Hard-to-Control Asthma

Although not all children who have wheezing will go on to have a diagnosis of asthma, parents do seem to dread a diagnosis of asthma because they think it will lead to life-long problems and limitations.

Fortunately, with proper treatment, most kids with asthma can live normal lives. In fact, as many pediatricians often remind parents and children, there are even athletes who compete in the Olympics who have asthma.

On the other hand, if your child is having chronic symptoms of asthma -- cough, wheezing, trouble breathing, frequent asthma attacks, interrupted sleep due to asthma symptoms -- or is missing school or sporting events because of his asthma, then his asthma is likely not under good control.

Your child's asthma may also be under poor control if he needs to use a quick relief asthma medicine, such as albuterol (Ventolin, Albuterol, ProAir HFA), pirbuterol (MaxAir Autohaler), or levalbuterol (Xopenex), more than twice a week because of his asthma symptoms.

If your child's asthma is not under good control, especially if he is having frequent asthma attacks, be sure to see your pediatrician to review or get an asthma action plan. It is likely that your child needs a "step up" in his long-term control medication regimen.

Hard-to-Control Asthma

There are many reasons why a child's asthma may be hard to control. It may be that they aren't on any preventative medicines (also called long-term control medications), their preventative medicines aren't strong enough, they aren't using them correctly, or they may be continually exposed to an asthma trigger, such as someone at home who smokes.

In addition to the Step 1 treatment of occasionally using a quick-reliever medicine for intermittent asthma, the preferred treatments or steps for children who have persistent asthma symptoms include long-term controller medicines:

• Step 2 - a low-dose inhaled steroid
• Step 3 - a medium-dose inhaled steroid (children less than four years old) or low-dose inhaled steroid combined with another medication or a medium-dose inhaled steroid
• Step 4 - a medium-dose inhaled steroid combined with another medication
• Step 5 - a high-dose inhaled steroid combined with another medication
• Step 6 - a high-dose inhaled steroid combined with other medications, including oral steroids

Which step to use will typically depend on how well your child's asthma is being controlled. For example, if your six-year-old has to leave soccer practice early because he is coughing, wakes up twice a week coughing, and has two or three asthma attacks a year that send him to the doctor's office or emergency room, then he likely needs to move up one or two steps in treatment.

Asthma Controller Medicines

There are so many long-term asthma controller medicines, and they are available in so many different dosage strengths, choosing one can be confusing. Keep in mind that your pediatrician will generally start with the lowest dosage of a steroid that is required to control your child's asthma symptoms and use the fewest medicines necessary.

As an example, for a two-year-old with asthma, your pediatrician might prescribe:

• Step 2 - a low-dose inhaled steroid (Flovent 44 HFA or Pulmicort Respules 0.25mg, Pulmicort Respules 0.5mg)
  
  
• Step 3 - a medium-dose inhaled steroid (Flovent 44 HFA, Flovent 110 HFA or Pulmicort Respules 0.5mg, Pulmicort Respules 1.0mg)
  
  
• Step 4 - a medium-dose inhaled steroid combined with another medication:
  • Advair HFA 45/21 or Symbicort 80/4.5 (these both combine an inhaled steroid with a long-acting beta₂-agonist, although not FDA approved for young children, they are often used off-label if a child has moderate or severe persistent asthma symptoms)
  • either Flovent 44, Flovent 110 HFA or Pulmicort Respules 0.5mg, Pulmicort Respules 1.0mg and Singulair 4mg
• Step 5 - a high-dose inhaled steroid combined with another medication:
  • Advair HFA 45/21, Advair HFA 115/21 or Symbicort 160/4.5
  • either Flovent 110 HFA or Pulmicort Respules 1.0mg and Singulair 4mg
• Step 6 - a high-dose inhaled steroid combined with other medications, including oral steroids:
  • Advair HFA 45/21, Advair HFA 115/21 or Symbicort 160/4.5 and Orapred (prednisolone)
  • either Flovent 110 HFA or Pulmicort Respules 1.0mg and Singulair 4mg and Orapred (prednisolone)

Keep in mind that except for Singulair and Orapred (oral medicines) and Pulmicort Respules (used with a nebulizer), the rest of these medicines are used with a spacer and mask.

Older children are usually started at a higher dose of inhaled steroid. For example, a six-year-old requiring Step 3 treatment might be started on a Pulmicort Flexhaler 180 twice a day. A teenager needing Step 6 treatment might be prescribed Advair HFA 230/21.

Managing Asthma

In addition an asthma action plan, it can help to get your child's asthma under control if you:

• see a pediatric pulmonologist if your child is requiring Step 3 treatments or higher
• start home peak flow monitoring, either every day or just during asthma attacks, to help better monitor your child's asthma control (if your child is over five or six years old)
• learn about the proper use of asthma medications, and learn to recognize asthma symptoms and early signs of an asthma attack
• identify and avoid asthma triggers, such as dust mites, mold, pet dander, smoke, high ozone days, changes in the weather, etc.
• get treatment for other conditions that may trigger your child's asthma symptoms or make his asthma worse, such as allergies, sinus infections, obesity, obstructive sleep apnea, and gastroesophageal reflux
• have pulmonary function tests performed at least every one to two years to monitor your child's lung function
• consider allergy shots if your child has persistent allergy induced asthma