Asthma Update -- Paul Enright, MD. -- 11/25/02

Last Editorial Review: 6/7/2004

By Paul Enright
WebMD Live Events Transcript

Asthma is on the rise in the U.S. What are the reasons behind the increase in childhood asthma rates? What are known triggers? What's the latest research? We asked these and other questions about prevention and treatment when WebMD's own asthma expert, Paul Enright, MD, joined us on WebMD Live.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live. Today's guest is WebMD 's asthma expert, Paul Enright, MD. Let's get to some member questions:

Member: My nephew is only 7 months old and he has asthma. He gets attacks at least every week. What is the best treatment for it? There is asthma in his mother's family.

Enright: The best treatment for infants is very similar to that for adults. Inhaled bronchodilators such as albuterol given by nebulizer and inhaled corticosteroids are popular these days. The good news is that over one half of children with asthma-like symptoms below age 2 do not have asthma by the time they start school (elementary school -- age 6).

Moderator: Can you address any genetic link as inferred by the member's question?

Enright: The risk of asthma in children is much higher when one or both parents have asthma or allergies. There is one medical test that can be done to assess the asthma risk in children under age 2, that is the blood IgE level.

Member: Are exercise-induced bronchial spasms the same thing as asthma? If so, will my child have this condition for the rest of her life? Is this also due to being overweight?

Enright: Exercise-induced bronchospasm happens to most people with asthma. It is usually easily prevented with appropriate medication.

About one-third of children with EIB or asthma grow out of it by their teen years. Obesity is associated with asthma, and weight loss and exercise in a person with asthma who is overweight can improve asthma control.

Member: My son's asthma only flares when he exercises in cold weather. Why is that?

Enright: Exercise in cold weather is a strong stimulus for EIB because of the drying of airways. Again, most EIB can be prevented by using albuterol or other asthma medications a half-hour prior to exercise. Walking or mild exercise in cold weather is less likely to cause EIB if a sweater or scarf is placed around the mouth and the nose. It recaptures some of the moisture and heat exhaled.

Member: Dr. Enright, thank you for answering my questions on the asthma message board. I take Advair twice daily and albuterol five days per week for exercise. I am concerned about long-term effects of these medications. Should I be concerned? I am referring to the effects of the bronchodilators, the pounding heart, elevated blood pressure, etc.

Enright: I appreciate your many insightful comments on the message board each week. There are no known long-term side effects of inhaled bronchodilators -- only short-term effects with which you are familiar, such as pounding heart, headache, and nervousness. If these side effects are bothersome, you may try alternate medications to prevent EIB such as Singulair, or even Cromolyn.

Member: My 17-year-old daughter is taking the medication Singulair to control her asthma. She began treatment with this drug three years ago and it has been a godsend. My question is, is it safe for her to continue this daily medication indefinitely? Are there any known side effects from long-term usage of this drug?

Enright: There have been no long-term adverse side effects reported from daily use of Singulair. It is an excellent asthma controller medication for about one-third of those who try it. Unfortunately, one-third of patients with asthma have no benefit from Singulair. And good or bad or lack of response cannot be predicted without trying the medication.

Moderator: What are the primary categories of asthma medications?

Enright: The two primary categories of asthma medications are controllers, which reduce airway inflammation, and relievers, which are bronchodilators that quickly open up the airways. It is important that if an asthma reliever or rescue medication is needed more than two times per week that a daily asthma control medication is indicated. The asthma controller medications can be subdivided into inhaled corticosteroids such as Flovent and Leukotriene; antagonists, such as Singulair; and a few people still take Theophylline pills or Cromolyn inhalers as asthma-controller drugs.

Member: My daughter was recently diagnosed with asthma. After visiting the specialist she recommended a nebulizer. After two weeks of once-a-day use my daughter's appetite is almost non-existent. Is this a normal side effect?

Enright: It is important to know what type of medication is placed in the nebulizer. It could be a bronchodilator, which makes her nauseated. Inhaled corticosteroids increase one's appetite, on the other hand. Ask the doctor if Xopenex might cause your daughter fewer side effects.

Member: What advantages are nebulizers over just rescue inhalers?

Enright: Nebulizers are usually driven by a motor or battery powered unit, costing about $200. It takes more time to deliver asthma medications by nebulizer, but for children under age 2 who cannot easily use a traditional metered dose inhaler (MDI) a nebulizer is useful. Studies have shown that inhaling most asthma medications by nebulizer for adults is no more reliable than using inhalers, especially the new dry powder inhalers.

Member: What are the most obvious signs of asthma in a child? My son is 26 months old and I've been wondering if he may have a slight case due to constant coughing and congestion. He also breathes thru his mouth.

Enright: All three of those can be signs of asthma. You might purchase a $5 stethoscope from a pharmacy to listen for wheezing, but it's not always present during asthma attacks. The next time your child has such an episode, take him to an urgent care center for evaluation.

Member: Can you diagnose asthma in a child under the age of one?

Enright: Pediatricians are loath to make the diagnosis of asthma in children under age 3, because more than half of them "grow out" of it. The risk of lifelong asthma is higher in children with asthma symptoms if their family members have asthma or if they have high blood IgE levels.

Member: Hello. I have twin girls 7 years old that were six weeks premature. They have been diagnosed with asthma. About two years ago their doctor put them on Flovent. They take two puffs from an inhaler a day. Brittany's asthma is worse then Jennifer's. Jennifer has now acquired high blood pressure. My question is whether or not this condition could be related to the daily use of Flovent.

Enright: Good question. Corticosteroids such as prednisone when taken by mouth are known to increase blood pressure and make diabetes worse, amongst other long-term side effects. Manufacturers of inhaled corticosteroids such as Flovent do not believe that such serious side effects are occurring more than 5% of the time when they are used every day. However, there are reports of children taking high daily doses of Flovent who have experienced serious side effects such as hypertension.

A SIDE COMMENT: A young man asked about taking Primatene Mist for asthma. He likes to treat his own asthma without seeking medical attention or using prescription medication. I believe this is a dangerous approach since asthma can worsen suddenly and even cause death. Asthma medications available only by prescription are much safer than over-the-counter remedies and are much more effective. Primatene Mist is adrenaline, and when overused has caused death in individuals with heart disease.

Member: Is there much difference in Advair 100/50 and 250/50? I am on 250/50 but would love to try and go down a step

Enright: Advair comes in three strengths, all of which contain 50 micrograms of salmeterol (Serevent), a long-acting bronchodilator.

The three strengths of Advair vary in their dose of fluticasone (Flovent), either 100, 250, or 500 micrograms per inhalation. Advair has quickly become the most commonly prescribed medication for asthma in the U.S. Once a person's asthma has become controlled taking a higher dose of Advair, for three months or more, the patient should work with his or her physician to step down the dosage. Therefore, you are correct in wishing to move to a lower daily dose if you have been in the green zone of good asthma control.

Member: Do you think Pulmicort causes less systemic effects and adrenal suppression than Advair or Flovent?

Enright: For equal daily doses, I believe there is no difference in either the effectiveness or long-term side effects when comparing these two potent inhaled asthma medications.

Member: What is causing asthma in our children and what do we need to change?

Member: Why the huge increase in childhood asthma? Is it pollution?

Enright: There are many factors that cause asthma. Choosing the wrong parents is a major factor. Indoor air pollution with allergens such as cockroaches, house dust, mites, and pet dander are also important factors.

Some people believe in the (hygiene) hypothesis that states that asthma has become more common in the developed industrialized countries due to the overuse of antibiotics and excessive cleanliness. Outdoor air pollution is also a factor and worsens asthma control, but I don't believe it's a cause of asthma, except in some occupational settings.

I believe the most important thing you can do to control asthma without the use of medications, or to reduce your need for asthma medication, is to obtain allergen skin testing, and then work to reduce your exposure to indoor allergens to which you have become sensitized.

Member: What is the link between allergies and asthma? Does having one make you more likely to have the other?

Enright: Good question. Absolutely. Both children and adults with hay fever allergies (rhinosinusitis) are much more likely to develop asthma than compared to people without allergies.

Member: What is silent asthma?

Enright: I believe that silent asthma means asthma that does not cause wheezing. Some people have asthma that only causes cough or chest tightness. Also, people whose asthma is becoming worse over several days will stop wheezing when their asthma is life-threatening.

Member: My granddaughter is 15. This is her third case of pneumonia. Her asthma seems to be getting worse right now. She is on 60 mg of prednisone and 4,000 mg of augmentin. Any suggestions?

Enright: Often pneumonia unless confirmed by abnormal chest X-ray in one with asthma is just a severe asthma attack. Very rarely an aspergillis infection can cause pneumonia and asthma that is difficult to control. Ask your granddaughter's doctor if the pneumonia was confirmed as viral, bacterial, or fungal. I highly recommend learning more about asthma from a book such as Dr. Tom Plaut's Asthma Guide or Jonathan Brostoff's book, Asthma. Then you can become a partner with your granddaughter's pediatrician in improving her asthma control.

Member: My 2-year-old granddaughter has asthma. She had RSV when she was six months old and her doctor says that some infants develop asthma after a severe bout of RSV. My question is this: She takes Singulair and has breathing treatments when it is at its worst. Since beginning the asthma medications and the breathing treatments she has nightmares and does not sleep well.

She was at the doctor's office last week for a bad spell with the asthma and chest congestion and was given a liquid steroid to take. She slept with me last night and I was awakened by her 13 times. I had to get up out of the bed with her once to quiet her. She was talking and crying about her toys. She never sleeps a full night and hardly ever sleeps longer that one hour without a restless period and crying out. Could this be a result of her medication, and if so will she outgrow it? She attends preschool and they say she is one of the brightest children in the class. I am worried that when she gets of regular school age the restless nights could play havoc with her school days. After one of her most restless nights this week the preschool teacher said she fell asleep while eating her lunch and slept for three hours.


Asthma is a chronic respiratory disease. See Answer

Enright: Indeed it is unfortunately common for a severe respiratory viral infection to leave children and adults with asthma for the rest of their lives. Sometimes, however, this viral-induced asthma will only last a few months. The nightmares could be a side effect of the Singulair. Ask the pediatrician to confirm this. Her asthma seems severe at this point, requiring the use of oral corticosteroid (Prelone). Ask her pediatrician if daily use of Pulmicort in a nebulizer might be a better choice to reduce her airway inflammation.

Unfortunately, severe asthma is worse at night, and causes daytime sleepiness both in children and their parents.

Member: My son has reactive airways disease. He is now 5 and his flare-ups are few and far between, but he had one this weekend and had to use a nebulizer. Does this mean he'll continue to have problems or should he grow out of it?

Enright: It sounds like your son has mild intermittent asthma, which is often labeled by pediatricians as reactive airways disease. If he requires albuterol rescue inhaler more than twice per week ask his pediatrician for an asthma controller medication. About one-third of young boys do indeed grow out of their asthma by the time they become teenagers.

Member: What is the significance of oxygen saturation during an asthma attack? My O2 stats rarely drop below 94% even when I am barely moving any air, but my respiratory rate will increase to 30-45 for hours at a time.

Enright: You must have very severe asthma for oxygen saturation as measured by a pulse oximeter on your finger to fall below 93%. Lung-function measurements such as FEV1 are much more sensitive than pulse oximetry to detect bronchospasm exacerbations.

Member: Have there been any studies on the difference in peak flow/FEV1 drop in cough variant and typical asthmatics, and its relationship to acute severity? If so, what have they shown?

Enright: Cough variant asthma is asthma without wheezing. It is poorly understood by physicians and very little research has been done on patients with cough variant asthma. It usually responds to conventional asthma therapy. Some patients with this disease also have decreases in lung function, but others do not.

Member: What hope is there on the horizon for those of us with more of an intrinsic rather than extrinsic asthma?

Enright: The terms intrinsic versus extrinsic asthma are rarely used anymore. There is very little differences in the way allergic versus non-allergic asthma are treated. If the new anti-IgE medication ever becomes approved for use in the U.S. it is more likely to help those with allergic asthma who have high blood IgE levels.

Member: Am I going to have stay the rest of my life on medication to control asthma? I've had it for five years and I am 34 now.

Enright: Unfortunately most people whose asthma started in adulthood continue to have asthma for the rest of their lives. You have an opportunity to reduce your need for daily medication by identifying triggers such as GERD (heartburn), or sinusitis, or indoor allergens at home or in your workplace.

Member: Should everyone with asthma have an action plan and peak flow meter? I have moderate persistent asthma and my doctor (wonderful man) said to just "pay attention" to my breathing and I should be fine.

Enright: Everyone with asthma should have a written asthma action plan from his or her physician. If your doctor has not given you one, download one from the site on WebMD and take it to your doctor at your next visit. Some, but not all patients with asthma find that objective measurement of their lung function using a peak flow meter or portable spirometer helps them to manage their asthma better than simply relying on symptoms. Dr. Tom Plout's Asthma Guide has several chapters that describe how to use peak flow meters for optimal management of your asthma.

Moderator: Dr. Enright, we are almost out of time. Do you have any final comments for us today?

Enright: Yes. You can find excellent information about asthma on the WebMD asthma site, asthma message boards, and Medscape areas. Don't hesitate to ask lots of questions about your asthma and its treatment from your healthcare providers and other sufferers. Asthma therapies are improving each year, becoming safer and more effective.

Moderator: Thanks to Paul Enright, MD, for joining us today. Please visit Dr. Enright on the WebMD Asthma message boards. To learn more about asthma, be sure to explore all the info here at WebMD, including our message boards, the Personal Reporter feature and live chats.

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