How to Deal with “Sensitive Lungs”
While the majority of coughs stems from a viral upper respiratory infection and will get better with time, a chronic cough shouldn't be overlooked. We never want to over-diagnose asthma, but we don’t want to miss it either. Doctors will make an asthma diagnosis based on family history, present illnesses, physical examinations, and sometimes laboratory data and ancillary tests. Doctors have become cautious about labeling very young children, so other terms such as reactive airways, wheezy bronchitis or sensitive lungs may be used instead of asthma.
Asthma is a type of sensitivity. A child with asthma has hyper-reactive airways, meaning that certain stimuli (dust, cigarette smoke, mold, cats, cockroaches, etc.) will trigger a reaction in the lungs. We've known for a while now that the reaction involves a constriction of the lung’s bronchioles, or small airways, causing children to feel a tightening of their chest and to have difficulty breathing. But there is also an inflammatory component to asthma, and this contributes greatly to the disease process.
Certain conditions run together, and people with asthma will often also have dry skin, eczema, and/or allergies. Sometimes a baby will develop all three at an early age. Researchers are investigating ways to prevent what’s called the “atopic march." Perhaps in the near future we will be able to prevent asthma from developing in a child with a strong family history of it, if he is already showing signs of eczema and allergies.
Testing for Asthma
When evaluating a child for asthma, family history is important, as the condition often (but not always) runs in the family. But a physical exam is even more important, since doctors need to listen for wheezing in the lower airways. Sometimes, however, you can have a normal lung exam and still have asthma. Conversely, a young child (usually less than 1 year old) can have certain viruses that cause wheezing, so not all wheezing indicates asthma.
There are tests for asthma such as spirometry or pulmonary function tests, but these tests require effort from your child, so it usually can’t be performed until he is at least 5 years old. For the younger child, the doctor will make a clinical diagnosis based on whether his cough is tight, non-productive or lingering. Other signs of asthma include a night-time dry cough, or coughing with exercise. Sometimes the best diagnostic tool is the child’s response to medicine, as Albuterol or steroids will not help conditions other than tight or sensitive lungs. If a child gets a wheeze or a tight cough with almost every cold, and his condition does improve with asthma medication, that is often the diagnosis of asthma in a young child.
Other common causes of a chronic cough include sinusitis, post-nasal drip, viruses (one cold after another), pertussis (whooping cough), walking pneumonia and acid reflux. It is normal for a common cold to leave behind a mild cough for up to 14 days, but if your child is suffering with a cough for more than 2 weeks, he should be re-evaluated. Sometimes an x-ray may be necessary. A pediatric pulmonologist can often be of value, but your pediatrician may save that referral for a child who doesn’t get better with medication, or whose asthma is so severe that he often ends up in the hospital or ICU.
Treatment
Asthma is treated with bronchodilators, or medication that opens up the lungs. Albuterol is the most common, (also called Proventil, Ventolin, Proair, Maxair) and is inhaled by the child from a pump or nebulizer machine. For young children, the pump needs to be used in conjunction with a spacer device to help get the medicine to the lungs. The nebulizer can be used at any age, but takes about 15 minutes to set up and administer, and will need to be cleaned. This medication should only be used as necessary. It is a fast-acting medicine that leaves the body in a few hours, so it needs to be given frequently during an asthma attack.
For children that have only mild asthma, Albuterol is all they need. If symptoms show up very often, however, you need to speak with your doctor about using a prevention medicine. Asthma really shouldn’t limit your child’s activities. If your child can’t exercise normally, can’t sleep without coughing, or starts coughing or wheezing with every single cold or weather change, it is best to use a prevention medicine. Although asthma does involve tight lungs, the more important component is inflammation. When there is a lot of inflammation in the lungs, the lungs have no reserve, and the airways become really narrowed. Albuterol will open the lungs a bit, but it can’t clean them out. Only an anti-inflammatory medicine, taken every day, can clean out the lungs.
Medicines that are anti-inflammatory include Singulair (a mild medicine that is not a steroid and can actually help with allergies as well) and steroid-based medicines such as Pulmicort (budesonide), Flovent (fluticasone), and Advair (a combination of Flovent and a long-acting Albuterol). Scientific studies show that only a trace amount of steroid medicine is absorbed into a child’s system if the pump or nebulizer is used correctly; your doctor can discuss with you the risks and benefits of each medicine. No one likes the idea of using a steroid medicine, but there are severe side effects to not treating asthma, including emergency room visits, your child suffering, and the necessity of a stronger oral steroid, which has more potential side effects. There are different doses of steroid medicines, and your doctor’s goal will be to find the least amount of steroid that adequately controls your child’s symptoms. Often we will fine-tune the dose to decrease during the warmer months and increase during the wintertime, when there are more cold viruses floating around.
Cold medicines, including Robitussin, Dimetap, Sudafed and Triaminic, as well as homeopathic medicines, are not proven to be effective for asthma, and you run the risk of encountering side effects or overdose, so stay away from these medicines. Also keep away from mold, cigarette smoke, dust, allergens, and children who are sick. Avoid dust mites by limiting your child’s exposure to stuffed animals, and use special covers for his mattress and pillow case. Above all, watch your child’s symptoms carefully.
What To Do When Athsma Attacks
It is safe to give Albuterol every 4 hours on the first day of the attack, which adds up to 6 times that day. If you feel your child needs more medicine than that, it may be time to see a doctor. We try to space out the Albuterol depending on the response of the child – so perhaps we’ll recommend using it every 4 hours the first day, every 6 hours the second day, and every 8 hours the third and fourth day, and hopefully by day 5 or 6 the attack is over. But each child and each attack is different, so watch his breathing as well as his response to medication.
For those who are on preventative medicines, those medications must be used every day. The doctor may advise increasing the dosage during an asthma attack. So if your child uses Pulmicort once a day every day, but a cold starts, it would be ok to use it twice a day until the cold is better and symptoms decrease. If your child gets two puffs of Flovent twice a day and an attack starts, or a cold is causing a bad cough, he may go to three puffs twice a day for 3 to 5 days. You’ll work all this out with your doctor and create an asthma action plan that will address what to do as the coughing or breathing gets worse.
Many other conditions such as bronchitis, sinusitis or pneumonia can mimic asthma, and those conditions require antibiotics. In addition, there are times where your child will need to get an x-ray or have his oxygen measured, so any real respiratory distress – fast, labored breathing that uses the chest muscles – means going to the doctor. Of course, it should be your primary care pediatrician whenever possible. (At our practice, the doctors are available 8:30 a.m. to 6 p.m. during the week, and on-site urgent care is available until 9 p.m. on weekdays and from 9 a.m. to 5 p.m. on weekends.) But if an emergency takes place after hours, it will be necessary to go to the emergency room. No one likes going to the ER, but asthma can get worse very quickly. Children can even die from asthma attacks, so don’t take labored breathing lightly. It is totally appropriate to utilize 911 or call for an ambulance if a child is breathing hard and not responding to medication.
Asthma is different in every child. Most children will outgrow their asthma, but this may not happen until he is a teenager. Some cases will remain mild and never require preventative medicines, but others will worsen, particularly during the first few winters of life. It is extremely important to keep track of all of your child’s asthma symptoms and to follow your pediatrician’s individualized asthma treatment plan. Together, we can make sure your kid lives his life to the fullest and never feel limited by sensitive lungs.