Understanding Asthma Medications

As an intern in 1978, I was terrified of asthma, because I had no idea how to treat it. Many years of subsequent work with asthmatics has taught me that families are often just as confused about asthma medications as I was. If I’m describing you, this article may help.   

Definition

  1. In asthma, there is a reversible narrowing of airways (bronchi) through a combination of bronchospasm — or spasm of the smooth muscle lining the bronchi — and inflammation of both the mucous lining and the smooth muscle of the airways.
  2. Triggers for asthma include cold viruses, exercise, allergies (such as to grass or mold), cold air, and air pollutants (such as cigarette and wood smoke, smog).
  3. Mild asthma is usually treated with a bronchodilator, which reverses the muscle spasm that causes most of the airway narrowing. Moderate or Severe asthma is treated with both bronchodilators (symptom reliever) and anti-inflammatory drugs (preventive).

Medications

  1. BRONCHODILATOR: Albuterol (Brands: ProAir, Proventil, Ventolin, Xopenex) 2 to 4 puffs via an AeroChamber or other spacer every 4 to 6 hours; 2 puffs are usually enough. If still significant cough or wheeze 10 minutes later, give a 3rd puff, 5 minutes after that give a 4th puff as needed. Children using nebulized albuterol should receive one vial of Albuterol nebulized every 4 to 6 hours.
      • Call your Doctor if your child needs albuterol more frequently than every 4 hours for 12 hours or more.
      • Potential side effects (especially when first started)
        • Increased heart rate
        • Jitteriness or tremors
  2. ANTI-INFLAMMATORY DRUGS (FIRE RETARDANTS)
    • ORAL STEROIDS: These would be prescribed by your doctor for moderate to severe symptoms: for example, if your child needs albuterol every 4 hours for 24 hours or more frequently than every 3 hours, they would be considered. Dexamethasone is often administered at Salem Pediatric Clinic as a liquid, sometimes as a single dose, followed a day or so later by one additional Dexamethasone dose in tablet form, or three to four doses of daily liquid prednisolone or tablet prednisone. Morning administration helps avoid potential sleep problems.
      • Potential side effects (especially when first started)
        • Use should be avoided if there is a possibility of chicken pox
        • Mood changes
        • Sleep problems
        • Long-term use (more than 30 days in a row, or more than five short-term uses in one year) could potentially interfere with growth, the ability to fight infection, or respond to physical stress
    • INHALED STEROIDS: These are administered most often daily on an ongoing basis to patients who are persistent, rather than intermittent asthmatics. That is, using the Asthma Rules of 2 developed by Baylor Health System, the child with persistent asthma uses albuterol more than twice every week, coughs more than 2 nights every month, uses more than 2 albuterol inhalers a year, or has needed oral steroids 2 or more times in 12 months.
      • The Constant Regimen is used for the majority of persistent asthmatics, especially if the child is prone to sudden, severe asthmatic attacks.
        • Constant Regimen:
          • Flovent 44, 2 puffs twice daily (less than 12 years of age)
          • Flovent 110, 2 puffs twice daily (12 years or older)
          • Qvar 40, 1 puff twice daily (less than 12 years of age)
          • Qvar 40, 2 puffs twice daily, or Qvar 80, 1 puff twice daily (12 years or older)
      • The Intermittent Regimen might be an effective regimen for persistent asthmatic children at the mild end of the asthma spectrum, who typically have a few days of cold symptoms before developing a significant cough. Use the intermittent regimen ONLY at the direction of your provider.
        • Intermittent Regimen: At first sign of cold, start 4 puffs of inhaled steroid twice daily until cough is gone for 3-5 days:
          • Qvar 40 (less than 12 years of age)
          • Qvar 80 (12 years or older)
          • Flovent 44 (less than 12 years of age)
          • Flovent 110 (12 years of older)
      • Possible side effects from Inhaled steroids: (minimized by a holding chamber)
        • Hoarseness
        • Yeast infection in the mouth
    • MONTELUKAST (Singulair): This is a non-steroid anti-inflammatory medication sometimes prescribed by your provider in addition to inhaled steroids if your child keeps having asthma flares despite the inhaled steroids.
      • Doses are as follows:
        • 4 mg nightly (less than 6 years)
        • 5 mg nightly (6 to 12 years)
        • 10 mg nightly (12 years or old)

Using Holding Devices

Your child is using an AeroChamber brand holding chamber. This is used to administer medication from HFA-propelled canisters, including ProAir, Ventolin, Proventil, Flovent, QVAR, Advair, Asmanex, Dulera: Waste 4 puffs if no use for 2 weeks (to prime). See package insert for cleaning of AeroChambers.

  1. MASK DEVICES: Insert inhaler canister into end of holding chamber, then shake. Hold mask gently over mouth and activate canister for one puff: Hold mask over the mouth for 6-10 breaths. If desired, may activate canister for one puff, then put mask on mouth within 1-3 seconds.
    • Repeat as many times as instructed, waiting 30 seconds between each puff.
    • Try to avoid crying: Drug is expelled and very few particles reach the airways. Give while your child is asleep, if necessary.
    • Encourage slow, steady breaths.
  2. ADULT AEROCHAMBER WITHOUT MASK: Insert canister into end of holding chamber, then shake.
    • Have patient activate canister for 1 puff, take a long, slow breath, up to 5 seconds, then hold the breath for 10 more seconds.
    • Repeat as many times as instructed, waiting 30 seconds between puffs.
  3. PROAIR RESPICLICK: This is a dry-powder inhaler, FDA approved for age 12 years or older. Swivel down red cap covering mouthpiece, slowly inhale over 5 seconds, hold for 10 seconds; wait 30 seconds before repeating.

Tips

  1. USE ALBUTEROL: Whenever your child’s cough develops early in a cold, or is worse laying down.
  2. CONSIDER AN OFFICE VISIT: If needing albuterol every 4 hours for 24 hours, or more frequently than every 4 hours.