Dr. John McBride, director of the Robert T. Stone Respiratory Center at Akron Children’s Hospital and one of the country’s leading experts on childhood asthma, recently participated in a live, call-in radio show, “On Call for Kids,” on the Sirius XM’s Doctor Radio.
The show covered everything from exercise-induced asthma and the impact of second-hand smoke to diagnosis and treatment.
Here are the questions and answers, edited for space:
CALLER 1: Is exercise good for people who have asthma or does it make symptoms worse?
DR. MCBRIDE: Many people have heard of the diagnosis, exercise-induced asthma. When I talk to patients about this, I like to back up and explain that the problem with asthma is that the patient’s bronchial tubes are very sensitive. So they respond differently to things like second-hand smoke than would the bronchial tubes of a person who does not have asthma.
When you exercise, you breathe in a lot more air than usual and that can be irritating. But the level of irritation also relates to the current condition of the bronchial tubes. If they are healthy and healed, there should be no irritation.
We do not limit exercise in our asthma patients. If they are having trouble breathing while exercising, that’s a sign that their bronchial tubes are not healed and that’s the role of our asthma medications (i.e. inhaled steroids). So, if a child has to stop exercise because he is doing a lot of coughing and wheezing, that just means we are not being aggressive enough in treating him.
Using a bronchodilator or quick reliever medication can usually stop the wheezing or difficulty breathing with exercise-induced asthma, and using that medication before exercise can prevent it.
On the other hand, it is often a better approach to use asthma medications regularly to heal up the bronchial tubes so that exercise is not a problem in the first place. Our medicines are very effective in helping patients with asthma, but, even before that, it’s important to try not to irritate the bronchial tubes in the first place.
By far, in my experience, the thing that is the biggest problem for kids – and adults – is smoking and exposure to second-hand smoke.
CALLER 2: When my 3-year-old daughter gets a cold, she develops a croup where she is gasping for breath and wheezing for days. Is this a sign she is at higher risk for developing asthma?
DR. MCBRIDE: Croup is a problem in the throat and, fortunately, it sounds worse than it is. It is a problem of breathing in and few kids ever need hospitalized because of it.
Many kids get croup just once, usually in the fall when they are 3 or 4 years old and get a viral infection. A few kids get croup over and over again, and we call that spasmodic croup. It comes with a viral infection, just like the kids who get it only once.
But it’s obviously not just a viral infection but the child’s response to the viral infection. So we actually consider spasmodic croup a variant of asthma. Many of these kids have brothers and sisters and parents with regular asthma. We treat children with spasmodic croup with asthma medicines. They don’t work quite as well as with kids who have regular asthma but they do help.
The other good thing to know is that it goes away. I rarely see a child with croup beyond the age of 6 or 7.
CALLER 3: What is reactive airway disease versus asthma?
DR. MCBRIDE: I don’t often use the term “reactive airway disease” with my patient families. I think the best way to describe asthma to newly-diagnosed patients is to say “your child has sensitive bronchial tubes that, when irritated, will give him problems.”
I know some parents are concerned that having a label like asthma implies that their child will have asthma for life. But, in fact, many kids who have wheezing or asthma at age 2 or 3 are going to be fine by age 6 or 7 and never wheeze again. I don’t care much about what we call it, but to me it is all a part of the same condition.
Having said that, when kids are hospitalized or have ER visits 3, 4 or 5 times, I don’t think it’s appropriate to say they have reactive airway disease. I think their parents should learn about asthma and what to do about it. If a young child has wheezing, and their mother or father has asthma or if they have eczema or allergies, it’s more likely that they are going to have a long-term problem.
CALLER 4: Every 2 months, my daughter has episodes of wheezing. Sometimes it is with something like strep or some type of respiratory infection. Along with my other children, she has congenital adrenal hyperplasia for which she takes medicine.
When she has these episodes, the pediatrician is hesitant to do much more than inhaled corticosteroids, which doesn’t make much of a difference. We end up just waiting it out. Just wanted your thoughts?
That sounds like a challenging situation so I understand your concern. With inhaled corticosteroids, their benefit is a long-term rather than an acute effect. There is some evidence that when children with sensitive bronchial tubes get a cold, high doses of inhaled steroids, might help a bit.
But, really, the benefit of inhaled steroids is to take them everyday and to get the bronchial tubes healed up. I tell my patients, it’s the inhaled steroids that they take 2 weeks before a cold that will do them the most good.
It’s been shown over and over again that kids with asthma who are having an exacerbation (an episode of coughing, wheezing, trouble breathing) almost always have a viral infection, even if it doesn’t look like they have a cold. We don’t have medications that will help the cold, but we can prevent or treat the asthma exacerbation that accompanies it.
Kids who have multiple wheezing episodes a year should be taking their steroids all the time. In terms of dosing, we strive to give kids the least that they need but enough to benefit them.
That is not something we arrive at in a month or even 2 or 3 months, but over time, by adjusting things up and down as we and their parents see what’s happening.
And this speaks to the importance of the doctor who is helping parents manage the asthma seeing the child regularly – not only when she is sick but also when she is well – to see that those medications are adjusted to the greatest benefit.
CALLER 5: I have a 5 year old with food allergies. He has recently started on immuno-therapies for his environmental allergies. How do I distinguish a reflux cough versus asthma?
DR. MCBRIDE: We see many kids with asthma who do not have allergies. But, there is no question that kids who have allergies are more likely to have sensitive bronchial tubes and, if you have sensitive bronchial tubes, it’s bad to breathe in allergens. It’s common for kids with asthma to have problems around inhaled antigens such as cat or dog dander, or other things to which they are allergic.
The relationship between asthma and food allergies is a little complicated and whether throat clearing is related to asthma or allergies can be a tough clinical decision without seeing your child.
CALLER 6: Around age 2, my daughter began to cough each night, and even vomit. Her pediatrician diagnosed asthma and she began to use albuterol and Flovent, which the doctor said would prevent scar tissue from developing in her lungs. She is now 13 and still uses the medication, but I am not convinced she needs it or if she ever really did. I wonder if she relies on it for more psychological reasons, especially when she exercises.
DR. MCBRIDE: That is an unusual presentation – to cough only at night – but not unheard of. When making a diagnosis of asthma, the most helpful thing is the response to therapy.
I tell my parents, “I am going to put your child on asthma medication for 2 reasons. First, I want them to be better, and, second, I want to know if the asthma medication is making them better.”
>A good response to therapy confirms that asthma is, in fact, the cause of the problem and also indicates how much of their problem is due to asthma.
If the medications made your daughter’s nighttime cough better, most likely asthma was the right diagnosis. I assume when your daughter started on the medication that she got better. It would have been interesting to see if the symptoms came back when the medication was stopped. Then I would be even more convinced it was asthma.
Most adolescents who find that an asthma medication helps them with difficulty with exercise have exercise-induced asthma rather than a psychological dependence. If your daughter needs the medicine consistently when exercising that also suggests she should take a controller asthma medicine more often to get her bronchial tubes healed up.
Regarding the issue of using medicine to prevent scar tissue in the lungs later in life, that was a theory about 10 to 15 years ago but it’s been clearly shown to not be the case. We don’t treat kids to make things better later. We treat kids to make them well right now.