Every Tuesday, my son and his classmates used to run a mile after school for Read Right and Run. A few weeks ago while watching the children, I noticed a young girl coughing repeatedly and struggling to run and keep up with her peers. The concerned mother explained her daughter’s asthma was causing such difficulties. However, I responded that it was due to poorly controlled asthma. My son suffers from asthma as well, yet he is unrestrained when participating in any physical activities.
Asthma is a disease that can most certainly be managed so that every child is able to participate in sports. The goal of asthma control is simple. With the right treatment, your child should be free of asthma symptoms,  able to play any sport without limitations, sleep at night without coughing spells, not miss school because of asthma, and finally, require no ER visits as a result of asthma related complaints. Despite your best efforts, however, asthmatic exacerbations may nevertheless occur. Your physician can without a doubt help you keep those exacerbations to a minimum.  To do so requires the right medications, and just as importantly, the right tools to administer such  medicines effectively.
To understand how asthma medications work, you need to understand what happens to your airways during an asthma attack.  As air enters your mouth and nose, it travels through a tube called the trachea.  The trachea divides into two branches and then into more branches and finally into millions of smaller branches (bronchioles) which end in small air sacs.  These tubes and their branches are lined by a thin layer of mucous and are surrounded by muscles which are like rubber bands.  
During an asthma attack, these little tubes swell and mucous production increases, which blocks the airways.  The muscles surrounding the bronchioles contract, making it difficult to move air through the airways.  The poor air movement and the mucous plugs result in coughing, wheezing, and difficulty in breathing.  To manage asthma, two strategies are followed.  The first is to prevent an asthma attack from occurring in the first place, and for this prevention “controller” medications are used.  But despite being controlled by the medication, asthma symptoms may nevertheless occur from time to time due to various triggers such as a cold, weather change, exposure to smoke, allergens etc.  So the second strategy is to relieve the symptoms of an asthma attack using “rescue” medications.  
Asthma Medications: Always use CORRECTLY and AS DIRECTED 
Rescue Medication:  The most commonly used rescue medication is Albuterol, which relaxes the contracted muscles surrounding the airways and helps move air through the airways.  Use this when your child is having an asthma attack or when you expect an asthma exacerbation such as during exercise.  Albuterol comes either as a liquid which you use with a nebulizer, or as an Inhaler which you use with an aerochamber.  Often, you are given a nebulizer if you have an infant.  Even so, always have an inhaler and an aerochamber that you carry with you in case of an emergency.  Using the aerochamber with the inhaler is vitally important in order for the albuterol to be delivered to the lungs in the proper amounts.  You can watch a video (“How to Control your Asthma”) that explains and demonstrates the correct way to use an aerochamber by clicking on this link.  There you will also find a lot more very useful information about asthma and how to manage it. 

Controller Medications…What are they? Prescribed if your child has asthma symptoms or uses Albuterol more than twice a week, these are medications which PREVENT your child from having an asthma exacerbation. Their purpose is to reduce the inflammation in the airways which can lead to an asthma exacerbation as described above. An array of controller medications exists, and your doctor will choose the one best able to treat your child. These medications can be inhaled steroids administered with the nebulizer (Pulmicort), delivered through an inhaler (Flovent) and aerochamber, or can be given as a dry powder by inhalation (Advair discus) or other nonsteroidal controller medicines such as Singulair or Cromolyn.  Regardless of the medication or the form through which administered, your child needs to use these medications EVERY DAY as directed by his or her doctor.  It is of the utmost importance that the medication be given to your child through the proper technique – (for example, the proper way for using an inhaler is with an aerochamber).  But no matter what medication your child is prescribed, all of these controller meds must get into the lungs in order for them to be effective. The proper technique for administering them ensures that the medicine reach the lungs.  These techniques are described in further detail in the video (“How to control your asthma”) here.  Controller medicines, however, will not help your child during an asthma attack.  If your child has an asthma attack, you must use the rescue medicine — Albuterol.
For some patients, asthma can be difficult to control.  If so, your physician may prescribe more than one type of controller medication for your child.  Remember to keep track of how often your child has asthma symptoms and how often they use albuterol. Discuss this information with your doctor.  Based on your observations, your doctor may add medications or reduce the dosage of medications as needed.  Do not stop using the controller medications without a discussion with your doctor.
Sometimes, flare-ups do occur even when asthma is controlled with the best possible means.  At these times, your physician may prescribe Prednisone or Orapred, oral steroids used to reduce the inflammation in the airways and help in the resolution of the asthma flare-up.  These oral medications are given for 5-7 days.  Note: you still need to use the rescue medicine Albuterol during an asthma exacerbation.
Whichever medications are prescribed for your child to treat his/her asthma, it is important that they are used correctly.  If your child has an asthma exacerbation and is seen in the ER, make sure you follow up with your child’s doctor in 3-5 days so that the medications are adjusted appropriately if necessary.  Remember, the goal is for your child to be symptom free and have no physical limitations.  
To meet that goal, a very useful tool is to have an Asthma Action Plan.  Contact your doctor or nurse to get an asthma action plan specifically and individually designed for your child.  Give a copy to the school/daycare/grandparents/any other caregiver.  An asthma action plan will help you manage your child’s asthma on a daily basis as well as serving as a guide for a) what to do if an asthma attack occurs and b) when to go to the ER for help. If you have older children with asthma, you can use a peak flow meter to measure air flow through their lungs.  During an asthma attack, air flow through the lungs is reduced which results in lower numbers when using the peak flow meter.  Measuring air flow can help you guide your asthma action plan.  You can watch a video on how to use a peak flow meter in the video “How to Control Your Asthma” here.  
Asthma Action Plan used at St. Louis Children’s Hospital
Child is well, no signs of asthma.  Peak Flow: above 80% of best
Good Job!  
Give your child the controller medicines every day as prescribed.  Do not stop giving them since they PREVENT your child from having an asthma exacerbation.
Early Signs of Asthma:         
Chest tightness                                  
Unable to sleep at night                    
Peak Flow: 50-80% of best               
Action Plan          
First:  Give your child Albuterol, 2-4 puffs or 1 nebulizer-- 1-3 times in first hour
Next:  If signs of asthma return, you may give: Albuterol 2-4 puffs or 1 nebulizer every 4 hours as needed.  Continue other controller medicines
Call your doctor or nurse if:  not in the green zone after 1 hour, albuterol needed more than every 4 hours or albuterol needed every 4 hours for more than one day  
Late Signs of Asthma                    
Very hard time breathing               
Trouble walking or talking            
Constant coughing                        
Use of neck and chest muscles to breathe                
Lips or fingernails blue                           
Peak Flow below 50% of best  
Action Plan
First:  Give your child Albuterol 4-6 puffs or 1 nebulizer immediately.
Next:  Call your doctor or nurse.  If you cannot reach your doctor or nurse, give albuterol 4-6 puffs or 1 nebulizer immediately. Then Go to the nearest ER or call 911
If oral steroids are prescribed for your child per the action plan by your doctor, you may give it to them also at this time.
1) St. Louis Children's Hospital Allergy, Immunology and Pulmonary Medicine
2) Breathe Easy to Keep Asthma Under Control
3) http://www.lung.org
Mythil Srinivasan, MD is a pediatric hospitalist with St. Louis Children's Hospital and Washington University School of Medicine, who also sees patients at Children's Hospital facilities at Missouri Baptist Medical Center and Progress West Hospital.


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