Asthma – PediaCast 186
Today's PediaCast is all about asthma. Listen as Dr. Mike and special guest Dr. Karen McCoy, Chief of Pulmonary Medicine at Nationwide Children's Hospital, define asthma, trends in diagnosis, symptoms, treatment, medicines, and risks associated with the respiratory inflammation.
- Dr Karen McCoy
Chief of Pulmonary Medicine
Nationwide Children's Hospital
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello everyone! And welcome once again to PediaCast, a pediatric podcasts for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. I’d like to welcome all of you to the show. We’re going to cover Asthma today, which is a popular topic. We got lots of parents writing in and wanting us to discuss that. So we brought Dr. Karen McCoy into the studio, and we could get into her after just a minute.
Dr. Mike Patrick: All right, Dr. Karen McCoy is the Chief of the Section of Pulmonary Medicine here at Nationwide Children's Hospital and a Professor of Pediatrics at the Ohio State University College of Medicine. Her clinical interests focus on the managing patients of all ages with cystic fibrosis and pediatric asthma. She's a principal investigator with both the Cystic Fibrosis Translational Therapeutic Developmental Center and the Asthma Clinical Research Center. She also serves as Associate Director of the Fellowship Training Program in Pediatric Pulmonology here at Nationwide Children's Medical Center. So welcome to PediaCast, Dr. McCoy!
Dr. Karen McCoy: Hey Dr. Mike, how are you?
Dr. Mike Patrick: Good! I actually should say welcome back to PediaCast. You actually did this once before by phone. It's been a long time ago. In fact, it was in 2007. It was four years ago, episode is 69. We did Vocal Cord Dysfunction and if you kind of vaguely remember doing that.
Dr. Karen McCoy: I do vaguely remember that.
Dr. Mike Patrick: But I was, but that time I was doing this in the basement of my house and it was nowhere fancy. So, we're glad to have you here face-to-face.
Dr. Karen McCoy: Thanks for having me!
Dr. Mike Patrick: And we actually, the two of us go back much further than that, I did some calculations, and back in 1993 so 18 years ago, my very first pediatric rotation as a medical student, you are my attending on the Pulmonary floor. We were still using Theophylline. It was a while ago. And of course I was stuck around here and did my pediatric residency and we've worked together on several other occasions. I am really happy to have you back.
Dr. Karen McCoy: Good to be here.
Dr. Mike Patrick: I guess a good place to start with asthma is what would be a good definition for asthma?
Dr. Karen McCoy: Well of course, asthma is a disorder that involves the airways mostly and it would be considered an inflammatory type of involvement that has several effects on the airways, mostly the small airways. That can be mediated through things that you’re infected with or things that you are allergic to or just because you are hyper responsive to some things.
Dr. Mike Patrick: Now, we see a lot of kids who wheeze and I’ve got into the point where I don't ask parents does your child have a history of asthma because it really does your child has a recurrent wheezing because they don't want to call it asthma. What point would you call a kid who has wheezing that they have asthma?
Dr. Karen McCoy: Well, you are entirely right. There's a lot of overlap. I do think though that children who wheeze repeatedly and specifically if they have those wheezing episodes that are unassociated with respiratory infection, and they respond appropriately to asthma type medications, then they would be better served to be designated as asthmatic for now, even at any age.
Dr. Mike Patrick: How common is asthma?
Dr. Karen McCoy: Very common. Much more common than most people realize or even our statistics would imply. I think most of the time it’s quoted that about 10%, maybe some people would say 15% of children have asthma. But in our experience and in some studies that we've done in specific populations, it can be much higher.
Dr. Mike Patrick: One of the things that you hear about the news is the incidence of asthma is increasing. Do you think that the disease is increasing, are we just recognizing it more and diagnosing it more or maybe a combination of these things?
Dr. Karen McCoy: I think it is a combination. I think that there has been a lot more recognition, although there still is underrecognition, and I do think that there’s unquestionably changes that have occurred as a result of the way we live, the way our air quality has been, and such related things.
Dr. Mike Patrick: Sure, I guess if we go down in, of course this podcast is aimed towards parents, but we do have a lot of educated parents in the audience. We have a lot of nurses and other clinicians who listen. Sort of at the tissue or cellular level, what exactly is happening to cause the inflammation of the airways associated with asthma?
Dr. Karen McCoy: Well, there is a chain of events. I’m not sure that anybody really understands which thing comes first, or if it’s the same for each suffering patient. But clearly, there is a combination of inflammatory cells that are present in increased amounts there and the airway walls actually become swollen. And of course, there's a contribution from the smooth muscles that can contract and tighten up.
Dr. Mike Patrick: In terms of triggers that sort of set that process into motion, and we’ve talked about viral upper respiratory infections can do it, what are some other things that can be the initial trigger for an asthmatic event?
Dr. Karen McCoy: Well, everything clearly is dwarfed by viral infections for pediatric patients, of course. But there are many other things, things that you are specifically allergic to and that trigger off that type of response in an individual. Things like poor air quality days that we are all very mindful of, especially during the summer. Exercise, activity increases sometimes associated with such things such as laughing, crying, even just emotion.
Dr. Mike Patrick: Do we understand why exercise and emotion would do it or create an inflammatory event?
Dr. Karen McCoy: Not entirely, and it's probably not always the same. There were probably times when you exercise outside you are exposed to a lot of outside allergens in addition to the exercising, but exercise is thought to be a trigger, known to be a trigger because the changes and the relative pressures in the airways and the cooling that takes place with relative high room ventilation.
Dr. Mike Patrick: Sure. So folks, who are prone to this, they have some sort of a trigger that starts the process off, whether we know what it is or we don't know what it is. And we get inflammation in the lower airway so that causes swelling into the actual passage of the small airway. So that it is more difficult for the air to flow through. And I know this is a little more basic but then there are other parents out there listening who need that. In terms of, when this can become life threatening obviously if there's so much swelling, you occlude so much of the passage the air really can't move and then oxygenation becomes impaired, her exchange of gases becomes impaired, then it can become a life threatening thing.
Dr. Karen McCoy: Yeah, although do think that it is important to remind ourselves that under the right circumstances, we always talk about the severity of asthma, mild, moderate, severe and so forth, and it’s been very clearly established that all levels of severity have the potential for really severe attacks – episodes of asthma flare that even can be fatal.
Dr. Mike Patrick: Yeah, and one of the things in the emergency department we ask have you ever been hospitalized before, have you ever been in an intensive care unit for your asthma. But even parents who have their child’s not really had that wheezing. Maybe it’s a once or twice a year thing and they do some albuterol and they're better and they've never even been to an emergency room. You can't let that give you a false sense of security that that's all the further this is going to go.
Dr. Karen McCoy: Exactly, and there is a subgroup of people, kids among them, who are less good at perceiving when they are having trouble. They do not have the signals that most other people do that tell them I'm short of breath, and these are the kids that walk in and say they are fine and you measure their lung function or their oxygenation, and clearly not fine.
Dr. Mike Patrick: What other diseases can lead to wheezing? So if you have a child who's having a wheezing at home, are there other things you have to think about other than asthma?
Dr. Karen McCoy: Oh, absolutely. Just, it's a viral infection. It can certainly present at the right ages with wheezing. We always think about a number of diagnoses that have to be excluded if you're wheezing. Cystic fibrosis is still on the list of things that if you wheeze repeatedly could be there; although we are reassured in a large percentage of cases with the advent of the statewide newborn screening, that does miss some cases and we still have to think about the disease.
Kids who have a lot of acid reflux can sometimes present as wheezers. Certainly, certain kinds of wheezing can be associated with the child having accidentally gotten that foreign body into the mouth and down into the airway, and started having distress.
Dr. Mike Patrick: And sometimes, it's difficult to tell if someone's really wheezing without listening with the stethoscope. So it is important that a doctor take a listen. Their parents would come and say my child was wheezing and then really what they’re hearing is just upper airway noise and it’s not what they are describing as wheezing isn’t necessarily wheezing. And sometimes, with croup, they can have stridor, which is not really the same thing as wheezing. And so, it is important that parents think their kid’s wheezing have been seen by doctors. They can make sure if that's going on or if there’s something different.
Dr. Karen McCoy: Absolutely the case.
Dr. Mike Patrick: So, how do you distinguish asthma from some of those other things?
Dr. Karen McCoy: Well again, everything else that goes with it. Our ears prick up when we are able to establish allergies in the child and/or the family. Clearly the pattern of flare is important to us. The absence of other things, I mean as you know, a lot of what we do, is rule out something that can masquerade with the same symptoms and so some testing needs to be done.
Dr. Mike Patrick: Sure. Chest x-ray usually, is that something at least in a new kid who’s just first diagnosed with it?
Dr. Karen McCoy: In a new asthmatic, particularly one that where the pediatrician has thought that they need a subspecialist to review them, then we don't hold our head hold up very high if we haven't done a thorough job of saying it's not this, it's not that.
Dr. Mike Patrick: Right. So once you sort of decided that a kid does have asthma, how do you treat that?
Dr. Karen McCoy: Oh, we treat it well – of course. There are some guidelines that are out there. They have morphed enough times that they have most people confused. But they are still fairly reasonable guidelines in general with the small child and with relatively infrequent and mostly virally associated things. We start with low-dose inhaled steroids. And with an older child, who has more impairment perhaps. We would go to medium and then for more severe presentations; we would go to high dose. We also have the option of adding adjunctive medications such as Singulair or montelukast. But always with these controllers, we need rescue medication available, things such as albuterol, xopenex that type of thing.
Dr. Mike Patrick: Right. So you really can divide the therapy into maintenance therapy. What you are doing on sort of a daily basis to try to keep that inflammation down so that you can avoid having an acute flare and then the rescue medicine. And I think it's really important that parents understand the difference between those two. Even today, you see people who come in saying that their kid had their wheezing and they use their Flovent. They clearly don't understand the difference between the maintenance medicine and the rescue medicine.
Dr. Karen McCoy: Right. This is a key point that to recognize that asthma is in most circumstances going to be a chronic condition at least for awhile. That doesn't mean chronic forever. But it does mean that it’s actually often a worst strategy to take the child on and off of the controller or maintenance medication. They always must have a rescue medicine available to them. And I think the parent’s job is to really clearly understand the difference – I mean it’s our job to make sure they know the difference but they need to understand the difference; the why’s, what side effects might be expected, and what not to worry about.
Dr. Mike Patrick: So, the rescue medicines tend to be bronchodilators. So if you have that inflammation to the passageway of the bronchiole, or the air passage, you're really trying to relax the smooth muscle to make the diameter bigger so air can flow through despite the fact that there's an inflammation present.
Dr. Karen McCoy: Yes, and you will still have that inflammation and that's what the controller medications are trying to do.
Dr. Mike McCoy: And when kids get a large dose of steroid medicines by mouth or through the IV, it’s not really rescue but is it to try to decrease the inflammation on a quicker way rather than the maintenance medicine.
Dr. Karen McCoy: It's kind of both when you think about it.
Dr. Mike Patrick: Now, in terms of a parent who maybe their baby has just been diagnosed with this or they've just gone through a couple of episodes of wheezing, but it is a recurrent thing and so they want some albuterol at home. There may have a neighbor who uses a machine and may have a neighbor across the street who they use an inhaler with a mask. Is there a difference between those two? Is one preferable to another in babies?
Dr. Karen McCoy: Most of the time, no. I mean, there are. Most children, most even small infants can be appropriately treated with an inhaler and the correct spacer and I emphasize the correct spacer and the correct technique. In some kids who really just absolutely go ballistic, most don't. But in those cases, we sometimes have to default to a mask with a nebulizer machine. It’s important to remember that we're in no way we are suggesting that we use the medication like it was on a hose, chasing after the child. It really still needs to be applied firmly to the face with a mask all the whole treatment long to get the benefits.
Dr. Mike Patrick: The way I explain that to parents is that you don't like to see your kid crying but we're talking 10 minutes, and if they’re crying their getting the medicine where it needs to go and they're taking big deep breaths when they’re crying.
Dr. Karen McCoy: Right.
Dr. Mike Patrick: What kind of side effects can parents expect with asthma medicines?
Dr. Karen McCoy: Well, that would pretty much divide between the rescue or immediate acting medicines such as albuterol and Xopenex and those things. Sometimes, parents see a little jitteriness. They can see the hand shake or the child get hyper or even have a higher heart rate. Now, most of those things are not mediated through the central nervous system, they really aren’t nervous. It is actually relaxation of the small muscles in the hand that cause the shaking. They don’t get into the central nervous system for the most part. Now, kids do have behavioral changes; some more than others. And we listen to that from parents. But in most all circumstances, a little increase in the heart rate is very well tolerated in the younger age group.
Dr. Mike Patrick: And kids who aren't breathing well tend not to be very active so you give them the albuterol and suddenly they’re oxygenating themselves well and perked up and they're running around…
Dr. Karen McCoy: And they may have make up time, make up for having not felt so well.
Dr. Mike Patrick: Right. What about the steroids? Parents hear, “Oh my child has to have an inhaled steroid every day.” And that word “steroid” they think about they could not grow as well, are there going to be side effects from that?
Dr. Karen McCoy: It’s a very important and frequently asked question. The inhaled steroids are extremely safe. Most long term studies say you know, have looked at this and found really no changes in growth that are sustained. Sometimes there’s a little bit of reduction in the rate of linear growth during the first year but without changing the medication, it goes away. There is almost no appreciable difference in the height at adult size between kids who are treated with inhaled steroids and those who were not.
That’s not to say that there’s not the occasional child who has a more pronounced response. They may have more sensitive receptors, in which case our backup for that is we monitor. We are looking for any kind of change in linear growth that takes place. Their endocrine systems, the adrenal glands, the eyes, anything else, for all intensive purposes, are not a worry for inhaled steroids at recommended doses.
Dr. Mike Patrick: Let’s say that you do have the occasional kid who may be a little bit of a problem. I think everyone agrees that there is no major problem. But even if there’s even a little bit of an issue with it, let’s say, they’re going to be an inch or two shorter than they otherwise would have been, could you also make the case that if you weren’t using those things, whether the problems that the end control of asthma's going to cause?
Dr. Karen McCoy: Exactly, actually I’ve actually never seen a child turn out an inch or two shorter than we expected even with chronic all through childhood use. Maybe a centimeter, but the problem that we have to differentiate is breathing is good. Even if you are going to be even a tad shorter but you are breathing well and able to be active throughout your childhood, then there’s a clear choice for most parents.
Dr. Mike Patrick: And we talk about risk versus benefit on this show all the time, so parents know exactly what we are talking about. What other complications can arise from poorly treated asthma?
Dr. Karen McCoy: A number of things. I think that it’s obvious if you aren’t breathing well and it can be so profound and I have seen this usually awhile ago, not too much anymore, but sometimes it interferes with growth. Even more common things would be to not have as healthy respiratory system, as you might have had, which can lead to permanent lung damage and even permanent changes in the airways that you can’t fix anymore. One of the nice things about asthma in pediatrics is most of the time, you can completely reverse these kids to normal lung function and keep them there.
I think something that's more subtle is the child who eight or nine, ten years old who is subtlety restricting their activity. The parents might not notice it because after all, they are usually part of the way more active than the parents are but they are not getting out there and having real age appropriate activity with sports, with that type of thing. And that starts the continuum that I see very frequently, which is more weight gain than you'd like, maybe some hypertension, and then maybe you have problems with obstruction during sleep, and it can really get to a point where even diabetes sometimes crops up in this sort of scenario. And all of that, which really is kind of a like early passage towards middle aged problems of health, because we were under treating an airways disease that is very, very manageable without almost any side effects.
Dr. Mike Patrick: So the symptom of the disorder way of the disease expresses it selves causes the disease to get worst. We have obesity, then that can make the asthma worst, and it becomes a cycle.
Dr. Karen McCoy: And parents just think that the kids just decided that they wanted to play computer games all the time, but sometimes it’s something more than that.
Dr. Mike Patrick: There’s also a cost to quality of life with regards to parents working and kids being in school if they have fairly controlled asthma too.
Dr. Karen McCoy: Absolutely, I don’t know a parent who is pleased to be in the emergency room at two or three in the morning, and these things don’t announce themselves at convenient time, there’s a lot of lost work, lost school, lost self esteem that goes with having asthma that’s not well controlled. And it impacts the entire family.
Dr. Mike Patrick: If the flu, obviously we are about to embark on the flu season here, kids with asthma have a little harder time with the flu?
Dr. Karen McCoy: They can, they certainly can. It’s a viral infection and it goes directly to the respiratory system. It’s not stomach flu or anything like that; although lots of things could call flu. Having attacked the respiratory system, like any other virus, it certainly can exacerbate an episode of asthma flare. It can make anybody, without any known respiratory disease, mortally ill.
Dr. Mike Patrick: In my younger days, I didn’t get the flu vaccine every year. I just get the flu naturally and thought that stronger immunity could do it and the flu shot would provide. And then I got the flu. And I wheeze, I had pneumonia, missed quite of work and I had flu shot every year after that.
Dr. Karen McCoy: And it doesn’t work to build up a natural immunity to flu, does it?
Dr. Mike Patrick: And Dennis Cunningham just stopped by the studio last week and we had this discussion about the flu. What is the long term outlook, sort of prognosis for kids with asthma?
Dr. Karen McCoy: It’s a very interesting answer. We have learned within the last two or three decades much more about this. We don’t know everything yet. A lot depends on when the presentation is, some of it luck at the draw. When you hit the early viral infections in infant and whether that has meaningful changes on the way your immune system reacts to things.
There’s also a tendency if you have wheezing illnesses at a very young age, to develop some degree of acid reflux for awhile which can compound this. So for the young child, who becomes a wheezer, and wheezes repeatedly, but has no appreciable allergic history in himself or the family, the outlook for growing out of wheezing at mid childhood is pretty good. For the allergic young child with a family history of allergies and so forth, then the outlook is not as clear cut to be good.
Dr. Mike Patrick: Can you kind of look at the family pattern with that?
Dr. Karen McCoy: Yes, absolutely, and we do. And then of course we all know about the business of boys get asthma earlier and more severely. Girls get asthma later and more severely as they go through adult life.
Dr. Mike Patrick: Is there any way to prevent this from happening?
Dr. Karen McCoy: Totally prevent, no. The predisposition is there and a lot of people, its multifactorial, we’re working with this genetically based studies, but it will be many, many genes and many different places. I think understanding that, and that tract in some cases with ability to respond to certain medicines properly is an important factor.
We can try to stay away from exposure, we can always get flu vaccine and not have that entering into the course of things, but absolute prevention, and there’s been a lot of discussion over last several years about early breastfeeding. The germ theory issues, that sort of things. I think something relatively new is this issue of Tylenol exposure. Where people are coming up with population studies and they’ve been reproduced in several parts of the world. That indicates that Tylenol exposure during early infancy in the dose response related way is more likely to relate be seen with the child developing asthma.
Dr. Mike Patrick: Could it be that kids who have more viral upper respiratory infections and fever and then they get the Tylenol, could that be a co-founding factor with, you know, that there’s really the recurrent viral infections, they just happen that they are getting the Tylenol?
Dr. Karen McCoy: It has to be considered of course but these studies were in populations and so they were able to employ epidemiologic techniques to control for confounding factors like that and it’s even implicated during pregnancy for the mother taking Tylenol as well. So I think that we never want to do any harm, and this is something that if it creates an odd ratio as I recall from my readings somewhere between two and three times compared to the no Tylenol given group, and that age group. Then we want to give these some credence and sort of see what’s next without just saying, “Oh, that can’t be.” Or it’s confounded by certain things. I think that they did a pretty good job of controlling the factors in the study.
Dr. Mike Patrick: Wow. Would this be a reason to start thinking more about ibuprofen instead of Tylenol or no fever reducers at all? And again this is not a medical advice, we’re just chatting.
Dr. Karen McCoy: Just for the sake of chat, it’s going to be hard to sell no fever reducers at all. On the other hand, if you listen to the nightly news recently, every vitamin or supplement we’ve been told will help with your breast cancer, help with your prostate, help with your colon and is now maybe being considered the opposite. It’s not helping. And so, I think we have to be careful without jumping too quickly to certain things. But if something has this strong of a signal, I think we better watch our Tylenol use wherever possible.
Dr. Mike Patrick: Gotcha. We really appreciate you stopping by to talk about asthma and were going to have some links in the show notes over the pediacast.org. One of them is the Pulmonary Medicine Division here at Nationwide Children’s Medical Hospital. So if you would like to know more about the Pulmunology Department here and what they are going to do with asthma, cystic fibrosis and such, it will point you in the right direction there. We also do see folks, I mean our audiences pretty far and wide. But we do have a lot of people who travel here and certainly our pulmonologist are always happy to see you, right? We’re getting a list where you live.
Dr. Karen McCoy: Folks or practitioners either one.
Dr. Mike Patrick: That’s right. We also have a link to the American Lung Association. They have some great asthma resources as well. And before you leave, one of the things that we’re asking all of our guests, here in PediaCast we encourage families doing things together and trying to get away from just watching TV from dinner time to bedtime. And in our house, one of the things that we like to do our board games or card games, we’re asking every guest to what’s your favorite board game or card game?
Dr. Karen McCoy: Long term, I have to say, Monopoly.
Dr. Mike Patrick: Yeah, that’s a popular one among folks. My kids love playing that, but it’s so long. I think like I have ADHD tendencies.
Dr. Karen McCoy: It is long. You know, they fall sleep.
Dr. Mike Patrick: Just straight classic Monopoly or do you like, you know, my kids like the Beetles Monopoly here. Do you have avail the specialty ones now?
Dr. Karen McCoy: I am pretty eclectic with my Monopoly.
Dr. Mike Patrick: Oh yes, so you don’t mind the different ones?
Dr. Karen McCoy: No, no.
Dr. Mike Patrick: Which one is your favorite one?
Dr. Karen McCoy: It’s the classic.
Dr. Mike Patrick: All right. We appreciate you stopping by Dr. Karen McCoy. Thanks so much. And of course listeners like you, we always appreciate that you’ve taken the time out of your day to listen to us. Don’t forget iTunes reviews are helpful as our mentions in your blogs, in your Facebooks, and in your Tweets. And make sure you tell your doctors, your friends and families about PediaCast; we’ll appreciate the good word.
I want to remind you if you like a topic that you would like to hear about, just go to pediacast.org, click on the contact link, you can also email email@example.com, or call the voice line at 347-404-KIDS, 347-404-5437. And until next time. This is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everyone!
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.