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Preventing Flare-Ups
Multiple arms to the advice I give There are multiple arms of advice of I give to families about how to prevent asthma attacks. The psychological piece of it is to help them not to panic, to give them a sense of “OK, this is something we can manage and that we know how to deal with.” Then more specifically, for most kids it's a matter of using their Albuterol inhalers at the frequency it needs to be used. For some families, particularly if they are newer to managing asthma, I might tell them to come into the hospital so that we can take a listen and a look at the child and figure out what other steps we need to do. For some families, I do it over the phone. A big part of it is empowering them to know they can and should call us as soon as they think something is wrong, and even if it is just to say “This is what's going on. This is what I was going to do about it. Does this make sense?”Shari Nethersole, MD, Pediatrician, Department of Medicine The idea of preventative therapy can take some time The concept of taking a medicine when you don't have symptoms can be challenging for some families to grasp. Most people understand that when you're sick you're going to take this medicine, it's going to make you feel better. But the idea that you have a chronic disease where you have to take medicine every day to actually prevent something from happening is not necessarily intuitive for folks, and getting them to understand the idea of a preventative therapy can take some time.Shari Nethersole, MD, Pediatrician, Department of Medicine Figure out a system so medicines get taken at proper times For a lot of families it's really hard to remember to take the medicines on a regular schedule. Most of the medicines should be taken twice a day, but in the hustle and bustle of life that can get lost. I try to help families figure out a system from so that medicines get taken or get used at the proper times. For a lot of families that means trying to simplify their medication regiment, so they maybe just take everything at night 10 minutes before going to bed. They can have a little checklist and check off all the things they're supposed to do.Shari Nethersole, MD, Pediatrician, Department of Medicine We advise kids to have their asthma medicines at school For most kids who have intermittent need for an asthma medicine, we advise them to have their asthma meds with them at school in the event that they develop symptoms. It varies a lot from kid to kid how much they will actually need to use their inhalers at school; sometimes it's a safety measure. Most school nurses are really comfortable with asthma and know how to recognize the symptoms and when to give the medicines, so it's never a bad idea to have the medicines at school. For some patients, having the school nurse give kids their meds on a regular basis is actually one of the best ways to ensure some level of compliance. For some of the kids we see who come from disorganized home settings and who need a twice-a-day asthma medicine who aren't doing well with their asthma, it's a good strategy to have at least one of their daily doses be delivered by the school nurse who can check it off on the calendar every day and make sure that it happens routinely. The school can be an ally in that way.Hans Oettgen, MD, PhD, Associate Chief, Division of Immunology, Children's Hospital Boston The importance of control medications Although most folks reach for the quick relief of an Albuterol pump to stem the immediate symptoms of an attack, too many fail to approach the problem from a preventative wellness perspective that relies, in great part, on the use of daily control medications. I ask parents at workshops all the time “How many of you have high blood pressure?” and their hands all go up. Then I ask “How many of you take medication every day for the high blood pressure?” and their hands go up. Then I ask “How many of you have symptoms every day of your high blood pressure?” No hands go up, because their daily controller medicines work. Then I explain it's the same thing with asthma.Amy Burack, RN, MA, AE-C, Community Asthma Programs Manager, Children's Hospital Boston Apparent acute attacks may occur because minor symptoms that were there for a long period of time were either not recognized or ignored. Minor symptoms may be very subtle: nothing more than a little shortness of breath with exercise, a nighttime cough, a cough with laughter or maybe the child seems a little fatigued or crabby or just doesn't feel well. Because parents are with their children all the time they might just think these things are to be expected, so sometimes it helps to have a doctor pick up on these subtle signs and advise what to watch for to try and avoid acute episodes. Once parents learn about what to look for and once they know they can intervene, I tell them to act quickly and use the tools they have. Parents, once they realize the importance of these mild symptoms are more ready to treat asthma before it becomes acute. They are the best ones to recognize early signs of deterioration. We tell parents that the earlier they start to treat a symptom of asthma the less likely that their child will be in trouble. If they notice symptoms on a Saturday night and think, “I'll wait until Monday to call,” it's more likely that by Monday night things are going to be worse. If you learn how to use the medications, learn what the early signs are for your child, and go to your doctor sooner rather than later, the chance of controlling asthma is much greater.Frank Twarog, MD, PhD, Senior Associate, Department of Medicine, Division of Immunology We emphasize early warning signs, so that treatment is started at the first signs of a problem, for example, when the child first starts coughing at night or gets a cold. We encourage parents to use their Asthma Action Plans* and be in close contact with their child's primary care provider, so that if the child's symptoms aren't improving or are getting worse, s/he gets seen quickly. Of course, they also need to recognize, when it is an emergency and they need to go to an Emergency Room, for example, if the Albuterol isn't working, the parents see the child's muscles being pulled in between the ribs, the child is having trouble speaking or is breathing hard and fast.Susan Sommer, RNC, NP, Nurse Case Manager, Community Asthma Initiative *To view examples of Asthma Action Plans, click here or visit the Clinician Contributions main page. There are overt signs and symptoms. The classic four are wheezing, coughing, shortness of breath, and complaints of chest tightness. But there are many early warning sighs that can appear long before breathing changes occur that signal parents to an impending asthma flare-up. The big one that should cause a parent to react is the very first sign of a cough or a cold. Even the most well-managed, well-controlled child with asthma is going to have a problem if they get sick. You can have very active kids running around but when their breathing becomes labored and their oxygen levels change, they slow way down. The very mellow kids can often get hyper and uncharacteristically agitated when their breathing changes. You want to look at these kinds of behavior changes. Some kids, usually those with allergy-related asthma, often wake up with dark circles under their eyes— a good early indicator that presents before breathing changes become noticeable, before the coughing and the wheezing kick in. Parents, family and friends, school teachers, and after-school staff all need to be able to recognize asthma early warning signs and breathing changes in these kids and refer to the child's Asthma Action Plan* to know which medications to reach for and how to dispense them. There's a huge misconception around the notion of an “asthma attack”— that an “attack” occurs only when asthma becomes so bad that a trip to the local ER is required or, worse, the child is hospitalized…WRONG! An “asthma attack,” “flare-up,” or “exacerbation” occurs anytime the child experiences symptoms- even the most mild symptoms of cough or wheeze. That's the point when action needs to be taken.Amy Burack, RN, MA, AE-C, Community Asthma Programs Manager, Children's Hospital Boston We have a nurse during the days and an on-call person at night and weekends that answers our clinic line hourly or can be paged within a few minutes. We try to tell families to double the inhaled steroid inhaler when the adolescent first starts coughing— so many families wait days after a cough starts to change meds. As soon as the adolescent starts getting a cough, that's when he/she needs to double the medicine dosages so they're ahead of the asthma. If you can stay ahead of an attack, you may never need Prednisone or have to come to the hospital, or at least not as often.Elizabeth R. Woods, MD, MPH, Associate Chief, Division of Adolescent/Young Adult Medicine, Director, Children's Hospital Boston Community Asthma Initiative We tell parents that the earlier they start to treat asthma symptoms the less likely that their child will be in trouble. If they notice symptoms on a Saturday night and think, “I'll wait until Monday to call,” it's a sure thing that by Monday night things are going to be worse. If you learn how to use the medications, learn what the early signs are for your child, and go to your doctor sooner rather than later, the chance of controlling asthma is much greater.Frank Twarog, MD, PhD, Senior Associate, Department of Medicine, Division of Immunology Figure out what the triggers are It's important to figure out what causes flare-ups for a child, because it's different in every individual. We focus a lot on identifying triggers for asthma in our patients. Triggers range from upper repertory infections— some kids get asthma every time they get a cold, to allergen exposure— some kids have specific things that they have allergies to (like certain pets or foods), or exposure to extremes of temperatures— going out on a really cold day it makes some kids cough. Also, exercise makes some kids cough; emotional stress can cause asthma attacks in some kids. If we can get a good handle on what a child's triggers are, then we can deal with the triggers individually to see how we're going to reduce that kid's exposure to them. If a cat is a trigger, for example, we can figure out how to prevent exposure to the cat. If the kid has to be exposed to a cat, we can work to see if there is something we can do right before the exposure to prevent that exposure from leading to an asthma flare-up, like giving him or her asthma medicine before he or she comes into contact with the cat. If a trigger is cold air, and the child plays hockey and is exerting himself or herself and being exposed to cold air at the same time, there are things we can do to minimize the cold air exposure. They can wear one of those masks that covers your mouth when you breathe, and/or use some asthma medicines right before hockey practice. A lot of what we talk about in clinic is what the triggers are and to identify the best strategies to prevent those triggers from actually causing an asthma attack.Hans Oettgen, MD, PhD, Associate Chief, Division of Immunology, Children's Hospital Boston I really focus on avoiding the triggers. If pets really trigger a child's asthma and the family has a pet, at a certain point you have to make a tough decision about what you want to do— either remove the pet or minimize the exposure to the pet. Maybe the cat doesn't go into the child's bedroom and the bedroom is a cat-free zone, or there's only one room in the house that the cat's in. Dust is a trigger for a lot of kids, so I make sure they have the allergy-proof covers for their mattresses and their pillows, and give instructions or information on how to minimize that exposure to dust in the household. For a lot of kids getting colds in the winter triggers them, so I focus on how you put the antenna up when you see your child's getting a cold and recognize that that it could potentially tip them over the edge.Shari Nethersole, MD, Pediatrician, Department of Medicine Asthma really is a family disorder. There are lots of things that family members do, or use, that can trigger a child's asthma, whether it be the family pet(s)that no one can bear to part with, the strong-smelling-colognes, hairsprays and body mists that some family members might use, or the scented candles and potpourri around the house. Then there's cigarette smoke, cleaning products or the other well-meaning relatives who love to have the kids on the weekends but have a ‘gazillio' pets of their own. The whole family needs to learn about environmental triggers and how they can negatively impact an asthmatic child's life.Amy Burack, RN, MA, AE-C, Community Asthma Programs Manager, Children's Hospital Boston Getting parents to stop smoking It's very hard to ask parents to stop smoking. If the parents smoke, my advice to them is, number one: try to quit. If they've tried before and it hasn't worked, I tell them to try again, to keep trying to quit. If they can't do that, we work on trying to cut down on the number of cigarettes they smoke. I tell them to try decrease the number of times they light up just out of habit's sake, and to only smoke when they feel they can actually enjoy it, and sometimes that's enough to cut back from a pack a day to seven a day.I advise parents, too, that they shouldn't smoke in the car while the children are with them, nor should they smoke in the house. I encourage them to use a smoking coat or jacket when they go outside to smoke, and to leave it either right outside or right inside the door. Most parents are surprised when I tell them that smoke can stick to their clothing, and that most kids of parents who smoke smell like smoke themselves. It is well-documented that children of smokers are more at risk for childhood illnesses such as ear infections and asthma than children of non-smokers. It's hard for a lot of people to eliminate smoking from their lives, and the people who have a really hard time with it are the people living in poverty who can't always control their living situations. If a family loses its home and has to move in with Uncle Joe and he smokes, for example, they have no control over that— he's paying the rent! I do try though to focus more on who the caregivers for the child are and get those caregivers to smoke responsibly. Beth Klements, MS, APRN, BC, Asthma Clinical Nurse Specialist, Pediatric Nurse Practitioner Asthma attacks are only the tip of the iceberg I don't think that in this country asthma is accepted as a chronic condition. For hypertension, for example, it is accepted that your doctor will give you medicine and you actually should take it all the time (even though perhaps you don't). There seems to be more reluctance to do that for asthma— many people, including doctors, view it as an episodic problem. What is not realized is that for the many who have asthma it's a continuum, and what they see during an asthma attack is really only the tip of the iceberg. It's amazing how often you will treat children and adults who have asthma and come in thinking they don't have a chronic condition, then advise them to take medication regularly the next month or two and when they return they say “Gee, I didn't realize I was limited before. I am doing much better, and I feel better.”Frank Twarog, MD, PhD, Senior Associate, Department of Medicine, Division of Immunology I do a lot of parent education workshops. I try to engage parents in conversations that make them feel comfortable enough to share information about themselves and their kids. I ask them “Tell me how asthma affects your lives and the lives of your children. What questions do you have that I can help you with?” There's never enough time in an office visit for the doctor to prepare and explain an asthma management plan in enough detail so you understand it all— what all the prescribed medications are about; delivery devices and the appropriate way to use them; next steps to take when your child is not feeling well. Asthma is about education— and more education. Encouraging parents to learn as much as they can about their children's asthma can be done in a variety of ways and locations— through workshops at the child's preschool or Head Start; at the YMCA and Boys and Girls Club; at church or social gathering places.Amy Burack, RN, MA, AE-C, Community Asthma Programs Manager, Children's Hospital Boston The Asthma Action Plan: An Asthma Management Tool It's important to really understand the step-wise progression from being in your good zone and managing your asthma, to starting to tip over the edge and needing to ratchet up the management a little bit to prevent it form becoming a more serious episode. We have Asthma Action Plans* that we've adapted from the national model that the National Heart, Lung and Blood Institute created. The green zone is when you are doing well and the medicines are doing what they are supposed to be doing and are being taken every day. The yellow zone is when they are starting to get into a little bit of trouble and there are some signs that their lung function isn't as good and they're starting to show some signs of a cold, and describes some things that you start to do to adapt and change your management. We list how they change the medicines when they get into that yellow zone. The red zone explains what to do when they're really bad and having many more symptoms and they need to use the medications more and when you need to contact the physician.Shari Nethersole, MD, Pediatrician, Department of Medicine *To view examples of Asthma Action Plans, click here or visit the Clinician Contributions main page. Why clinicians like Asthma Action Plans As clinicians, we love that Asthma Action Plans* are written out in color so that families can stick it to their refrigerators. That way, if it's Dad who's in charge one day for giving meds and he's not used to giving out the medication, he can see exactly what to do. We love that there are many copies of Asthma Action Plans, so if parents are divorced we can give a copy to each household, we can give one to the daycare, and one to the school nurse so that everyone knows this is what Suzie Q does when she's feeling well and in her green zone, this is what needs to be done when she starts to get a cold and is in her yellow zone, and then if she is not getting better, to do what the red zone indicates, whether it be giving her Albuterol right away, or calling the doctor or calling if the Albuterol doesn't work, or getting her to the nearest health care provider even if it means calling 911. The Asthma Action Plans are great devices, and help put Parents “in the driver's seat” for their children's asthma.Beth Klements, MS, APRN, BC, Asthma Clinical Nurse Specialist, Pediatric Nurse Practitioner *To view examples of Asthma Action Plans, click here or visit the Clinician Contributions main page. Why other people like Asthma Action Plans School nurses love Asthma Action Plans* because when a child comes to them and is short of breath, they know exactly what they should do. Families like it to because it puts them in the driver's seat: instead of having to call their health care office, over time they learn that if child gets a cold, they can look right to their Plan and know what to do, and maybe doing what the Plan says will be all they need to do to get back to their child's green zone, or maybe they can call up their health care provider and say, “You know what? Suzie Q's had a cold for a week and she's been in her yellow zone for a couple days. I've been doing everything and she's still not getting better. What do I do?” The Asthma Action Plans are a win-win situation for everybody: the providers, the parents, and the school. So we really like everyone with asthma to have an Asthma Action Plan.Beth Klements, MS, APRN, BC, Asthma Clinical Nurse Specialist, Pediatric Nurse Practitioner *To view examples of Asthma Action Plans, click here or visit the Clinician Contributions main page. |
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Hospital Boston Department of Psychiatry. All Rights Reserved. The information on this website should not be taken as medical advice, which can only be given to you by your personal health care professional. Updated: June 5, 2007 |
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