Recurrent wheezing was often called asthma in the past and more recently, is called Reactive Airways Disease or RAD. This new term attempts to get across the points that the wheezing is a reaction that can be triggered by many factors (such as viral upper respiratory infections, inhalant allergies to pollens and molds, cold air, exercise, emotion, cigarette smoke, paint fumes, ozone) and that the site of the problem is obstruction to airflow in the lower airways of the lungs (as opposed to noisy breathing due to nasal drainage or laryngitis). The obstruction to airflow is due to narrowing of the airways by constriction of muscles around the airways as well as swelling of the lining of the airway and collection of secretions within the lumen of the airway. The signs and symptoms of RAD include: increased work of breathing manifest by an increased respiratory rate and retractions of the spaces between and under the ribs; frequent and repetitive cough often follwed by vomiting; decreased oral intake due to fatigue and cough. Signs seen in more severe episodes may include; use of the muscles of the abdomen, neck and nose to assist in breathing; inability to lie down due to respiratory distress and cyanosis (a bluish color about the mouth).
The initial therapy of RAD is with a bronchodilator, albuterol (Ventolin, Maxair, Proventil HFA) given (depending on the child’s age and severity) as a liquid, by aerosol mist delivered with an aerosol machine or by a metered dose inhaler (MDI) with a spacer. The spacer is a tubular device that is inserted between the MDI and the child’s mouth allowing the child to inhale the dose in two to three breaths rather than one. The liquid is given at six to eight hour intervals and the inhaled forms are given at four-hour intervals. If your child is requiring more frequent doses, you should let us know, so that we can help determine if other medications are needed. The intervals are lengthened between doses over a few days as the episode subsides. If a child as mild, infrequent (separated by weeks to months) episodes that are quickly resolved, no other treatment is usually needed. Another device that is very helpful in children old enough to cooperate (~6 years and older) is a peak flow meter. This is a tubular device that allows an objective measurement of airway obstruction. You should make several measurements when your child is well to assess what the normal baseline is and to be sure that he or she understands the task and can give a reliable maximal expiratory effort. At the first signs of suggestive symptoms, a decreased peak flow of 10-20% under baseline allows the parent to distinguish the coughing and congestion of an uncomplicated cold from the beginnings of a RAD episode. In the latter instance, early treatment with albuterol may abort a more serious episode. The peak flow meter is also helpful in monitoring the weaning process as the parent tries to lengthen the intervals between doses of abuterol. If a child had further deterioration of peak flow vales along with increasingly severe symptoms, you should contact our office or an emergency room immediately.
If the episodes are becoming more intense or frequent, please let us know as there are many items that need to be reviewed in order to gain better control:
Review dose of abuterol, method of delivery and technique with aerosol machine or MDI/Spacer
Review the use of the Peak Flow Meter
Depending on severity, consider adding an oral or inhaled anti-inflammatory steroid to diminish the swelling of the airway’s lining. These medicines will be used in a manner that will not have adverse effects on growth or the immune system.
Check for accompanying infections: pneumonia, bronchitis, sinusitis
Discuss feasibility of avoiding known triggers: viral URI’s (Daycare); allergy evaluation; prevention prior to exercise.