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Common triggers; most common trigger, under about 3-5 years of age, RSV. Most common trigger after five-years-of-age that’s viral, is actually rhinovirus. Interestingly, a virus that primarily affects the nose – for reasons that are not clear – leads to exacerbations of asthma. Most bacterial infections do not exacerbate asthma with one big exception; sinusitis. I’ve seen kids with bacterial pneumonia and chronic asthma come in and they don’t wheeze. And yet they come in with an adenovirus or influenza and they are wheezing up a storm.

Irritants; the biggest that you need to know about is cigarette smoke and we need to deal with that. Allergens; we’ll talk about these in a little more detail when we talk about allergic rhinitis. Change in weather, cold weather definitely will stimulate it. Dry weather will stimulate it. Emotions can trigger some episodes, although it certainly is not causative, and again you have to treat the nose. If you have a kid who has asthma and he is having an exacerbation, but him on a pulse of steroids and if he is not responding, think sinusitis. If you have a kid with asthma who you’ve got on chronic inhaled steroids and you can’t get him under control, treat his allergic rhinitis. Get that under control. Other things are in your handout. Rarely, things like GE reflux may play a bigger role, and some drugs.
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If they give you a kid with any of these presentations, this is asthma until proven otherwise. Prolonged cough with URI’s; either they caught two colds back-to-back or they have sinusitis, or they have asthma. Prolonged usually being beyond 10-14 days. Obviously, exercise-induced symptoms that we will talk about, and a lot of kids with asthma get admitted for “pneumonia”. They get mucus plugging, their chest x-rays show a little bit of atelectasis, they might have a little fever because they came in with a virus stimulus, and they get diagnosed as pneumonia.

A couple of terms from the allergy literature that you have to know about, the early response to asthma. If you are allergic to cats and I throw you into a room with cats, you are going to start wheezing pretty quickly, within about five or ten minutes. If I then take the cats out of the room and leave you there, you’ll actually get a little better after about an hour or two and actually recover a lot of your airway function. What’s happening is that the cat antigen is stimulating mast cells to release histamine and other things like that. You are getting smooth muscle constriction and then gradually as those pre-formed mediators break down you start to relax again. This early response is blocked by the bronchodilators, and also blocked by things like cromolyn, and we’ll talk about some of the anti-leukotriene agents. If I leave you in that room and still keep the cats out of there, you are going to have a secondary phase where you start to wheeze again, and this is due to the inflammation, the edema and things that occur secondary to inflammatory mediators. This is important in that even in the clinical world, but if you have a child, for example, who goes over to Grandma’s house and you know he’s allergic to cats and he goes over there for dinner and starts to wheeze, and mom gives him some albuterol, well he may look great when he comes home to go to sleep at night. But then wake up at one in the morning really tight and really in a lot of trouble. So the late response, which is inflammation, is blocked by your antiinflammatory agents and because you get bronchoconstriction during that phase also, the long-acting beta agonists also can be effective.
Asthma medications
Onset of asthma; this is a childhood disease. Eighty percent of all asthmatics present by five-years-of-age. It is more common in boys in childhood. It is about equally common in boys and girls during teen years, and then it is more common in women as adults. The risk of developing asthma; very heavily weighted on a genetic basis. Overall the incidence of asthma around the country is about 7%, but if just one parent has asthma you jumped up to about a 20% risk, and if both parents have asthma, you are up to about 65%. What happens over time? Parents always like to ask us, “Is my kid going to grow out of it?” We usually fudge and say, “Oh, yeah, maybe it will get a little better. We’ll have to see. Can’t promise anything.” Then we go onto the next question, right? Here’s some data for you. Kids who have asthma at about five or six-years-of-age; if they are followed up for about 6-10 years, 30% of them become asymptomatic. Of that 30% though, if I were to put them into pulmonary function testing, about half of them would still have abnormal pulmonary function tests. They are not sick enough to be symptomatic, but their airways aren’t normal. About half of them have mild to moderate symptoms. So when you tell them, “Yeah, chances are your asthma will be not too bad as a teenager or as an adult” you are probably right. About 20% will be moderate to severe. On the flip side, of kids who have mild asthma as children, unfortunately about 5-10% develop severe asthma as adults. So just because you are mild as a child doesn’t mean you can’t get worse as an adult. Another thing to always be aware of, remember that if you have one atopic disease you can get another. Eighty-five percent of these kids develop allergic rhinitis or atopic dermatitis and as we’ll talk about, allergic rhinitis … it’s very important to keep the nose under control if you want to keep the asthma under control.

What about the wheezing infant? We’ve all had the kid who comes in with bronchiolitis. And he wheezes. Maybe he comes in a second time with a cold and he wheezes. What can you tell parents about the likelihood of them growing out of it? If you look at children who have wheezed once in the first three years of life – and these are usually due to things like RSV or other viral infections – over half of them stop wheezing by the time they are six- years-of-age. So again, the prognosis is good. Those kids who stop wheezing are probably kids who are just born with small airways and all they needed was a little bit of inflammation with each URI to cause them to obstruct. And as they grow, and literally as their airways get bigger in size, their wheezing ends. The 40% who are still wheezing are the kids who are developing allergens and allergic reactions. These are the kids that will test positive on skin testing or RAST testing to specific allergens. So persistent wheezing is associated with maternal asthma, but interestingly not so much with the dad, with other atopic features in the child. So if the child has eczema, allergic rhinitis, the child is more likely to persist. Frequent wheezing; it is somewhat true that the more frequent your exacerbations, the more serious your asthma, the more likely it is to persist. Episodes not associated with URI’s basically means allergic rhinitis and maternal smoking. Maternal smoking is actually a cause of wheezing in the first four or five years of life, regardless of whether you are going to grow out of it or not. It also is a cause for increased medication use, increased lower respiratory infections and increased hospitalizations with asthma.

Asthma is an inflammatory disorder. Even in mild asthma there is inflammation. Recurrent episodes of wheezing, shortness of breath, chest tightness, coughing. The key symptom in kids is coughing. Not wheezing. Prolonged cough in children, especially at night or in the morning, is asthma until proven otherwise. Asthma obviously has three main components, and we’ll talk about these in depth. The airway obstruction is due to bronchoconstriction, mucus production, as well as local edema. The inflammation is key and the inflammation leads to something called increased airway responsiveness, that you should know about.
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First of all, the inflammation; where does it come from? It’s probably initiated though mast cells and some pre-formed factors, histamine and other signaling agents like that. Leads to local edema and also is chemotactic for a lot of other inflammatory cells; neutrophils, lymphocytes are involved. Macrophages as well, and over time the main thing that we see that causes problems is you can actually lose some of the airway epithelium, you can get smooth muscle hypertrophy, but even more seriously, over time even children with chronic asthma can start to get some collagen deposits in the basement membrane. Basically they are getting fibrosis around the airways. That can lead to a permanent airway obstruction. In fact there is evidence now that in kids who are allowed to have chronic asthma symptoms for long periods of time before starting prophylactic steroids, that those kids ultimately have poor lung function further down the road. If we intervene early we may be able to block this last step that may cause some chronic obstruction.
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Increased airway responsiveness; what this means is that the airways in asthmatics constrict too quickly, too easily. After you have a cold, and you are a little kid, and you get your asthma, for about the next six weeks any mild stimulus will make you react more quickly and more severely than if you had been fine for about two or three months. Those can be very non-specific stimuli, like cigarette smoke or change in temperature. Things like that. We see this as increased exacerbations. An idea that you have to know about is the peak flow variability. What this means is that everybody’s peak flow normally varies from a low in the middle of the night to a high at about 12 o’clock to 2 o’clock in the afternoon. Normal individuals who are not asthmatic usually drop, at most, about 10%. For an asthmatic we allow the difference to be about 20% and when you are having ongoing inflammation or increased airway responsiveness, that peak flow variability is above 20%.