Asthma - Diagnosis and Treatment
is the best example- and what most people think of when you bring up the topic. Asthma is a recurring obstruction to exhaling normally, usually reversible- with medication- and sometimes a life long diagnosis- especially if symptoms continue after age five. It can involve the large and small airways- including inflammation of the airway, spasm of the airway, and/or fluid and mucus in the airway. Asthma like symptoms (coughing and wheezing) before age five are typically defined as "reactive airway disease" rather than asthma. Although the patient coughs and wheezes like an asthma patient- they "grow out of the problem" as their lungs mature. Infections, such as the RSV virus, may "irritate" the lungs and cause inflammation, fluid accumulation, and hyper-reactivity- all similar to an "asthma attack"- but unlike true asthma- the patient has a good chance of NOT having it recur throughout their life. The treatment during "reactive airway disease" is the same as asthma treatment. Families with allergies have a greater liklihood of genetically having asthma. In fact 80% of asthmatics have an allergy component- therefore treating allergies is a key component of controlling asthma. Allergies are a "trigger" for many asthmatics to have an exacerbation. Babies with food allergies and skin allergies (eczema) are also at an increased risk for one day obtaining the diagnosis of asthma. This is called the "allergic march". Not every baby that starts the march - food allergy, skin allergy (eczema), runny nose (allergic rhinitis), asthma- completes the march to asthma- but there is that chance. Some studies suggest that attempting to stop the march with aggressive diet restrictions during infancy and aggressive treatment of eczema, if present, with antihistamines- may slow or even halt the allergic march before it leads to asthma. These studies are inconclusive but interesting to discuss with your doctor.LINK TO: (The ETAC study) Other "triggers" for asthma include exercise, certain foods, stress, weather changes, smoke, animal dander, dust mite, coachroach feces, and then there is a huge genetic component. Every asthmatic may have a different "trigger" to avoid. Dr. Goldstein uses several mechanisms for diagnosing asthma. The NIH (National Institute of Health) has made it relatively straight forward for clinicians to diagnose and treat this common, complex problem. And because it can be life-threatening- it is important for clinicians to do it "right". Clinically, asthma can be discovered by a night time cough, an exercise cough, or a wheeze. Don't be fooled! Note that not all asthmatics wheeze- some only cough- "cough variant asthma". Another mechanism is spirometry- lung function testing. The NIH has guidelines for how much air you should be able to breathe out in one second (FEV 1) and in a total breath out (FVC) as well as looking at the small airways (FEF 25/75). These values are compared to others of the same race, gender, and height. Obviously, a good physical exam is also essential in making the diagnosis. A chest xray is NOT necessary, and frankly, rarely helpful to make the diagnosis. Depending on the patient's lung function and amount of coughing during the week can determine the diagnosis as well as the severity and need for medications. Mild asthma can be as seldom as 2 times per week of symptoms during the day, and as seldom as 2 times per month of symptoms at night. Some people may think their child would only be diagnosed if there were daily symptoms- and that is just not the case. Medications include allergy medicines (antihistamines such as Zyrtec or Allegra- as well as leukotriene inhibitors such as Singulair) Other allergy medications may include nasal inhalers such as Nasonex, Flonase, or Rhinocort as well as allergy eye drops. Asthma medications include inhaled steroids such as Flovent, Pulmicort, Asmanex, or Q-var. Non-steroid medications such as Cromolyn and theophylline may be considered. Advair and Foradil are other commonly used medications for asthma-LINK TO: Dr. Goldstein is more cautious using these medicines- read the alert on long acting beta-agonists. Exacerbations require oral steroids such as Prednisone or Prednisolone. Sometimes inpatient hospital stays are necessary for more aggressive care, oxygen, and intensive therapy. And Albuterol is the fast acting "rescue medication" used before exercise, before exposure to "triggers" or during an acute worsening of symptoms. If there is an increased need for Albuterol- it is time to re-visit your doctor and insure the medication list is adequate and doesn't need adjusting. Exacerbations occur during illness, season changes, increased exposure to "triggers" or poorly controlled medication. Although Albuterol decreases symptoms for four to five hours- using it more than expected is a clue that your asthma is "out of control" and needs attention. The only time most clinicians feel it is ok to use Albuterol on a daily basis is before exercise (rather than waiting to need it during exercise because of wheeze, cough, or distress)- if, and only if, exercise is a "trigger" for that athlete. Maintaining control of your asthma can be done various ways as well. Avoiding "triggers", carefully monitoring Albuterol use and need, careful followup by your clinician with spirometry, and routine exams are all essential in good asthma care. A home peak flow meter, a "cough calendar" to document night time cough, and a medication sticker log (to insure compliance with daily medications) are all important to keep control. Ask your clinician for a peak flow meter and an explanation of your child's expected performance. If your child is doing well, does not have symptoms such as a night-time cough, and is not using Albuterol- he can be considered in the green zone and can followup at the next scheduled appointment. If your child has symptoms such as a cough, increased albuterol use, or a drop in his peak flow (of 10-20% expected), then he is in the yellow zone, and should discuss medications with the doctor that week. If your child is distressed, can not reduce his cough with albuterol, or has a peak flow change of above 20% expected- he is considered in the red zone and should discuss medications with the doctor that day- or seek assistance at an urgent care center. Asthma is a life-threatening problem and everyone has a different severity- just because the neighbor has asthma but never seems to have a problem- doesn't mean your child has the same mild symptoms. The full text of the NIH guidelines can be found at: LINK TO: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf If you believe your child may have symptoms of asthma, please discuss them with your doctor. This information is meant to add to, never substitute, the doctor's evaluation and treatment of your child. |
| "DIAGNOSIS" |
| "Triggers" should be avoided. |
| "TREATMENT" |
| 80% of asthma patients have allergy problems. |
| "MAINTAINING CONTROL" |
| "THE NIH GUIDELINES" |
| THIS INFORMATION IS TO BE USED IN CONNECTION WITH YOUR VISIT TO THE DOCTOR- ASTHMA IS A COMPLEX PROBLEM, IT CAN NOT BE FULLY DISCUSSED HERE. |
