Identifying and Managing Asthma

Symptoms, treatment options, resources and more.

When my little sister was about 7, her room got a makeover, of sorts. No, Paige Davis from “Trading Spaces” didn’t come over or anything fun like that, but rather all her stuffed animals went into trash bags, her bookshelves were replaced with locking white storage cabinets, and her double closet doors were lined with plastic sheeting.  Her mattress and pillows were zipped into protective encasings and a giant air purifier took up residence on top of the new storage cabinets, constantly whirring. The reason? An asthma diagnosis.

Like many other children diagnosed with asthma, my sister had countless sick visits for bronchitis, double pneumonia and infections that went straight to her lungs and stayed there. We also saw a pediatric allergist, who filled her arms and back with tiny doses of allergens, and checked off the reactions against a clipboard full of reactions and severity scales. Turns out she was allergic to a host of outdoor pollens, dust, molds and pet dander. She had ‘allergic asthma,’ the most common type of asthma, which means that an allergic reaction to an environmental stimulus could and would trigger an asthmatic response. The bedroom makeover was recommended by the allergist to limit her exposure to allergens, along with weekly allergy shots.

In Tulsa, as in most cities, the majority of children with asthma are treated by their pediatrician or general family doctor. Since the first national guidelines for treating asthma were released in 1997 by the National Heart Blood and Lung Institute, asthma diagnoses have been on the rise, from 3 percent of the pediatric population to 8 percent. While earlier disease recognition and effective treatment have benefited patients with asthma, the prevalence of asthma has continued to rise since the 1980s. Many asthma experts will point to environmental issues as contributors to poor lung health.

While asthma patients come from all social sectors, race and ethnicities, families who live in poverty do tend to be diagnosed with asthma and other lung conditions more often. Environmental factors can intensify symptoms; factors include exposure to secondhand smoke, mold in housing and living closer to highways (which increases exposure to nitric oxide). Many families lack the resources to ‘makeover’ their environment, says Dr. Nancy Inhofe, a physician with the Pediatric Asthma Clinic at OU-Tulsa. While there are some grant funds available for remediation, many families cannot access those funds.

Dr. Inhofe is an associate professor of pediatrics and medical director of the Pediatric Asthma Clinic at OU Physicians Clinics on the Schusterman Campus in Tulsa. She is an Academic Generalist whose practice focuses on treating children with asthma, while advocating for the use of evidence-based treatment guidelines for long-term control of this disease. Dr. Inhofe sees patients from the OU clinic as well as those referred to her from outside healthcare providers.

Her patients regularly credit her with improving the quality of their family and child’s life, while she credits this to longer, more focused patient visits and better parent/patient education. An average pediatrician visit is 15 minutes, although many will book a double slot for asthma patients; Dr. Inhofe spends 45-60 minutes spent evaluating and counseling her asthma patients and families.

Working through the complicated condition with patients and their families requires extra time and on-going monitoring by a healthcare professional. The natural history of asthma is variable and not well understood.  Asthma is a chronic condition, like diabetes, which means that it cannot be cured, but can be managed through the use of appropriate medications and non-medicinal interventions. Some very young patients will “outgrow” their lung condition around age 6, while others may have fewer symptoms and better lung function as they reach adulthood. Patients who are no longer exposed to environmental triggers also may see symptoms improve. For example, my sister moved to a different area of the country for college and was able to taper off her regular allergy shots; many of her environmental allergic triggers were no longer a problem. However, she still uses her prescribed rescue inhaler before exercise and on an as-needed basis.

While many pediatric asthma patients are triggered by their allergies, not all children with allergies necessarily have asthma.

Symptoms of asthma include:

• shortness of breath or a feeling of not being able to get enough air
• nighttime cough
• multiple instances of “wheezy bronchitis”, persistent or recurring cough or wheeze with viral respiratory infections
• being unable to keep up with classmates during activities or sports

Asthma affects the lungs two ways. First, the function of the lungs is compromised by the body’s own immune system that causes inflammation inside the breathing tubes; the airways in the lungs become narrower due to swelling and mucus production. Second, the smooth muscle around the lungs constricts and squeezes, further impeding the function of the lungs to move air in and out of one’s body.

If your child has chronic breathing issues or suffers from lung infections on a regular basis, ask your pediatrician if asthma is a possibility. You can also take an asthma control test, like the one on the right. If your child scores a 19 or lower, ask your pediatrician to investigate.

If a child is diagnosed with asthma, educating the child and the family on monitoring the condition and using proper medication becomes part of the treatment. Nearly every patient visit with Dr. Inhofe begins with her asking patients to demonstrate their inhaler technique, so that she can see whether or not the medication is being properly administered. She insists that proper use of the inhaler (including a spacer), good posture, and correct dosage are essential to treating the patient’s asthma.

Patient education can also include a detailed explanation of the roles of the different medications, the importance of adherence to the medication regimen and regular follow up, symptom awareness, trigger avoidance, treating asthma flares at home and, importantly, discussion of when to go to the emergency room. Each visit concludes with an individualized written home management plan. The home management plan functions on a familiar “Green light/Yellow light/Red light” scale and includes bullet points of how the child should feel or symptoms associated with each “zone” as well as treatment actions.

Dr. Inhofe has also developed a “low literacy” version of the home management plan, which relies more on visual communication. For example, using a smiley or frown-y face instead of “green” or “yellow” zones. It has color pictures of the child’s inhalers and which spacer type should be used with every dose of inhaled medicine at morning and/or night. The goal is to clarify and simplify instructions.

While patients’ correct use of medications is key, Dr. Inhofe also strongly advocates for the use of national guidelines in the treatment of asthma. These guidelines are expert-supported and evidence-based on wide-scale studies. Following national guidelines can be irksome for many general practitioners, because they are admittedly complicated. The complexity is really about the time needed to correctly grade the severity or control of the asthma, prescribe appropriate medications, teach inhaler with spacer technique and provide education on the roles of each medication. However, much like her development of a “low literacy” asthma management plan, Dr. Inhofe is also developing a “decision support” template to help her colleagues and students make quicker and more specific asthma diagnoses.

A quick reference template based on guidelines from the National Heart Lung and Blood Institute and recent updates from GINA, give the health care provider recommended treatments based on the impairment and risk from asthma for each individual. This could mean that patients with persistent asthma will receive daily controller medications sooner.

To Learn More…

The American Lung Association: www.lung.org

The Center for Disease Control: www.cdc.gov/asthma