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.