests are is considered. What the patient's risk of having a really BAD episode is considered. (Patients who have already shown they can get so sick they require hospital treatment would be an example of a higher risk group.) After reviewing all these issues, the physician makes the decision whether to recommend daily medication, and what sort of daily medications to use. After the patient's been taking the medication for a while, they then see the patient back to check to see if the medications are working (with a goal that the patient is rarely having any asthma symptoms!) and adjust as needed. There are a host of different medications available to help control asthma. Extensive research has shown that by far and away, the "mainstay" of daily controller medication is inhaled steroid therapy. This involves inhaling a tiny dose of steroids designed to coat the inside of the airtubes (where the problem is.) The doses involved are MUCH smaller than the by-mouth (oral) steroids used for acute attacks, and the risks of steroid side effects are very, very limited. Meanwhile, the benefits are huge - less symptoms, less hospital stays, less ER visits, less risk of death from asthma. Sometimes, depending on the patient's individual asthma "story" and testing, higher doses of inhaled steroids, or addition of other medications to the inhaled steroids (Advair is an example of that - inhaled steroid combined with an albuterol-like medication that lasts 12 hours all in one inhaler) may be recommended. Your doctor sounds like he/she is doing a great job of identifying what your child's problem is, and is being on-the-ball about making recommendations that should help your child feel well, from a cough and breathing angle, most of the time. I suspect that the fact that your child's breathing tests weren't normal, in addition to the symptoms he's had, were factors in the decision to recommend Advair. If you feel uncomfortable with the medication, though, you should discuss this further with your doctor so they can specifically explain to you what about your son's case led them to make the recommendation. Asthma is definitely one of those problems that doctor, parent, and patient all need to be on the "same page" in order to achieve the best results.
Elizabeth D Allen, MD
Clinical Associate Professor of Pediatrics
College of Medicine
The Ohio State University