Asthma and Medications
By Christine P. White, MD, FAAP
July 11, 2017
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"Ummmm, I think he has a brown one, but he only uses the red one now."

This is a common answer I hear when I ask a parent which inhalers their child is taking for their asthma flare. "The brown one" is likely Qvar – an inhaled steroid or anti-inflammatory inhaler. "The red one" is likely ProAir – a bronchodilator or rescue inhaler.

This blog doesn't go into what asthma is or how to diagnose it. This blog will try to explain what the different medications are that are used to treat asthma, how they work, and when they should be used, etc. I think this information is misunderstood by the majority of parents who have kids with asthma. And I don't blame them. It can be confusing to know what to start and when, and how long to continue it. But I think if you understand WHY you are using something and WHAT it does at the cellular level, then you will understand WHEN to use which inhaler and for how long.

I'm using the term "asthma". But you should take this to encompass a diagnosis of recurrent "wheezing" as well as "reactive airways disease". Infants or kids that have only wheezed once or twice in their lives (like with bronchiolitis) don't necessarily need to be on these medications. Sometimes you just get a bad bug and it makes you wheeze for the duration of that cold – but you never do it again. Kids with asthma wheeze and cough with almost every cold they get – and they cough for weeks with most colds.

Asthma is the most common chronic disease of childhood. The prevalence of asthma is increasing. This is also the case with other allergic conditions, including eczema, seasonal allergies, and food allergies. According to recent CDC data, asthma affects approximately 8.5% of the pediatric population in the U.S., or more than 7 million children. Asthma accounts for more school absences and more hospitalizations than any other chronic condition in this country.

Before we go over the main meds we use to treat asthma, lets look at what causes the cough and wheeze – at the cellular level. There are two main things that occur: the muscles around the tiny airways constrict which tightens the airway or closes them off somewhat. And inflammatory cells along the airway release chemicals and mucus into the airway. When you have asthma, you have to treat BOTH of these components to adequately treat the problem.

Medications that relax the muscles around the airways are called "bronchodilators". Albuterol (brand names ProAir, Proventil, Ventolin, Maxair, and Xopenex) is an example of a short acting bronchodilator meaning it's effect on the muscles lasts about 4 to 6 hours. There are some longer acting bronchodilators (salmeterol, formotorol found in Advair, Symbicort, and Dulera for example) that can be used for more persistent cases of asthma.

The most commonly used anti-inflammatory asthma meds are inhaled steroids. Examples of these are Qvar, Flovent, Pulmicort, Asmanex, and budesonide.

For the sake of this article, we are going to consider the most common type of asthmatic seen in an outpatient clinic or the ED: that is the infant or child who does totally fine with their breathing when they have no cold or viral illness, but as soon as they get a cold they start to cough and possibly wheeze. This is the kid whose parent knows the kid is supposed to be taking some inhalers when they get sick, but they don't exactly know which one to start first, when to start it, or how often or long to use it. Now, there are a few of you out there that have this figured out, so don't be offended and scream at your computer, "Hah! Dr. White, I know how to use the inhalers!" You are the minority, and I'm proud of you.

For the rest of the world, here's a simplified way to use your child's inhalers. The second he even has a hint of a cold – you start the inhaled steroid. That's your Qvar or Flovent inhaler or Pulmicort/Budesonide (in the nebulizer). You do it the second you get them home from daycare or school that day. You don't wait 2 to 3 days to see how bad this cold is going to get. You don't wait to see if they'll get a cough. You do it if they sneeze a few times and they have a touch of nasal congestion. The reason you jump on it so soon is because these inhaled steroids are going to act on those inflammatory cells in the airways to keep them from releasing all their chemicals and mucus that fill up the airways during an asthma flare. If you wait until the cold is in full nasty mode you have missed your chance to really shut those cells down. You will use the inhaled steroid twice a day for the duration of the cold plus three more days. You have to keep this one going until you haven't heard any cough or seen boogers for 3 days!!!

Now the albuterol you will use when you start to hear a cough. If the cough is mild, infrequent, not interfering with play, sleep, daily life – you can probably do the albuterol twice a day – like AM and PM when you are doing your inhaled steroid. If the cough picks up in frequency, your child coughs with play, coughs during sleep you need to increase the frequency of the albuterol, perhaps to every 6 hours. If the cough is severe, almost constant, keeping the child from playing or keeping him up at nite – you should do the albuterol every 3 to 4 hours. If you are needing to use the albuterol more often than every 3 hours, that child needs to be seen. Once the cold/cough have peaked and things start to improve, you can start to wean down the frequency of albuterol doses. About every 2 days you can take a way a dose as long as you feel symptoms are improving.

Anytime you use an inhaler, you should use a spacer (except with breath activated inhalers such as ProAir Respiclick or Pulmicort Turbohaler for example). If you try to do your inhaler without a spacer you will end up getting the majority of the medicine deposited on your tongue or throat because the medicine shoots out so fast. If you use your spacer the majority of the medicine will make it's way to your lungs. It doesn't matter if you're 4 years old, 14 years old, or 40 years old – USE YOUR SPACER.

The proper way to do inhalers is to shake up the medicine, insert in the spacer, do one puff and take 5 normal to big breaths. Wait one minute and repeat. If you just did your inhaled steroid you should get a drink to rinse your mouth so you won't get thrush.
This information is generalized and you should check with your pediatrician to see if your child needs this plan tweaked. If you have more persistent or severe asthma, you will likely have a more aggressive asthma plan to follow.