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Ongoing Asthma Symptoms

It's important to consider how a flare unfolds. At the very beginning, symptoms may appear to be very mild and remain so for a day or two before more serious problems appear. Typically, peak flow rates will begin to drop at the same time that symptoms increase. Sometimes the very first sign that a flare might begin is the appearance of a common cold or upper respiratory tract symptoms, such as runny nose, nasal congestion, or fever. Be aware, however, that not every cold virus will trigger an asthma flare. Also remember that as a child gets older, cold symptoms can be very mild or absent, even though a virus has infected the respiratory tract and will trigger a new asthma flare. In this case, the presence of nasal symptoms is not a useful clue.
When an asthma flare becomes severe, virtually all children will have either a cough or other lung-specific symptoms (such as wheezing) late at night usually after midnight. These nighttime symptoms can last for one or two nights in milder flares or much longer with severe flares. And as a new flare begins to get better, coughing and other symptoms during this midnight-to-6-A.M. time frame begin to disappear. This decrease should reassure you that a flare is changing for the better, and the medicine plan is working. If symptoms don't improve during this time frame, look at your plan again. More medicine and perhaps monitoring may be indicated, so let your doctor or nurse practitioner know of your concern.
Parents and children are often confused and frightened when symptoms reach their fullest expression late at night. Why do symptoms get worse after midnight or in the early morning hours? An asthma flare rep-resents increased inflammation in the lungs.

Protective mechanisms against inflammation decrease. Blood levels of cortisol and adrenaline decrease during this time, allowing inflammation to increase. Another reason that symptoms flare is the tendency of the lungs' airways to be "twitchy" or tighten easily. This is called "airway hyper-reactivity." Simple things like laughing or crying hard, running and playing or breathing cold air make a child cough, get short of breath, wheeze, or have chest tightness or pain. If there is enough closure of the airway, this obstruction causes more severe shortness of breath. This "twitchiness" is the first symptom to appear with a new flare and the last to leave. In fact, with any asthma flare, an increase in lung twitchiness can last for days or even weeks. A child who is completely well between cold virus—triggered flares might have the tendency to cough easily for a prolonged time after a flare. After nighttime cough is gone, the child usually begins an increase in daytime activity like play-ing outside. When he comes in for dinner, he might cough all evening before midnight. It might seem that a new flare is starting, but after mid-night there are no symptoms. In this common situation, a child needs only some quick-relief medicine before bedtime. If no new symptoms occur after midnight, a new flare is not beginning. This youngster only has a temporary increase in "twitchiness" from his last flare. Increased production of mucus by the lungs is another reason that symptoms occur during asthma flares. This happens at the beginning of a flare, but the excess mucus will not flow up the bronchial tree very well until the severe tightening of the airways begins to decrease. When the flare is at its height, a child may cough as though he wants to get some-thing out of his chest, but nothing may come up. Later when the airways are more open, or after a bronchodilator treatment opens them farther, mucus begins to travel upward more easily. This may cause cough in itself Thick mucus secretions need forceful coughs to move upward through narrow passageways. Often a treatment with albuterol or other bronchodilator may increase the cough because lung secretions are loos-ened. This is to be expected and should not be a cause for alarm unless the cough and choking is not relieved within a brief period of time. After night coughing diminishes, airways are typically more open,
and coughs caused by "loose" secretions of mucus become more promi-nent. Coughing usually occurs upon waking in the morning, and a "loose" cough appears during the day. This pattern should not be con-fused with mucus made in the nose or postnasal drip because the lungs make their own mucus. Typically, the period of time when a child shows symptoms from increased airway mucus will end before the extra twitchiness does.
At best, no signs such as nighttime cough or increased mucus should be present between flares. If symptoms begin and quick-relief medicines are needed, a new flare likely has begun, and your management plan should be started. Remember that any child who has daily symptoms of severe persistent asthma will have trouble detecting the start of a new flare. These children have most symptoms on a daily basis, including night cough. Their symptoms don't turn on and off, and therefore these children have significant difficulty knowing when to begin their manage-ment plans. For these youngsters to successfully manage their asthma, daily symptoms (especially the nighttime symptoms) need to be reduced by adjusting daily controller medicines and environmental controls.
     "" When Caryn woke up the next morning, she seemed a little better. She said she felt fine and was eager to go to school because her class was having a special art program that afternoon. Caryn only coughed once or twice during breakfast, so her parents—needing to rush to work themselves—sent her off to meet the school bus and forgot about calling the pediatrician. That night Caryn woke up coughing hard at four o'clock. She went to her parents' room and told them she was having a lot of trouble breathing. The scared look on her face alarmed her parents. They dialed the pediatrician's number, got the answering service, and explained that they thought this could be an emergency.When the doctor called back a few minutes later, she asked Caryn's mother about the symptoms—what they were, how long they'd lasted—and asked if Caryn had begun her asthma management plan for flares. Her mother immediately realized that she hadn't even thought "asthma." She'd been assuming all along that this was just a cold! The pediatrician told her to give Caryn albuterol immediately for quick relief and to increase the dose of Flo vent, the inhaled corticosteroid specified in Caryn's asthma management plan, and to continue using this anti-inflammatory medicine for the next five to seven days. The pediatrician called back a few days later to see how Caryn was doing. The albuterol had helped, she'd started the increased dose of Flo vent, but she still had some nighttime coughing for two more nights, so her parents had decided to keep her home from school for two days.The doctor reminded her mother that Caryn was close to needing a course of oral steroids and told her to review Caryn's asthma management plan and immediately take action when symptoms arise or change in the future. Caryn's mother said she was embarrassed that she hadn't linked her daughter's recent symptoms to asthma. "It's easy to overlook," the doctor replied, "because Caryn's asthma has been under good control for months. But the key is to recognize symptoms quickly and notice any changes in symptom patterns because they can signal the beginning of a flare. Even symptoms of a cold can be asthma triggers, and you want to take control sooner rather than later? ""

Managing an Asthma Flare

One of the characteristics of asthma is that it changes over time, sometimes unexpectedly. Every child with disease has some episodes of increased symptoms. The overall pattern of symptoms—how consistently she is at her best and how often flares occur—will determine the type of treatment plan prescribed. Children with persistent or daily symptoms and those with frequent flares need daily controller medicines. But all children with asthma, even those who don't take daily medicines, To use the plan properly, the family and child must know when to start it. New flares can begin at any time and in unpredictable ways. But all new flares can be recognized at their very beginning. As a parent, you can best help your child through a flare by being prepared and staying calm. Use your child's asthma management plan and your own understanding of your child to give him the appropriate medicines right away and get her to her doctor or an emergency room if necessary. A major reason children with asthma end up in the hospital is because a flare has gone on for too long. Learn to recognize the warning signs of a flare and act immediately to treat them.
Caryn is an active seven-year-old with ten-year-old twin brothers. She always seems to be in motion—dancing to CD's, taking ballet lessons, running around outside with her neighborhood friends. Since Caryn's asthma was diagnosed two years ago, her parents have seen that she takes her controller medicine twice a day.She needs a plan to manage Asthma flares. She very rarely has asthma symptoms, but when they do appear she uses her albuterol inhaler for quick relief. Caryn caught a cold in early January. Her nose ran, she sneezed and coughed occasionally, but her parents didn't think it necessary to keep her home from school. Caryn seemed otherwise normal she teased her brothers, ran away from them when they dished it back, and occasionally got into a fairly friendly wrestling match with one or both of them.
A few days into the cold, Caryn's parents heard her coughing more often, especially after laughing with her brothers. And she seemed more tired than usual. Instead of actively playing, she lolled on the sofa and watched TV. Caryn's parents heard her coughing in the middle of the night, but she didn't wake up. When they heard the coughing, they assumed it was another symptom of her cold, that it had moved from her head to her chest and was perhaps bronchitis. "Maybe we should call the pediatrician tomorrow," they thought.

A basic definition of a flare is any worsening of asthma symptoms. In the simplest terms, mild increases in symptoms need less medicine than severe or prolonged symptoms. In general, if your child needs more than one dose of albuterol or quick-relief medicine in a day, a new flare may be starting. A sure sign that a flare has started is when symptoms such as night cough (after midnight) are present. As discussed in former article did you read that?, the family and child can use either "symptom recognition" or peak flow monitoring to detect the beginning of a new flare. Each is effective, but symptom recognition is most commonly used. Whether mild or severe, worsening symptoms means that inflammation is increasing in the lungs. The more rapidly symptoms rise or the more severe they become, the greater the increase in inflammation. Therefore, for any level of severity, increased doses of anti-inflammatory or controller medicine should be given. Detecting a new flare is easy in a child who is under good control and has no daily symptoms and normal lung function. The start of symptoms such as cough, wheezing, shortness of breath, chest pain or tightness usually tells us that control is slipping and a flare may be starting. Another sign may be your child's decreased activity or need for quick-relief medicine such as albuterol.
Many parents find it helpful to think about their child's previous flares in order to identify which symptoms indicate that a flare is beginning. For example, have past flares usually been triggered by a cold virus? The trigger may not be a single symptom; it's also important to know what mixture of symptoms your child commonly has in a flare. Most children cough a lot when asthma worsens. This is hard to miss. Some children only cough a little at the start of a flare, unless their flare is severe. For these children, flares may be characterized by shortness of breath, chest pain, wheezing, or decreased activity. Children with less obvious symptoms may get worse without their parents noticing, unless they have learned to recognize the typical pattern of symptoms for their child. Some children may wheeze infrequently or rarely. In these youngsters, obviously, wheezing cannot be used to detect a flare. But most children will have a mixture of symptoms including cough, shortness of breath, chest pain or tightness, wheeze and/or fatigue. And parents can learn to remember this typical "snapshot" of their child when she has worsening symptoms. It is very helpful for parents to discuss this picture with their child's asthma caregiver. In this way, everyone will learn more about the child's disease, and symptom recognition will get better and better over time.Parents should also remember how their child tends to handle her symptoms. Most children cannot hold back their symptoms, but some will attempt to hide them because they want to please their parents or not make them worry. A child who conceals or denies symptoms can delay the detection of a new flare unless peak flows are monitored on a regular basis. Obviously, other circumstances can interfere with recognition of symptoms, such as separation of parent and child during work or school hours.

A typical diary of Asthma Symptoms

If a child can breathe out. If her airways are starting to swell and tighten with asthma flare, the peak flow reading will drop.Tt is not for every-one. Children younger than age five or six usually can't use it. An adult should supervise the use of a peak flow meter until the child is fourteen to sixteen years old. Peak flow meters are inexpensive and available without a prescription at any pharmacy. Ask your doctor or nurse practitioner which type is best for your child. To keep the readings consistent, stick with the same brand when you buy a new one. For younger children with smaller lung capacity, you may want to choose a low-range model instead of the regular adult kind. Young children have lower peak flow readings than older, taller children. Because young children can't blow very hard, their numbers may barely move on an adult type of peak flow model. If they can't see their numbers moving up, young children sometimes feel discouraged about their readings. A low-range meter is not only more accurate and age-appropriate for smaller children, it will also give them more positive reinforcement as they see their numbers rise. 

The peak flow meter measures your child's peak expiratory flow rate (PEFR), or how much air flows out of her lungs as she breathes out forcefully. Think of it as a thermometer for the lungs. Just as a thermometer tells you if your child has a fever and how high it is, a peak flow meter tells you if her airways are starting to close down and by how much. Learning to use the peak flow meter takes a little practice. To get an accurate reading, have your child follow these seven steps: 

1. Hold the peak flow meter by the handle and set the pointer to zero. Be sure your child's fingers don't block the pointer or the hole in the back of some meters because this will give an inaccurate reading. 
2.  Stand up straight. 
3. Take a really deep breath and fill the lungs with as much air as they will hold. 
4. Put the mouthpiece in the mouth, and breathe out through the mouth as hard and fast as possible. The goal is a fast blast, not a slow blow. Make sure your child doesn't cough or spit into the meter because this will make the reading higher than it really is. Your child needs to give her best effort. If she doesn't breathe in as deep as possible and blow out as hard as possible, the reading will be lower than it should be.  
5. Look at the scale on the meter to see where the pointer has stopped. Write down the number.
6. Repeat the process twice and reset the pointer to zero each time. If your child has learned how to use the meter properly, the numbers on the scale from all her tries should be fairly close together. If they're not, she probably needs to practice the technique a bit more.
7. Write down the highest number of all her tries. Don't average all the readings together. The highest number is your child's personal best peak flow for that day.

Although the peak flow meter is a valuable tool for asthma management, No matter how often you check peak flow readings, keep an ongoing written record of them. A simple piece of paper with the date, time of day, and peak flow reading is all you really need. If you can make a note of any other information about your child's health at the time of the reading, that's even better. If the peak flow reading is low, for example, and your child also has a cold or was visiting a friend with a cat, that information helps explain the reading. Peak flows and any other infor-mation you can provide will be very helpful to you and the doctor as a way to determine how well your child's asthma is under control. It will also help you track down asthma triggers and help your child understand why she should avoid them.

Understanding the Peak Flow Numbers Once a child has mastered the peak flow meter, it's time to find her personal best reading. This is the number that will be her benchmark, the one you compare all other readings with in order to see if they're below normal. To find your child's personal best reading, start on a day when she's feeling well and her asthma is under good control. Take three good readings and find the personal best number in the morning before she takes her everyday controller medicine. Repeat the process each day at the same time for two to three weeks. The best numbers from each reading should be fairly close together. If they are, take the best number over the whole period and use that as your child's personal best. As your child grows, her personal best peak flow number should rise along with her increasing lung size. Redo the personal best readings every six months or whenever your physician or nurse practitioner recommends it to keep the number accurate and in tune with her growing size. Every peak flow meter comes with a table that tells the normal values for that meter. In other words, the table lists what a normal reading on that particular brand of peak flow meter should be for an imaginary average child of your child's height. Don't worry if your child's personal best peak flow isn't the same as the average given by the meter manufacturer or in the table on the following page.
Doctors have used these readings to develop a color-coded peak flow zone system modeled after a traffic light similar to the one for symptom recognition (see former article). Here's how it works: 

• Green zone-Go! Your child is taking everyday controller medicine and doing well, with no cough, wheeze, shortness of breath, or chest tightness. He sleeps through the night and his activity is normal. His peak flow meter reading is 80 percent or more of his personal best.

• Yellow zone-Caution! Your child's asthma is getting worse, even though he's been taking his everyday medicine. His airways are start-ing to narrow. He's coughing, wheezing, and short of breath; asthma symptoms are waking him up at night; and he's not as active as usual. An asthma flare might be starting. His peak flow meter reading is 50 percent to 80 percent of his personal best.

• Red zone-Medical alert! The quick-relief medicine isn't helping, or the asthma is getting worse. Your child is having an asthma flare. He's very short of breath, wheezing and coughing a lot, and his peak flow meter reading is 50 percent or less of his personal best.

Is it Necessary to Start Extra Asthma Medicines?

When your child has some coughing, wheezing, or shortness of breath, it is time to give her albuterol, the quick-relief medicine. If she needs to use albuterol more than two times in one day, it is time to move to the next step in the management plan. When a child has a cold or asthma flare for any other reason (such as coming in contact with a neighbor's pet or visiting a home where a smoker lives), she will also develop more symptoms and need quick-relief medicine. Whether a child needs quick-relief medicines two times in a day for a cold or any other reason, an asthma flare is starting, and it's time to move to the next step in the management plan albuterol and extra inhaled corticosteroids.
Monitoring Symptoms and Recognizing When A Flare Is Starting For asthma control to be ideal, it is important to recognize changes in symptoms.
Your careful observations will help determine whether your child's asthma is becoming better or worse. Symptoms vary from child to child and may include coughing, wheezing, shortness of breath, rapid breathing, difficulty catching his breath, chest pain, or increased mucus in the chest. These symptoms may appear alone or in combination with one another. You can monitor symptoms in two basic ways: by recognizing and tracking symptoms as they appear or by measuring breathing with a peak flow meter. The National Institutes of Health recognizes both methods as accurate. The choice depends on the child, family, and physi-cian or nurse practitioner to determine what is best.

Asthma Day to Day

Will this disease necessarily keep children from climbing on jungle gyms, riding bikes, skateboarding, swimming, dancing, and doing all the other things that youngsters want to do? No. With proper medicine and recognition of symptoms, children with asthma should have no symptoms, no missed school days, and no restrictions on their activities. If you or your child don't quite believe that, take a look at the Olympic gold medalists, professional athletes, Oscar-winning actors, doctors, and even presidents of the United States who have this disease (for example, Charles Dickens, John F. Kennedy, Kristi Yamaguchi, Sharon Stone, and Ricki Lake; see Resources for a long list of famous people with that disease). A "normal life" with this disease means children should have no cough-ing, wheezing, shortness of breath, or chest pain during the day or night. They should be able to participate in activities without limitation. Flares should be rare when that disease is properly controlled, as discussed in former article. Minimal side effects from medicine are another important goal of good asthma care. Children should grow to normal adulthood without any lifelong side effects or disabilities. It's important, therefore, to work with your physician to make sure that your child is on the right medi-cines. Your mutual goal is for your child to lead a normal life, so proper medicine is necessary to prevent, control, and treat symptoms. The med-icines should not be too many or too few. Identifying triggers that set off symptoms is another essential ingre-dient in preventing flares and assuring a normal life for children with this disease. These triggers include various allergens such as pet dander, dust, pollen, and viral infections. Some triggers are easier to avoid or eliminate than others. Viral infection is the most common trigger in young children and nearly impossible to avoid. But an annual influenza vaccination (a flu shot) will help prevent asthma flares from the flu virus.

If your child's physician or nurse practitioner hasn't already helped you make a written asthma management plan, be sure to ask about one at your next appointment. Your child's plan should detail a specific course of action to start whenever symptoms appear. Plans will vary from physician to physician and patient to patient. An asthma management plan used at The Children's Hospital of Philadelphia is included on pages 220-222 in Resources. You're encour-aged to copy it, take it to your child's doctor, and use it as a model to construct your child's individual plan. Whether you use this or any other form, a clearly written asthma management plan should contain the fol-lowing components that are tailored to your own child:

• A list of everyday controller medicines, with instructions about which medicines to give, how much, and how often;

• Your child's "personal best" reading if he or she uses a peak flow meter;

• Instructions for using an inhaler when breathing becomes trouble-some during exercise or sports, how many puffs to take and when to take them (usually fifteen to thirty minutes before exercise)

• Instructions about what to do when symptoms start, which quick-relief medicine to use, how many puffs to inhale and how often,or what medicine to give by nebulizer and how often;

• Instructions about what to do when a flare starts, with a range of peak flow meter readings during a flare; Instructions about when to give extra anti-inflammatory medicine, name of the specific medicine, how many days to continue giving it, and number of times per day;

• An emergency section: what to do if symptoms get worse, name and number of physician to call, when to call 911 or go to an emergency room.

An asthma management plan has three levels. Think of it as a ladder. You move up a level or step as symptoms become more serious or fre-quent. Doctors have developed a color-coded system modeled after a traffic light to represent the three levels of severity:

1. Green Go! The first level is the everyday plan the daily con-troller medicines your child takes to keep asthma symptoms away even when she's feeling well.
   
2. Yellow—Caution! Move to the second level when symptoms appear (coughing, wheezing, or chest tightness). This level includes use of the quick-relief medicines (usually albuterol) that your child needs right away to get the symptoms back under con-trol and usually includes increasing the dose of inhaled cortico-steroids or adding an oral corticosteroid.
   
3.  Red—Medical Alert! The third level is more serious. It is used when symptoms continue or get worse. This part of the asthma management plan helps you decide how much more quick-relief medicine to give and if your child needs to see the doctor or go to the emergency room.

The key to asthma control is finding the right controller medicine. Controller medicines must be taken every day, although for some chil-dren they sometimes can be stopped in certain seasons. But don't stop the medicine without first checking with your child's physician or nurse practitioner.

Care Of Asthma Devices

Caring for asthma devices as important as using them in the correct way. In general, these devices require very little care. Peak flow meters can be washed monthly with soapy water.
A spacer is easy to care for if you simply follow the directions that come with it. Most spacers need to be washed with dish washing soap to remove medicine residue, then rinsed and allowed to air-dry once a week. Whenever you wash your child's spacer, make sure that none of the plastic or rubber, such as the valve or ring where the MDI fits into the spacer, are dried out or cracked. If they are, replace the spacer. Keep the caps on MDI spacers to keep out any tiny foreign particles that could be inhaled. Nebulizers have to be cleaned properly. The air compressor should be wiped off with a damp cloth only. The filter needs to be replaced once a month or sooner if it becomes discolored. More filters can be ordered from the durable medical equipment company that provided you with the nebulizer. Nebulizer tubing should be changed each month. The tubing may be disposable or reusable. Tubing with a mouthpiece or mask has to be replaced. A disposable nebulizer should last a month and should be cleaned after each use. Wash the nebulizer with water and dish washing detergent, rinse it, and disinfect it by soaking it in a solution of water and vinegar. Some reusable nebulizers can be washed in the dishwasher and also need to be disinfected.It is a reusable nebulizer may last between six months to one year.
Strong Medicines at Home
It is best if all the medicine is kept together in a plastic container that is stored in a cool, dry place, and out of the reach of younger chil-dren. Some preparations of medicine have specific care concerns. Dry powder inhalers, for example, need to be in a moisture-free environment to keep the powder dry. This means that you don't want to keep DPIs in the bathroom medicine cabinet because that room tends to have a lot of moisture from baths and showers. Other areas to avoid include the base-ment, the top of the refrigerator, or near leaky faucets. If moisture causes the powder to cake, your child will probably not get a full dose of the medicine when he inhales.
Metered dose inhalers and spacers should be stored with the cap on. If not, a small object may be present in the inhaler or spacer that could get stuck in your child's airway when he inhales. Most importantly all medicines should be out of the reach of younger children (under ten years old).You need to be able to give asthma medicine using the proper device with the proper technique and know how to clean and maintain the device. You also need to teach others who care for your child how to give med-icines. The personnel at school or day care may tell you that they know how to give asthma treatments, but it doesn't always mean that they were taught correctly. In our busy lives, sometimes parents put the responsibility on chil-dren to take their own medicine because they seem old enough or smart enough to do it. Talk with your pediatrician about your child's behavior and development in order to determine how ready and able your child is to assume this job independently. As children with any chronic condi-tion grow and develop, they should begin to take on increasing respon-sibility for their own care. But even so, they will still need supervision and support from their parents. To be absolutely clear about the medicine plan for your child, you need to communicate with your child's health care professionals and ask whatever questions you may have. Both parents and professionals need to review together whether the medicine is being given correctly whether the parent is administering the medicine or the child is taking it himself.Correct use of asthma medicines and devices also requires consistent scheduling. In the hectic pace of our lives, monitoring the use of medi-cine takes some forethought and planning. 
To keep your child's asthma under control, he needs to take his asthma and allergy medicines regu-larly. Medicines will help most if they're taken correctly at about the same time every day. Many families find that setting up a regular routine helps them remember to give the medicine to a young child. It also helps older children and teens who can take their own medicine do so without a lot of reminding.A good time for taking inhaled medicines is in the morning at tooth-brushing time. This way a child can use his inhaler and then brush his teeth. This assures that he takes his medicine and rinses away any residue that might still be in his mouth—and it ensures that he brushes his teeth as well. Sometimes older children like to keep it at their bed-side to take as soon as they wake up and before going to sleep. Encour-age your child to find a system that works best for him. For children who need medicine more than once a day, try to sched-ule the later doses around something that happens regularly. Some do well with a routine that has them take another dose when they get home from school in the late afternoon. It's easy to remember, and it saves the embarrassment that some feel when they need to use their inhaler or take other medicine in front of their friends and classmates. Peak flow readings are best taken first thing in the morning and again in the early evening. If your child uses an everyday bronchodilator drug such as salmeterol (Serevent), he should check his peak flow before he takes the medicine for asthma.
What are appropriate responsibilities for children in managing their medicines? In general, medicines should be kept out of reach of children until they can understand dangers of taking medicines inappropriately. For most children, this is age ten. Even though we want older children to begin to take responsibility for their medicines, they still need to be monitored by parents. It is recommended that most children be given their medicines by their parents until they are at least eleven years old. Of course, you know your child best and may want to wait until he is even older. After a child has been given this responsibility, parents should still make sure that they check the medicines each month to mon-itor their appropriate use.

Nebulizers Of Asthma

A nebulizer is a machine of asthma that uses an air compressor to mix liquid medicine with air and form a mist that is inhaled through a mouthpiece
or face mask. (Technically, the "machine" part is the air compressor, and the "nebulizer" is the tubing with medicine cup. "Nebulizer" is used here in its broader, more common meaning as the whole device.) When children are first diagnosed with asthma, many times they are treated using a nebulizer. After this initial experience, parents may think that a nebulizer is the most preferred way to administer medi-cine. Nebulizers are just one way to give asthma medicines. Other devices may be more effective and less cumbersome. While many parents and even some health care professionals think that the nebulizer is the best way to give asthma medicine, research has not shown that to be true. Many children, especially infants and tod-dlers, don't seem to improve on a nebulizer because their caretakers have not been taught the proper technique for giving a nebulizer treat-ment. Proper technique is just as important when medicine is given by nebulizer as it is when given by an MDI/spacer or a DPI.
Sometimes parents observe incorrect techniques for nebulizer treatments administered by the "blow-by method," which is holding the tube, with mist coming out of it, in the child's face. This technique is often used when a child won't cooperate by wearing a mask or is too young to use a mouthpiece. The main problem with the blow-by method is that very little medicine gets down deep into the lungs where it is needed, and most of the medicine is wasted. When a mouthpiece or face mask is used with a nebulizer, it's important to be sure that your child takes slow, deep breaths and holds each breath for five to ten seconds before inhaling the next breath. If a child is allowed to breathe normally during the nebulizer treatment, the medicine won't get into the airways effectively. Another problem with using a nebulizer for an infant or toddler is that, while you may get him to wear the face mask, he is also crying and taking fast, shallow breaths rather than the proper deep, slower breaths. (See chapter 12 for more about infants and toddlers.)
Even when the proper technique is used, nebulizer treatments take about ten minutes or longer. Another drawback is that a nebulizer is not easily portable. This is an important issue because families are constantly on the go, and children may need to take medicine at day.
controller medicines. If a child uses Advair, for example, she would also have to be able to take quick-relief medicine by MDI with a spacer or nebulizer (discussed later in this chapter). The Diskus comes with a dose counter. Another controller medicine, budesonide, is an inhaled cortico-steroid that comes in two forms: Turbuhaler is a dry powder, and Respules are a liquid solution for a nebulizer. If a child is on the Pulmi-cort Turbuhaler, she'll need to take her quick-relief medicine (albuterol) by MDI/spacer or nebulizer. The Turbuhaler has an indicator to let you know when it's running empty. A third DPI device is the Aerolizer that contains formoterol (Foradil), which is similar to salmeterol. Both formoterol and salmeterol are long-term controller medicines, but they are not anti-inflammatory medi-cines. If formoterol or salmeterol is prescribed for your child, she will also need both an anti-inflammatory medicine and a quick-relief medi-cine. The Aerolizer is loaded with a one-dose capsule for each use so it's easy to check that the whole dose has been taken. When you discard the capsule after taking the dose, you can see whether or not the capsule is empty.
It's important to understand that there may be variations in how different DPIs are used. For example, the Pulmicort device is twisted one way, then the other. With Advair, the device is opened and then a lever is pulled. For both of these, a child must breathe in quickly and deeply once the tablet is crushed, and the medicine is deposited into his lungs. Advair has a slightly sweet taste, and Pulmicort does not. Often par-ents of children taking Pulmicort worry that their children aren't getting the medicine because they cannot taste anything. Your physician or .nurse practitioner can assess whether your child is capable of inhaling deeply enough to draw the powder into her lungs. These devices are very easy to use, and they have counters that tell how many doses are left.

Medicine the Right Way of Asthma

Asthma medicines come in several different forms. When you think of medicine, you probably think of liquids or pills, but only a few asthma medicines are taken by mouth. Asthma is best treated by inhaled medicine because it goes directly where it needs to work—the lungs—rather than into the intestinal tract, the bloodstream, and throughout the whole body. This chapter focuses on the correct ways to use inhaled medicines and the proper methods of taking care of them. One of the most important issues in controlling asthma is matching the treatment to the individual child. That means not only giving the most appropriate medicine, but also being sure its delivery device is used the right way for it to work effectively.
Treatment for asthma comes primarily in three types of inhaled midi-cines: metered dose inhalers (MDIs), dry powder inhalers (DPIs), and neutralizers.

MDIs have been used for Asthma medicines and other lung diseases for several decades. These small, plastic, handheld devices contain medicine in an aerosol canister. When sprayed, the inhaler expels an exact, measured dose of medicine either a controller or a quick relief type. The MDI container also contains a chemical propellant that delivers the medicine very fast. If you've ever put an MDI in your mouth and sprayed it, you have felt a wet, cold spray in your mouth and throat. But the problem with feeling that spray is that the medicine landed in your mouth and throat instead of going deep down your windpipe and into the lungs where it needs to work. In the past, many children used an MDI by itself, but today it is highly recommended that a spacer be added to the MDI for a more effective treatment. A spacer—also called a "holding chamber"—holds and slows down the spray so a child can inhale a slower, deeper breath. When a child uses a spacer with a one-way valve, he can't exhale air into the spacer, so he's able to inhale all the medicine deep into his lungs. (Other kinds, without a one-way valve are available, but the one-way valve type is preferable.) He will not feel a wet cold spray in his mouth. When using a spacer with an MDI, a child should be reminded to take a slow, deep breath and hold it for ten seconds.

 A number of different brands of spacers are on the market. They require a prescription, and prices vary. Most brands have a mouthpiece that adults, teenagers, and children as young as five or six years old can use correctly and consistently. Spacers are also made with a face mask for babies and toddlers. Many children, particularly those with mild asthma, have been using MDIs without spacers for some time. They and their parents may assume that the MDI alone is enough, but it can present problems, as this fifteen-year-old discovered: David had been taking Flovent 44 as his controller medicine without a spacer for over two years. He used it when he was supposed to,
every morning and every night, but he still had symptoms during colds and exercise. When his nurse practitioner asked David how he knows when the inhaler is empty and how often he refills it, David said that he asks his mother for a refill whenever the inhaler feels empty and no spray comes out. The nurse explained that David's par-ticular MDI comes with 120 "actuations" (individual doses of med-icine). That means that if David takes four puffs a day (two puffs twice a day) for thirty days, one Flovent MDI should last a month. The nurse practitioner also urged David to get a new MDI every month even if he still feels liquid in the canister and sees spray come out. After.120 puffs of medicine have been taken, there may still be some liquid (preservative and propellant) in the canister. It may not "feel empty," but it contains no medicine. 

Not all medicines that come as MDIs contain 120 doses per canister or are priescribed for four puffs a day. Be sure you understand how often your child is supposed to use the MDI/spacer and check the individual canister for its number of total doses. Sometimes parents worry that older children, who are allowed to monitor their own medicine, are taking it too often or too little. A rule of thumb to remember is that quick-relief medicine, such as albuterol dispensed as an MDI, should contain 200 doses. If a child's asthma is well controlled, a refill will be needed every six months. If your child is using more than this, or is taking albuterol twice a week or more, dis-cuss this with your child's health care professional. After David's nurse practitioner explained this, he and his mother decided to keep better track by writing down the date on the kitchen cal-endar each time he starts a new MDI—both controller and quick-relief medicines. This not only reminds them to call the pharmacy for a refill before the medicine runs out, but it also helps them both be aware of how much quick-relief medicine David is using so they can keep an eye on over-use or under-use.
Instead of increasing his dose of Flovent to 110, David's nurse prac-titioner considered two options. One was to continue the Flovent 44, but teach David how to use a spacer and explain that it will also help him get better relief by controlling airway inflammation and preventing symptoms. The second option was to switch him to a dry powder inhaler
DPIs are the newest device on the market. They deliver medicine to the airways as a dry powder. Taking medicine with a DPI is quick—it takes less than a minute to take a dose. DPIs require no special care except to keep them dry. Most children older than five years of age are able to learn the administration technique. But regardless of a child's age, par-ents still must pay attention to make sure their child performs the correct technique consistently. If your child has previously used an MDI/spacer and is just begin-ning to use a DPI, be sure she understands that the DPI is used differ-ently—she must be able to take in a fast, deep breath rather than the slow, deep breath required by an MDI/spacer. With both an MDI and DPI, a child should hold the breath for ten seconds after inhaling the puff of asthma medicine.
Since not all asthma medicines are available in the DPI form, your child needs to know the proper technique for more than one device—in other words, she'll have to become a switch-hitter and learn when and how to use at least two or maybe even three techniques for taking dif-ferent inhaled medicines. You may wonder what difference it makes whether she inhales a fast, deep breath or a slow, deep one. The answer lies simply in the fact that an MDI contains a chemical propellant that expels the spray very fast. As discussed earlier, the spacer holds the puff of medicine so, as a child slowly inhales it, the medicine is more effectively delivered deep down into her lungs. DPIs, however, do not contain a propellant. A DPI can only work and get deep down to her lower airways if she takes a fast, deep breath.

Prevention and Treatment of Asthma

Many treatments continue to be developed to fight airway inflammation found in asthma. New approaches are aimed at cells, chemicals, and antibodies responsible for allergic inflammation. Some of these involve genetically engineering antibodies to affect parts of the immune system. Some may involve injections and may be rather expensive. As a result, they may initially be indicated for individuals on high doses of corti-costeroids or those with symptoms despite traditional therapies. Other treatments are being developed to prevent or alter the natural history of asthma by introducing immune-modifying treatment of asthma in early childhood.
Despite the possible side effects of some of these medicines standard, traditional, and complementary the biggest asthma risk is the disease itself. In some children, untreated inflammation can lead to irreversible changes in the airways. Asthma is the most common cause of hospital-ization in children, and each year about 200 American children die from asthma. Even children with mild asthma are at risk for any or all these complications. Fortunately, taking medicine appropriately can minimize all the risks.
Saiboku-tois is the most popular anti-asthmatic herbal treatment used in Japanese Kampo medicines. In China, it is called chaipu-tang. It is supposed to decrease the metabolism of steroids, and it therefore increases the potency and effectiveness of inhaled steroids. It also increases the risk of side effects from inhaled steroids, but when taken by itself, it has not been found to be as effective as inhaled steroids.
Tylophora indica is an herb used commonly in the Ayurvedic system of medicine practiced in India. It is claimed to increase mucus clearing and is also recognized as a bronchodilator similar to a quick-relief med-icine like albuterol. The effectiveness of this medicine is quite variable, with helpful effects in one study and no effects in other studies. Several studies have examined high-dose vitamin C in the treatment of asthma. Similar to many herbal therapies, vitamin C's effects vary, with some studies reporting beneficial effects and other studies report-ing none.
Interestingly, many current Western medicines are based on previous complementary medicines. An old therapy for asthma, for example, was ground adrenal glands of animals. Adrenal glands have steroids and albuterol-like compounds that have similarities to the inhaled steroids and bronchodilators used today. Many herbal supplements can be safe when used appropriately, but known and potential risks of such compounds do exist. A misconception exists that herbs are safe because they come from plants. The chemical makeup of plants and herbs is sophisticated, and many are toxic. Often other medicines, such as steroids and aspirinlike medicines, are added to these herbal supplements to improve their effect and potential side-effects. Other factors can cause problems, including inconsistent dosing and drug interactions
There is also no licensing body for the practice of herbal medicine in the United States. Most herbs are marketed as dietary supplements and are not regulated by the FDA. There is no guarantee, therefore, of qual-ity or consistency. The advantage of traditional Western medicines is that they are controlled, regulated, and given in more palatable formats.

Allergy Medicines for Asbestosis and Asthma

Many children with asthma also need allergy medicine. Treating allergy symptoms in the nose has been shown to help control asthma and per-vent flares. One often-overlooked function of the nose is to warm, moisturizer, and filter the air we breathe. Some children with allergies cannot breathe through their noses so they inhale colder, drier, dirtier air through their mouths, which can aggravate their asthma. Antihistamines with or without decongestants and nasal steroids may be prescribed to control allergies. If allergies are not adequately controlled, allergy shots may be given to make your child's body less allergic.
About one of every three Americans has tried herbal medicines, acupuncture, traditional Chinese medicine, homeopathy, yoga, chiropractic manipulation, high-dose vitamins and minerals, and relaxation techniques. These types of complementary medicine, also called "alter-native" or "integrative" medicine, have not been studied and evaluated with controlled studies as rigorously as traditional Western medicines. But alternative approaches are coming into mainstream medicine. At least seventy-five medical schools—including University of Pennsylvania, Harvard, Yale, Johns Hopkins, and Columbia now offer courses in complementary medicine. Because complementary therapies have become so widely used in recent years, parents may wonder if they could help relieve their child's asthma symptoms. The following review of the most common alter native therapies is based on published studies of their merit. Chiropractic manipulation was not found to be helpful for asthma in any study. The results were more mixed for acupuncture. Five studies found that acupuncture was not beneficial, and eight studies found that it worked better than nothing. But in all studies, acupuncture didn't work as well as al buterol in treating asthma symptoms.

Yoga was studied in conjunction with standard asthma medicines, such as inhaled corticosteroids. Individuals who did yoga or relaxation therapies noted an improvement in their asthma symptoms (fewer, milder symptoms and improved lung function). Yoga did not replace standard therapies but was added to them in these studies. Many modern medicines are derived from herbal therapies. The advantage of modern medicine over herbs, however, is that potential benefits are maximized, while potential serious side effects are mini mized. One of the most common herbal therapies is Ma Huang, whose active ingredient is distantly related to albuterol, the common quick-relief medicine for asthma. Its active ingredient, L-ephedrine, is also very similar to Sudafed, an over-the-counter decongestant. High doses of ephedrine are known to have adverse effects that include high blood pressure, rapid heart rate, nervousness, headache, insomnia, dizziness, seizure, stroke, and fatal myocardial infarction (heart attack).The second most common herb used to treat asthma is Atropa bel-ladonna (deadly nightshade). 

Its active ingredient is atropine, which is similar to the active ingredient in Atrovent, a common medicine for other lung diseases. Belladonna was once burned in cigarettes, referred to as "asthma cigarettes." These primitive "inhalers" were a popular treatment for asthma and other respiratory conditions in Europe and North America in the early part of the twentieth century. Potential side effects include dry mouth, dangerously low heart rate, nausea, and headache.Ginkgo biloba is used around the world for a variety of illnesses. The main ingredients, ginkgolides, may prevent twitchy airways or cough-ing. Side effects of ginkgo include nausea, vomiting, diarrhea, saliva-tion, anorexia, headache, dizziness, ringing in the ears, and allergic reactions. No controlled studies have shown a benefit of ginkgo biloba for asthma. Licorice root is used to prevent cough and increase the clearance of mucus. Its active ingredients include glycyrrhizin, which may prolong the action of steroids. No controlled studies of licorice have been conducted for asthma in humans, so it's important to discuss with your child's physi-cian any complementary medicines you are using, particularly in the case of an herb like licorice.

Antihistamines for Asbestosis

The most popular medicines for allergies are antihistamines. As the name suggests, antihistamines counteract the swelling and other effects of histamine. They are very effective for keeping allergy symptoms from starting and for treating them when they do. The most widely used antihistamines today are called H1 receptor antagonists and are available by prescription only. They are sometimes also called second-generation antihistamines because they have taken over from the older, first-generation antihistamines that used to cause drowsiness. H1 receptor antagonists block the release of histamine and help reduce or prevent inflammation. They dry up runny noses, stop sneezing, and help prevent wheezing. Desloratadine (Clarinex), fexofe-nadine (Allegra), and cetirizine (Zyrtec) are the most commonly pre-scribed antihistamines and have been approved for children as young as two years of age. They're also long-lasting, and some are available in syrups or dissolving tablets to make dosing easier for young children. Your doctor will choose which medication to prescribe, depending on your child's age and symptoms. In 2002, a formerly prescribed H1 receptor antagonist antihistamine, loratadine (Claritin), became available as an over-the-counter medi-cine (OTC, or nonprescription). OTC antihistamines such as Actifed, Benadryl, or Tavist can relieve allergy symptoms but will probably make your child drowsy. It is best, therefore, to talk to a doctor before giving any OTC medicines to your child.

Decongestants are sometimes used in addition to nasal sprays and anti-histamines to reduce the congestion that some people have with allergic rhinitis. Nonprescription decongestants in pill or syrup form are sold separately and are also found in many nonprescription allergy formulas along with an antihistamine for asbestosis. These medicines usually contain a drug called pseudo ephedrine that can make your child irritable or hyper-active. Talk to your doctor before using any of these products. Oral nonprescription spray decongestants, such as phenylalanine (Nero-Synephrine), are safe for occasional use but shouldn't be used for more than a day or two. If they are used longer, your child's body could react with rebound congestion, which is stuffiness and/or a runny nose that are made even worse by overuse of the decongestant.
The final step in treating a child's allergies is allergen immuno therapy, better known as allergy shots. These shots work by repeatedly giving a child a very small, controlled dose of the allergens that affect him. Aller-gen immunotherapy eventually slows or even stops his reaction. Think of it as training the child's immune system to stop interpreting an alter-gen as a threat. Allergy immunotherapy is highly effective and usually reduces symptoms and the number of medicines that children need to control their symptoms of allergies and asthma. The most exciting potential benefit is that it might prevent additional allergies from developing. Children who might benefit from allergy shots:

• Have allergies all or most of the year

• Are allergic to things that can't be avoided, such as pollen

• Need to take a lot of medicines to control allergy symptoms

• Need to take medicine to treat another ongoing health problem, and those medicines are affected by allergy medicines

• Do not respond to or do not tolerate medicines

Cannot use or are unwilling to use medicines Allergy shots are not for everyone. They may have side effects because they give a child the very allergen that she is allergic to. Side effects or reactions tend to occur in the first thirty minutes after the shot. The most common side effect is a hive or rash at the site of injection.

Asthma Medicines

A century ago, people with smoked "that cigarettes" rolled from an herb called belladonna, or deadly nightshade. Modern medicine has come a long way since those early inhalers. Today a wide array of medicines is available to control and treat asbestosis effectively. But these therapies often are confusing because numerous generic and brand name medicines come in various doses and forms of delivery. Some are inhaled. Others come in pill or syrup form. To add to the confusion, your neighbor's child and your may child share virtually the same symptoms, yet different medicines have been prescribed for each child. How is a parent to understand this pharmacopoeia? This chapter reviews current medicines. Here is the essential starting point: medicines fall into two basic categories.
1. Controller medicines
2. Quick-relief medicines Doctors, nurses, and pharmaceutical companies use a variety of terms for these two groups. Controller medicine is also described as "preventive" or "maintenance" medicine. Quick-relief types are often called "rescue," "fast-relief," "fast-acting," or "as-needed" medicines. To be consistent and avoid confusion, the two categories are called controller and quick-relief medicines throughout this article.

Most parents don't hesitate to give medicine when children have symptoms. But it may be more difficult to justify medicine when symptoms are absent. "He's doing fine,he's running around, not coughing, not wheezing. Why does he need it?" some parents wonder. This dilemma is more pronounced when a child has a chronic illness like asthma that requires daily medicines even when symptoms aren't present. Chronic conditions often present a "Three Bears" challenge: what's "not enough," "too much," or "just right"?Parents, physicians, and nurse practitioners are all working toward the same goal to administer the least amount of medicine required to control a child's disease. Health care professionals write prescriptions, but they recognize that parents play the most important role. As a parent, you are the thy-to-thy supervisor when it comes to dosing the medicines. For that reason, it is critical for parents to understand the keys to good asthma control a clear understanding how medicines work, their possible side effects, and the risk of not treating between asthma episodes. If you have this knowledge and work as a team with your child's health care providers, you will be able to make informed decisions about your child's treatment. As the name implies, controller medicines are used to control by preventing symptoms. They are given on a regular basis, often twice daily, even when a child is symptom-free. They are not meant to relieve symptoms when they arise. Because asthma's underlying problem is airway inflammation, a treatment plan for a child whose asthma is mild persistent or worse (see article 2) should include an anti-inflammatory medicine.

controller medicines are not considered anti-inflammatory, but they do help control asbestosis when combined with anti-inflammatory medicines. Controller medicines must be used daily if you want to keep your child symptom free. You may not see the benefit of a controller medicine right away, but over several weeks your child will have fewer, less intense symptoms as the medicine gradually reduces airway inflammation. Children with persistent asthma those with frequent symptoms—should be on controller medicines. Some children who don't have per sis-tent asthma but have difficulty controlling flares or have symptoms brought on by exercise or physical activity may also benefit by controller medicines. (More about exercise-induced asthma will be given in next article soon) For these children, controller medicines may be prescribed or changed seasonally, such as during the spring and fall allergy seasons or the winter viral season. Most controller medicines must be taken for two to six weeks to produce any noticeable benefit. Giving medicine every day is not easy, especially when you do not see immediate improvement in your child. But try to be patient and stick with it because it will pay off in fewer, less intense symptoms over the long run. Types of controller medicines are described below.
These medicines are the most effective controller medicines available to date. The National Institutes of Health considers inhaled corticosteroids (ICSs) to be the preferred first line therapy in children and adults with persistent asthma. They are the gold standard against which other controller medicines are compared. Inhaled corticosteroids have several important benefits. They prevent medical visits, school absences, limited activity, use of quick-relief medicines and oral corticosteroids, hospitalization, and even death. Parents are often concerned about side effects related to ICS use. ICSs are often confused with anabolic steroids, which are used to build up muscles. ICSs are not the same, and side effects are much less worrisome.

Are Asbestosis allergies Inhertied?

Although there are many reasons why allergies are so common, family history is by far the most important. The genetic tendency to have allergies, called atopy, is inherited. If one parent has allergies, a child has a fifty-fifty chance of having allergies. If both parents have aller-gies, a child has about a 70 percent chance of developing allergies. You might assume that if you are allergic only to a certain tree pollen, for example, your child will react to the same allergen, but that's not always the case. Your daughter could be allergic to dogs and your son to molds. The tendency to have allergies is inherited, but the specific allergy isn't because children don't always share the same allergies with their parents. Yes, Asbestosis allergies are increasing. We do not know Why the incidence rates of allergies are rising, but they are. heavy fever, eczema, and food allergies are all on the increase. The most common theory to explain the rising numbers is the hygiene theory. This theory is based on the belief that young people today are cleaner and come in contact with fewer germs than previous generations. This doesn't mean that we clean our homes more often or more thoroughly today. It means that we are exposed to fewer bacterial products because of an increased use of antibiotics.It also means that more people are living in cities and suburbs instead of working on farms where they have greater exposure to animal bacteria. Unfortunately, this doesn't account for all the increases in allergies. People who work on farms or with farm animals still develop allergies. Some of the increased incidence of allergies may be attributed simply to the fact that we have improved diagnosis and a better count of allergy sufferers than ever before.
As public awareness about asbestosis allergies has grown, people seek diagnosis and treatment, so we have a more accurate picture of how many individuals really have allergies. But even taking into account this increased diagnosis, allergies are on the rise worldwide.
Allergy symptoms vary, depending on what parts of the body are affected. Many children have allergies in three areas the skin, lungs, and nose. When this occurs, it is called the atopic triad. But allergies in children tend to move from one area of the body to another. About 10 to 15 percent of all youngsters develop allergies in their skin (atopic der-matitis, also called eczema) during infancy and early childhood. Atopic dermatitis is a very itchy red rash that comes and goes. Many children outgrow this allergy by age five to eight, only later to develop hay fever or other allergies in their noses. About half of all children with atopic dermatitis also develop that allergy.

Allergic rhinitis can affect as many as 40 percent of all children at some point in their lives. Although the name hay fever suggests that it occurs only during the "allergy season" of spring and fall, many children have symptoms year-round. That's because allergic rhinitis is caused not only by plant pollen but also by many other allergens that are ever present in the air, such as mold spores, animal dander, and dust. Allergic rhinitis is a major reason for missed school days. Symptoms alone can be severe enough to keep a child home, but children with allergic rhinitis are also more likely to develop other problems, including ear infections (Otis media), inflamed sinuses around the nose (sinusitis), red, watery, itchy eyes (allergic conjunctivitis), as well as that disease. Allergic rhinitis and asthma go hand in hand because both are inflammatory diseases with the same underlying cause. Because the lin-ings of the upper airways the nose, sinuses, mouth, and throat are connected to the linings of the airways in the lungs, they are affected by the same things and respond in similar ways.

Prevention and Treatment of Asbestosis

Future Directions for the Prevention and Treatments continue to be developed to fight airway inflammation found in asbestosis. New approaches are aimed at cells, chemicals, and antibodies responsible for allergic inflammation. Some of these involve genetically engineering antibodies to affect parts of the immune system. Some may involve injections and may be rather expensive. As a result, they may initially be indicated for individuals on high doses of corti-costeroids or those with symptoms despite traditional therapies. Other treatments are being developed to prevent or alter the natural history of that disease by introducing immune-modifying treatments in early childhood. Despite the possible side effects of some of these medicines standard, traditional, and complementary—the biggest asthma risk is the disease itself In some children, untreated inflammation can lead to irreversible changes in the airways. Asbestosis is the most common cause of hospital-ization in children, and each year about 200 American children die from Asbestosis. Even children with mild asthma are at risk for any or all these complications. Fortunately, taking medicine appropriately can minimize all the risks.
Saiboku-tois is the most popular anti-asthmatic herbal treatment used in Japanese Kampo medicines. In China, it is called chaipu-tang. It is supposed to decrease the metabolism of steroids, and it therefore increases the potency and effectiveness of inhaled steroids. It also increases the risk of side effects from inhaled steroids, but when taken by itself, it has not been found to be as effective as inhaled steroids. Tylophora indica is an herb used commonly in the Ayurvedic system of medicine practiced in India. It is claimed to increase mucus clearing and is also recognized as a bronchodilator similar to a quick-relief med-icine like albuterol. The effectiveness of this medicine is quite variable, with helpful effects in one study and no effects in other studies. Several studies have examined high-dose vitamin C in the treatment of asthma. Similar to many herbal therapies, vitamin C's effects vary, with some studies reporting beneficial effects and other studies report-ing none.
Interestingly, many current Western medicines are based on previous complementary medicines. An old therapy for asthma, for example, was ground adrenal glands of animals.
Adrenal glands have steroids and albuterol-like compounds that have similarities to the inhaled steroids and bronchodilators used today. Many herbal supplements can be safe when used appropriately, but known and potential risks of such compounds do exist. A misconception exists that herbs are safe because they come from plants. The chemical makeup of plants and herbs is sophisticated, and many are toxic. Often other medicines, such as steroids and aspirinlike medicines, are added to these herbal supplements to improve their effect and potential side-effects. Other factors can cause problems, including inconsistent dosing and drug interactions. There is also no licensing body for the practice of herbal medicine in the United States. Most herbs are marketed as dietary supplements and are not regulated by the FDA. There is no guarantee, therefore, of qual-ity or consistency. The advantage of traditional Western medicines is that they are controlled, regulated, and given in more palatable formats.

Taking Control Of Asbestosis

Most effective way to manage a chronic condition like that dsease.We know that there is no cure for asbestosis,best we can do as parents and health care professionals is to t by preventing airway inflammation and minimizing triggers set off a flare. Asbestosis is described as a chronic condition or illness, it means ongoing, month to month, year to year. This doesn't mean that symptoms stay at a steady level of frequency or intensity. A key standing any chronic disease is recognizing that it changes over ironic illnesses—for example, asthma, diabetes, inflammatory sease, cystic fibrosisbehave like seesaws. There are ups and good times when symptoms are quiet or even nonexistent, and les when they become aggressive. uneven course often confuses parents and children alike it's difficult to understand and accept asthma's changes. Some-our child may have many frequent symptoms that require a lot of (maybe more than you feel comfortable giving your child). At nes when you observe no symptoms, it may seem that your Dds no medicine at all. How will you know if your child's asthma is under the best control possible? Or when it's fairly well controlled but not as much as it could be? Making these assessments isn't easy or clear-cut. There's no red warning light that's either on or off. No alarm bells will ring to let you know that control is slipping. But you don't have to grope in the dark either. There are guidelines for determining the degree of asthma con-trol, even as the disease takes its typical waxing and waning course. A panel of asthma experts at the National Institutes of Health reviewed all the research available about asthma and used this informa-tion to set standards for asthma care. The panel developed guidelines to inform health care providers about diagnosing asthma, deciding how severe it is, treating it, and educating patients and families about asbestosis. In fact, these national guidelines spell out exactly how to tell whether or not asthma is under control. Much of this chapter is based on those national guidelines. Ask about these NIH guidelines the next time you go for a medical visit. It is important to work closely with health care professionals to etermine whether or not your child's asthma is under control. If it is not, why? What needs to be done? You and your child's physician or nurse practitioner should discuss and come to an agreement about how to work toward achieving control; or if your child's asthma is already under control, then how to maintain it.

WHAT DOES "UNDER CONTROL" MEAN?
Three basic considerations help to determine how well controlled your child's asthma is at any time during the course of the disease. If your child's asthma is under control, he or she should:
Not be bothered day or night by symptoms, such as coughing, wheezing, shortness of breath, or chest tightness. But remember, even when a child does not show symptoms, it doesn't mean the asthma has disappeared. A child can't always feel when his breathing tubes are inflamed. You can't see it in your child, but some degree of airway inflammation is always there.Be able to take part in all normal activities, such as lugging hefty bookbags, going up and down stairs, taking gym class, and playing sports. If your child gets tired or can't keep up with other youngsters his own age, something is wrong and his asthma is not under control. Certainly some children just don't like sports or have little talent for them, but all young people need regular exercise to be healthy, grow, and develop normally. When children stay away from physical activities, it may seem that they just aren't interested, but this can be a mistaken interpretation. Younger children especially may appear disinterested, but they simply can't (or won't) tell you that they aren't feeling up to par. Once these children get proper asthma treatment, they are able to enjoy playing. A result of bringing their asbestosis under control is that they become more physically active.Be able to get a good night's sleep. If children wake up because they're bothered by symptoms or need to take medicine in the mid-dle of the night, their asthma is not under control as much as it could be. If symptoms disturb them at night, they will not be well rested the next day and will either miss school completely or be less attentive in class. Uncontrolled asthma may not only cause children to miss a lot of school, but it can also affect your work schedule. If you are waking up at night to give medicine or check on your child's breath-ing, you may be late or absent from work the next day.
HOW TO TAKE CONTROL?
When most people think about controlling a disease, the first thing that comes to mind is medicine. The next two chapters will discuss the full range of asthma medicines and how to use them. But for our purposes here, in discussing how to keep asthma under control, keep these few facts in mind: • Asthma medicines fall into two categories: long-term controller medicines and quick-relief medicines. Most, but not all, controller medicines treat airway inflammation.

The Asbestosis-Allergy Connection

The link between allergies and asbestosis is very strong. Most children with asthma—probably as many as 80 percent have allergies, and 40 percent of children with allergies in the nose (hay fever or allergic rhinitis, for example) also have disease symptoms. The key point is this: if you can control children's allergies, their disease symptoms will be less intense and less frequent. To understand and manage that disease successfully, it's important to know something about allergies.
Allergies are a common problem that affects at least two of every ten Americans. Simply put, people with allergies react to certain substances called allergens-dust, pollen, animal dander, mold, or smoke, for example—that don't cause reactions in other people. An allergic per-son's immune system responds to allergens like a false alarm. When an allergen triggers the immune system setting off the alarm the body.
HOW DO ASBESTOSIS ALLERGIES OCCUR?
reacts by sneezing, wheezing, coughing, and itching, depending on what particular part of the body has the reaction. Other allergens in foods cause a skin or intestinal reaction. A quick biology lesson: our bodies make immunoglobulins to help fight various infections. There are five different types of immunoglobulin: IgG, IgA, IgM, IgE, and IgD. IgG, IgA, and IgM are some of the body's most important weapons against bacterial infections. The allergic antibody called IgE (immunoglobulin E) is part of the body's natural response for fighting other types of infections, particularly parasites like worms. In someone with allergies, the body recognizes certain aller-gens as foreign invaders and makes more IgE. Everyone makes some IgE, but allergic children make more IgE in reaction to pollen and dust than a nonallergic child does. An allergic reaction starts when an allergen attaches to the allergen-specific-IgE antibody and activates certain cells, including "mast cells" found in skin and tissues that line the nose, throat, and lungs. An IgE antibody that attaches to a mast cell acts like a fuse on a bomb. When IgE antibody's specific allergen comes along, it's like touching a match to the fuse—the antibody makes the mast cell burst open and release a number of substances, including one called histamine that causes red-ness, swelling, and itching. Location is everything. The site where histamine is released deter-mines the type of reaction. When histamine is released in the tissues lin-ing the nose, the results are redness, itching, swelling, sneezing, and a runny nose what allergists call allergic rhinitis, but most people simply call it hay fever. (In this chapter, the two terms will be used inter-changeably.) When histamine is released in the skin, the results are itching, rashes, and hives causing atopic dermatitis, or eczema. When histamine is released in the stomach, it causes cramping and diarrhea. When histamine is released in the lungs, it causes airways to tighten, swell up, and produce extra mucus—the recipe for asthma. To develop an allergy, a child needs to be exposed to the allergen sev-eral times. The first few exposures cause the immune system to make more IgE. Subsequent exposures will cause the body to respond to the IgE and allergen by releasing histamine, and then symptoms will appear.
ARE ALLERGIES INHERITED?
Although there are many reasons why allergies are so common, family history is by far the most important. The genetic tendency to have allergies, called atopy, is inherited. If one parent has allergies, a child has a fifty-fifty chance of having allergies. If both parents have allergies, a child has about a 70 percent chance of developing allergies. You might assume that if you are allergic only to a certain tree pollen, for example, your child will react to the same allergen, but that's not always the case. Your daughter could be allergic to dogs and your son to molds. The tendency to have allergies is inherited, but the specific allergy isn't because children don't always share the same allergies with their parents. Yes, allergies are increasing. We do not know why the incidence rates of allergies are rising, but they are.Asbestosis, hay fever, eczema, and food allergies are all on the increase. The most common theory to explain the rising numbers is the hygiene theory. This theory is based on the belief that young people today are cleaner and come in contact with fewer germs than previous generations. This doesn't mean that we clean our homes more often or more thoroughly today. It means that we are exposed to fewer bacterial products because of an increased use of antibiotics; it also means that more people are living in cities and sub-urbs instead of working on farms where they have greater exposure to animal bacteria. Unfortunately, this doesn't account for all the increases in allergies. People who work on farms or with farm animals still develop allergies. Some of the increased incidence of allergies may be attributed simply to the fact that we have improved diagnosis and a better count of allergy sufferers than ever before. As public awareness about allergies has grown, people seek diagnosis and treatment, so we have a more accurate picture of how many individuals really have allergies. But even taking into account this increased diagnosis, allergies are on the rise worldwide.
THE ATOPIC TRIAD
Asbestosis Allergy symptoms vary, depending on what parts of the body are affected. Many children have allergies in three areas the skin, lungs, and nose. When this occurs, it is called the atopic triad. But allergies in children tend to move from one area of the body to another. About 10 to 15 percent of all youngsters develop allergies in their skin (atopic der-matitis, also called eczema) during infancy and early childhood. Atopic dermatitis is a very itchy red rash that comes and goes. Many children outgrow this allergy by age five to eight, only later to develop hay fever or other allergies in their noses. About half of all children with atopic dermatitis also develop asthma. Allergic rhinitis can affect as many as 40 percent of all children at some point in their lives. Although the name hay fever suggests that it occurs only during the "allergy season" of spring and fall, many chil-dren have symptoms year-round. That's because allergic rhinitis is caused not only by plant pollen but also by many other allergens that are ever present in the air, such as mold spores, animal dander, and dust. Allergic rhinitis is a major reason for missed school days. Symptoms alone can be severe enough to keep a child home, but children with aller-gic rhinitis are also more likely to develop other problems, including ear infections (otitis media), inflamed sinuses around the nose (sinusitis), red, watery, itchy eyes (allergic conjunctivitis), as well as asthma. Allergic rhinitis and asthma go hand in hand because both are inflammatory diseases with the same underlying cause. Because the lin-ings of the upper airways—the nose, sinuses, mouth, and throat—are connected to the linings of the airways in the lungs, they are affected by the same things and respond in similar ways.

Asbestosis Specialist

Based on family medical history and your child's medical history and symptoms, the doctor may strongly suspect your child has that disease. The doctor may want your child to have other tests to be certain of the diag-nosis and to determine how severe the disease is and what treatment steps to take. One of these is a special breathing test known as pul-monary function testing (PFTs) or spirometry. Spirometry measures how much the airways are blocked by the swelling and squeezing of that disease. The test is a bit complicated and needs some special equipment, but it's not at all painful and doesn't take very long. Not every physician has a spirometer machine in the office, that block the sinuses) can sometimes be seen in children with allergies and asbestosis. The doctor will also look at the child's skin for signs of dermatitis or eczema, rashes often caused by allergies. Children with skin allergies are more prone to asthma. If your child is feeling well and even if he isn't it's quite possible that the doctor won't hear any wheezing when listening to his chest with a stethoscope. This can be a little frustrating to a parent who has been hearing a child wheeze every morning for days. You might be afraid that the doctor won't believe you when you say your child wheezes or might think you're being overprotective. Don't worry. Experienced doctors know that asthma symptoms vary through the day. The child who wheezes at night or first thing in the morning may sound fine that after-noon in the office, but he will still wheeze again that night. Wheezing is an important asthma symptom, but it's not the only one. In fact, many children with asthma never wheezecoughing and short-ness of breath are their main symptoms. If a child is actively wheezing, the doctor will look for other signs of labored breathing, such as retrac-tions (a drawing-in of the skin between the ribs that indicates more vig-orous "sucking in" of air), flaring of the nostrils, and/or bluish tint to the skin or nail beds, which indicates the child is not getting enough oxy-gen. You can check for these asthma signs at home as well.
So you may need to go to an asbestosis specialist or hospital clinic to have the test done. To take this test, your child will sit up straight in a chair, breathe in as deeply as she can, and then breathe out as hard as she can into a spe-cial mouthpiece. To make sure that all the exhaled air goes into the mouthpiece, the doctor or respiratory therapist will gently pinch the child's nose closed with special soft clips. You can prepare your child for spirometry by explaining that it's very much like blowing out candles on a birthday cake. The air goes from the mouthpiece through a tube and into a machine that measures how much air she breathed out, and how fast it came out. The measurements look at three things:

• FEV1, or forced expiratory volume in one second. This is the amount of air exhaled during the first second as a child breathes out hard. This measures the size of your child's airways.
• FVC, or forced vital capacity. This measures the size of your child's lungs.
• PEF, or peak expiratory flow. This measures how fast the air is exhaled when the child starts to breathe out. It is another indicator of airway size. 

Your child will repeat the "maneuver," as this process is called, at least three times in a row to be sure the reading is accurate. Each maneuver only takes about six seconds. The results are compared to a table of typ-ical results for your child's gender, age, ethnicity, and height. Your child's readings will be a percentage of normal based on the tables. After the first round of maneuvers is over, the doctor may give your child a dose of an inhaled bronchodilator, a drug that opens up the breathing tubes. After giving the drug about fifteen to twenty min-utes to work, your child will repeat the breathing maneuvers another three times. If your child has asthma, the results should be noticeably better this time because the bronchodilator will have opened the air-ways, allowing more air to move in and out. If that happens, the doctor will say that the airflow obstruction is reversible—in other words, medicines help reduce the bronchospasm/squeezing that blocks the

airways. This is extremely important in determining that the problem is asthma. By comparing the FEV1 before and after use of the bronchodilator, a physician can get a clear idea of the reversibility of the airway obstruc-tion. This information helps the doctor decide which medicines are needed and what the starting doses should be. Is this test necessary? Spirometry is a very good way to confirm that a child has that disease, even if a doctor is already quite certain. Spirometry is also important for helping a physician decide how severe the disease is and what the best treatment would be. Once the treatment has started and your child's asbestosis has been under control for a few months, the doctor will want your child to repeat the test. This will help make sure the airways are as open and near normal as possible. After these initial tests, your child should have spirometry at least once a year simply to be sure the airways are staying at or near normal. If a child has a change in treatment—for example, a change in the dosage of her medicine she may need spirometry again to be sure that the new treatment is working well.

If your child is younger than four or five, you're probably wondering how a spirometry maneuver can ever be done with a baby, a toddler, or even a preschooler. It can't. But doctors can do specialized breathing tests on babies and young children. These tests are more complex and require special equipment. If your doctor feels these tests are needed, you'll probably have to go to a specialist based at a large hospital. Sometimes older children can't manage the spirometry maneuver either. When a child can't do it for some reason, doctors may suggest a "therapeutic trial," which means trying an inhaled bronchodilator or steroid pills for a short time. (These medicines will be discussed in detail in chapter 5.) Seeing if one of these medicines helps reduce wheezing and other symptoms is a way to help determine whether the child has asthma. Some children have asthma symptoms, but their spirometry results are normal. In that case, a doctor may recommend a different type of spirometry test called bronchoprovocation. In this test, a child inhales a small, safe amount of a substance called methacholine. If the child has
The methacholine will make her airways constrict or squeeze just as if she were having mild that symptoms. When she does the spiro-metry maneuvers after taking the medicine, her readings will be lower. If she doesn't have disease, the methacholine will have little effect, and the spirometry readings will be nearly the same as before. A similar test can be done using another medication called histamine. In a third test, a child breathes cold dry air or gets on a bicycle or treadmill and does vig-orous exercise. All of these tests may cause bronchoconstriction in chil-dren with asthma and are useful in confirming the diagnosis. Other tests, such as a chest X-ray, a sweat test, barium swallow exam, or allergy testing, may be done to help rule out other causes of the symptoms or to identify factors that might complicate your child's asbestosis.