What you need to know

about asthma

EAST TENNESSEE CHILDREN’S HOSPITAL

Asthma is a chronic (long-term) illness. It can be hard to diagnose. The signs of asthma may not be present every day. Unless a doctor sees a child regularly, asthma can be hard to recognize.

If not treated, asthma can seriously affect a child’s health. For these reasons, it is important for you to know as much as possible.

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Table of contents

My child has asthma. What does that mean? ................................................... 4

How do I find out if my child has asthma? ........................................................ 6

How will a child older than age 5 be diagnosed? ........................................... 7

How did my child get asthma? .............................................................................. 8

What is an asthma trigger? ..................................................................................... 9

How can I protect my child from triggers? ......................................................10

Should I buy new cleaning tools? .......................................................................14

How can I tell when my child is starting to have an attack? .....................15

How can I tell when an attack is an emergency? ..........................................17

How does asthma medicine work? ....................................................................18

Are steroids safe for my child? .............................................................................20

What is the best way to give breathing medicine to a child? .................21

What should I do when an attack starts? .........................................................27

How can I keep my child safe at school? ..........................................................30

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Do not let asthma hold you backPeople with asthma have gone on to be:• PresidentsoftheU.S.• NobelPrizewinners• Admiralsandgenerals• KingofEngland• Famousactors• Famoussingers• Olympicmedalists• Professionalathletes

My child has asthma. What does that mean? Asthma is a long-term lung problem. Asthma will get better with good care, but it never goes away. It is different than having a cold or pneumonia one time. Asthma problems occur over and over.

Asthma causes lungs to react in an extreme way when irritated. Irritants of the lung are called triggers. Common triggers can be secondhand smoke, pollen or molds. We will talk more about triggers later in this book. When exposed to a trigger, three things happen in the lung. •Lungmusclestighten(bronchospasm). •Thelungmakesextramucus(phlegm). •Airwaywallsswellwithfluid(edema). Thesethreeproblemsmakeairwayopeningsverysmall.Smallairwaysdeep in the lung may even swell shut. Breathing becomes very hard work. Oxygencanhavetroublegettingthroughthelungsandintotheblood. Youoftenhearthatchildrencangrowoutofasthma.Thisisnottrue.Aschildren grow, their airways also grow and become larger. Asthma attacks can still happen for them, but may not seem as bad because of the larger airways.

Younger children may have reactions (allergies)tofoodthat look like asthma, butarenot.Foodallergies often go

away as children grow older.

Facts about asthma•About100childrenintheU.S.dieeachyear

from an asthma attack. Some children who die have had only mild asthma.

•Asthmaisverycostly.Itcanleadto: - Repeated colds and pneumonias - Missed school days - Missed work days for parents -Extratripstothedoctoror EmergencyDepartment - 911 calls and hospital stays to treat bad attacks•Asthmacankeepachildfrombeingactive

and enjoying sports. •Lackofenergyduetoasthmacanbeone

cause of extra weight gain in a child.•Asthmacancausepoorsleep.Poorgrades

in school can result. •Poorlytreatedasthmacancausepermanentdamageinthelungsovertime.Thisiscalledairway remodeling. While remodeling is serious:

- You should not panic. Remodeling is not caused by one bad attack.

- Changes occur if asthma is poorly treated for long periods of time.

- With proper care, asthma can almost always be controlled.

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How do I find out if my child has asthma?

Your doctor will need your help. You and he may have to be detectives.Thisisespeciallytrueifyour child is younger than age 5. Asthma is diagnosed in young children by looking at signs and symptoms. You are the person best able to describe exactly what happens when your child is ill. You also know when, and how often, your child has trouble breathing. It can be hard for a doctor to get all the facts needed to diagnose asthma without your help.

Threethingsmustoccurifasthmaistrulyyourchild’sproblem. •Breathingproblemswilloccurmorethanonce. •Breathingtroublegetsbetterafterusingcertainmedicine(bronchodilators).Bronchodilatorsrelaxtightmusclesinthelung. •Allotherreasonswillberuledout.Acidreflux(GERD),vocalcord problems or heart problems can all look like asthma. Asthma often looks like a simple cold. Your doctor needs a full history ofyourchild’sbreathingproblems.Tellhimifyouhaveseen: •Repeatedbreathingproblems (includingproblemstoomildforadoctorvisit) •Twoormorecoldswithacoughinayear’stime(eachlastingforsixdaysormore) •Breathingproblemswhenaroundpets,atacertainhouseorwhen outside •Coughingleadingtothrowingupmucus •Coughing,especiallyatnightorfirstthinginthemorning

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As you can see, all of these signs are quite common for many childhood illnesses.

Airway swelling due to asthma can be hard to detect, even for your doctor.ItusuallydoesnotshowonX-rays.Theonlysignoftheswellingmay be a child who has a cough.

Itcanbefrustratingtonotquicklyknowtheexactcauseofyourchild’sproblem.Thegoodnewsisthatafirmdiagnosisisnotneededtobegintreatingmostbreathingproblems.Thesamemedicinewillbeusedat first, no matter what is causing the problem. Your child will begin getting the care he needs without a definite diagnosis.

How will a child older than age 5 be diagnosed?

Yourchild’shistorywillbeimportant.Thathistorymustincluderepeatedattacks and breathing that improves when given bronchodilator medicine. All other possible causes must be tested and ruled out. More tests will now be possible and can give more reliable results.

Allergytestscannowbedonetoidentifyspecifictriggers.Yourchild’sallergydefenses(theimmunesystem)arenowmoremature.Testsare more likely to be accurate. Some children with asthma have many allergies. Some children may have few ornoneatall.Everychildwillbedifferent. Apulmonaryfunctiontest(PFT)can also be done. Your child is old enough to cooperate in the testing process.Thistestmeasureshowwell air moves into and out of the lungs. Your child will be asked to blow hard into a tube for about six seconds.Thetestdoesnothurtatall.

YourdoctormayaskthattwoPFTsbedone.Oneofthetestswillbeafter your child breathes a small amount of lung irritant. It will show how strongly the airway muscles react to irritants.

Donotforgetthatyoustillplayakeyroleinhelpingyourchild’sdoctor.You are the person who knows what happens with your child between visits.

How did my child get asthma?

Asthma can have different causes. •Itcanbeinheritedfromaclosefamilymember. •Itcanresultfromheavyexposuretotriggers,suchasairpollution or second-hand smoke. •ItmayappearafteraseriousRSVvirusinfection(bronchiolitis).

Familyhistory(genetics)isamajorcauseofasthma.Tellyourdoctorifanyclosefamilymemberhas(orhad)breathingproblems.Youmayrecalltalkofrelativeshavingallergies,eczema,reactiveairways,bronchitisorwheezybronchitis. It is important to add if those relatives were also smokers, miners,etc.Thosetypesoflungdamagearenotinheritedbyachild.Regarding family history, studies show the chances of a child inheriting asthma are: •5to15percentifneitherparenthasasthma •25percentifoneparenthasasthma •50percentifbothparentshaveasthma

Studies show that long-term exposure to air pollution increases the risk for asthma.Theriskcomesfrombreathingbothsmallparticlesandchemicalsin the air. Both will irritate the entire lung, down to the smallest and deepest airways.

Second-hand smoke and outdoor air pollution are equally harmful to achild’slungs.Ifsmokeispresentinahome,childrenwillbeunabletoescapethisdamagingirritant.Theresultmaybethatachild’slungsstayswollen and irritated all the time.

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• Dust• Pollen• Cigarettesmoke• Woodsmoke• Dustmites• Cockroaches• Moldormildew• Pollution• Petsorotheranimals

• Chemicalfumes• Strongodors(perfumes,cleaners)

• Strongemotions• Sinusinfectionsorallergies• Lunginfections• Hotorcoldair• Exercise*

*Exerciseisconsideredtobeaspecialtypeoftrigger.Itisthetriggerthat should not be avoided. A major goal of asthma care is an improved ability to do exercise. Rescue medicine can be used before exercise if your child has breathing trouble when doing sports or otheractivities.Talktoyourdoctorifthisisaproblemforyourchild.

Common triggers for asthma

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IthasnotbeenproventhatsevereRSVinfectionscauseasthma.Therearemany cases, however, where asthma symptoms are present for a time after such an infection.

What is an asthma trigger?

A trigger is anything which causes the lungstobecomeirritated.Thelungsreact with muscle tightness, swelling and excess mucus. Increased work of breathing, shortness of breath and cough can be the result.

Differentchildrenreacttodifferenttriggers. Some will have many triggers. Some may only have one or two.

Surprisingly, there are often more triggers indoors than outside.

How can I protect my child from triggers?

Simple things can go a long way in protecting your child. Many of them will not cost you a lot of money. Here are some of the most effective: •Learn your child’s triggers.Thiscanbethemostimportantthing you do for your child. You must know what your child needs to be protected from. •Avoid your child’s triggers whenever possible. Help everyone who cares for your child know what to avoid. •Clean.Tryseriouscleaningbeforeanythingelse.Doitoften. Aggressive cleaning can be very effective in reducing triggers, although no one can keep a completely clean house. •Bedrooms are important. Just as exercise is a special type of trigger,thebedroomisaspecialroominthehome.Thisisthe room your child may spend the most time in every day. You can get the most benefit from your cleaning efforts by tending to the bedroom.

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Tips for trigger control in the bedroom are: • Donotallowpetsinthebedroom. • Dust,vacuumandremovecluttermoreoftenthananyotherroom. • Limitfuzzytoys.Useplastictubswithlidsforstorage. • Washimportantfuzzytoystodecreasetriggerlevels.Freezefor 24hoursinaplasticbaganyfuzzytoythatcannotbewashed. • Shampoocarpetseverythreetofourmonths.Considerremoving carpet, if needed. • Changebedlinensweekly.Washbedlinensinveryhot (130degree)water. • Washcurtainsorbedcanopies in hot water. • Buy protective covers for the box spring, mattress and pillows. • Usedisposablefiltersincentralheatandairvents. • Avoid opening windows in the summer for cooling. • ConsiderusingHEPAairfiltrationatnight.Runitwiththe bedroom door closed.

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Managing asthma triggersAir pollution, dust and pollen• Checkweatherreportforair

quality and pollen count.• Limitoutsideactivityonorange

or red air quality days.• Takeextracareduringspringandfallpollenseasons(restartcontrollerdrugs).

• Useairconditioninginsteadofwindow fans in summer.

• Stayinsideorwearamaskwhengrass is mowed.

Cigarette smoke• Avoiditcompletely,ifpossible.• Nosmokinginthehome.• Alwayssmokeoutside.• Wearasmokingjacketandahat

when smoking outside. Smoke sticks to clothing and hair.

• Washhandsaftersmoking.• Nosmokinginthecar,even

when children are absent.• Teachrelativesandallcaregivers

about smoking and asthma.

Other smoke• Lookforhomeheatsources

other than an open fire place.• Ifcamping,keepawayfroma

camp fire.

Infections and nasal allergies• Bealertfortheearlysigns.Watch

for new coughing or poor sleep.• Keepyourchild’snoseasclearas

possible. Saline drops may help.• Talkwithyourdoctorabouttreatments.Treatasearlyaspossible.

Pets and other animals• Donotallowpetsinthe

bedroom.• Keeppetsoutsidethehome,if

necessary.• Anyanimalcanbeatrigger.This

includes dogs, birds, rabbits and all farm animals. Beds, pens and cages can also be a problem.

• Saliva,urine,feces,andskinscales can also act as triggers.

• Catdanderisespeciallylight.Itfloatseasilyintheair.Itstickstoall surfaces when it settles.

• Batheandgroomproblempets.• Considergivingawayaproblem

animal.

Chemicals and strong odors• Avoidallstrongperfumes.• Avoidstrongbath,kitchenand

rug cleaners.• Avoidroomdeodorizers.• Useyourstove’sventfanto

remove cooking odors.

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• Freshpaintfumescanbeaproblem.

• Keroseneorpropaneheaters can produce fumes.

Dust mites• Dustmitesareverycommon.

Anyone can have them as a problem.

• Changebedlinensweekly.Washin 130 degree hot water. Mites feed on dead skin cells. Bedding contains lots of dead skin cells.

• Usemattressandpillowcovers.• Useaclosetlightbulbtoprevent

mold and dust mite growth.

Mold, mildew and cockroaches• Anyhomecanhavemoldor

roaches.• Locateallwetordampplaces.Lookatcrawlspaces,basement,baths and spaces under the sink.

• Getridofasmanycardboardboxes as possible.

• Keephomehumiditycomfortable, but below 50 percent.

Heat and cold• Rapidchangesinair

temperature can trigger asthma.• Useyourrescuedrug

if such temp changes can be foreseen.

• Wearascarformaskover the mouth and nose in cold weather.

Emotions• Beawarethatstrongemotionscanbetriggers.Extremelaughter, sadness, anger or fear can cause an attack.

• Teachyourchildtobeawareofthis trigger.

Exercise• Asnoted,exerciseisaspecial

trigger. Sensible exercise should not be avoided. •Preventproblemsbyusinga

rescue drug before exercise.•Teachyourchildtostop,

tell an adult, and get treatment if they begin

to have an attack.

Should I buy new cleaning tools?

Maybe. Your plan should be to try all simpler, cheaper steps first. Buy a costly new tool only if needed, and after doing some research. • New vacuum cleaner: Possibly. Make sure you have a good

vacuum that cleans well. Your current vacuum may be just fine. A morecostlyvacuumwillnotalwaysbebetter.Vacuumslabeledfor treating asthma may not work well at all. Bagless vacuums may be veryhardtoemptyandclean.Doyourresearchbeforebuying.

• Hepa air purifier: Possibly,butnotrightaway.Tryallsimpler, cheaperstepsfirst.SomestudieshaveshownthatHEPAair purifiers can be helpful in asthma. Consider using one at night in yourchild’sbedroomwiththedoorclosed.Itcanbequitecostly. Doasmuchresearchaspossiblebeforebuying.

• Room humidifier: Probably not. Home humidity is mainly for comfort.Itisnotaprimarytherapyforasthma.Lotsofhumidity can lead to mold and dust mite growth. Humidifiers can be hard to clean. Bacteria or mold can grow in it if it is not kept clean.

• Room dehumidifier: Possibly, if you think your home may be too humid.Youcanbuyacheaproomhumiditymonitor(hygrometer). Keephumidityat50percentorless,butnotsodryastocause discomfort.

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How can I tell when my child is starting to have an attack?

Differentchildrenshowdifferentsigns with an attack. You need to learn the key signs to look for in your child.Knowingyourchild’ssignscanleadtoearlytreatment.Treatingearly will help keep your child out of thedoctor’sofficeortheEmergencyDepartment.Itisalsothebestwaytoavoid a life-threatening attack.

Coughing is often the earliest sign of an attack. Watch for: •Coughingwhenwakinginthemorning •Wakingwithacoughatnight •Coughinginthedayfornoreason •Extracoughingduringplayorexercise •Coughingthatleadstothrowingup

Restlessorpoorsleepisasecondearlysignofasthma.Ourbodiesmake adrenaline when we are awake and active. Adrenaline is a bronchodilator chemical. It is like the asthma medicine albuterol. When we sleep, our adrenaline levels fall. Irritated muscles in the lungs can thentighten.Thismaywakeachildwhosechestfeelstight.Thiswakingoften occurs in the early morning hours.

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Therearefiveclassicsignsofanasthmaattackallcaregiversshouldknow.Theyarecalledthe5-T’s.Lookforbreathingthatis: •Too hard–Achild’snostrilsmaypulloutwardwhentheybreathe. Thisiscallednasalflaring.Youmayseeyourchild’sskinpullingin atthethroat,andbetweenorbelowtheribs.Thesearecalled retractions.Theyshowthatbreathingishardwork.

•Too fast–Count the number of breaths in a minute. Compare that numbertothenormalrateforyourchild’sage.

- Younger than a year – 40 to 45 breaths a minute - 1 to 2 years – 35 to 40 breaths a minute - 3 to 4 years – 30 to 35 breaths a minute - 5 to 7 years – 25 to 30 breaths a minute - Olderthan8years–20to25breathsaminute •Too noisy–Youmayhearmusicalwheezingsoundswhenyour

child exhales. •Too tight–A child may complain he feels tight and unable to take

a deep breath. •Too tired–A child may say he cannot catch his breath. He may be

unable to keep up with others when playing. He may be sitting down when you expect him to be playing hard.

Children with asthma get used to having trouble breathing. Working hard to breathe can feel normal to them. Children may not be aware oftheirownproblems.Theymaysimplybetoobusyplaying.Forthisreason,itisimportanteverycaregiverbeabletorecognizethesignsofan asthma attack. While children may not be the best monitors of their asthma, it is still importanttoteachthemaboutit.Teachthemtoalwaystellanadultifthey feel an attack coming on.

How can I tell when an attack is an emergency?

Allofthesignsbelowaresignsofabreathingemergency.Donotignorethem.Donotwaitforthemtogoaway.Asthmacanbefatal.Some attacks happen very quickly. Mild attacks may start slowly, but become an emergency quickly.

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Signs of an asthma emergency •Grayishorbluishlips,

fingernails or skin •Breathinghunchedover •Havingtroublewalking •Havingtroubletalkingor

crying(Can’tspeakawhole sentence.) •Aninfanthavingtrouble

breathing and feeding •Beingtooagitatedor

restless to sit still or fall sleep •Havingsevereretractions

due to the hard work of breathing

•Breathingmoreslowly than is normal •Breathingveryshallowor

withpauses(apnea) •Beingdifficulttoarouseor

awaken

How does asthma medicine work?

Therearetwotypesofmedicineyoushouldknowabout: •Quick-actingrescue medicine •Gradual-actingcontroller medicine

Both types play a part in asthma treatment. Both are important in good asthma care.

Rescue medicineThismedicine: •Relaxesthetightmusclesinthelungs.Workofbreathingbecomes easier as the medicine works. •Isusedwheneverbreathingisdifficult. •Actsquickly,inabout10to15minutes. •Worksforaboutfourtosixhours.Themedicinemayworkfora much shorter time in a serious attack. In very severe attacks, it may not seem to be working at all. Several treatments may be needed to decrease work of breathing in serious attacks.

Typesofrescuemedicine: •Albuterol(Ventolin,ProAir,Accuneb) •Levalbuterol(Xopenex)

Rescue medicine can have some side effects. Theseareusuallynotdangerous.Theytendto decrease in an hour or so. Possible side effects are: •Highheartrate •Muscletrembling,jitters •Highactivitylevels •Inabilitytorestorsleep

Rescue medicine is used only when needed. Call your doctor if you are using your rescue medicineoften.Discusswithyourdoctorexactlywhen they would like you to call them.

Controller medicineThismedicine: • Isnotforuseduringabreathing

emergency. Only rescue medicine will help your child in an emergency.

• Calmsthemusclesandothercellsinthe lung.Thishelpsbothpreventandheal airway swelling. It also reduces and thins

airway mucus. • Mustbeuseddaily. • Mustbeusedexactlyasorderedbyyour

doctor. Some children are given two different controllers to take at first. Change how you give them only after

talking with your doctor. •Isusuallygivenforaperiodofweeks,orevenmonths.Youwill

likely be asked to use the medicine long after your child seems to bewellagain.Thegoalistogetcompletecontrolandhealing before the medicine is weaned or stopped.

Typesofcontrollermedicine: • Inhaledsteroids(Flovent,Pulmicort,QVAR,Asmanex) •Leukotrieneinhibitors(Singulair) •Longactingbronchodilators(Foradil,Serevent) •Anti-allergymedicine(Allegra,Zyrtec) •Nasalmedicine(Nasonex) •Combinationdevicescontainingtwotypesofmedicine (Advair,Combivent,Symbicort)

Controllers work slowly over time. You may feel like nothing is happening. Be patient. Complete healing from a bad attack often takes two or three months. You will know the controller medicine has done its job when your child: •Usesrescuemedicinenomorethantwotimesinaweek. •Sleepswellatnightwithnowakingorcoughing. •Isabletotakepartinactivitieswithoutdistress.

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Are steroids safe for my child?

Steroidshaveabadreputation.Theyareverypowerfulmedicine.Ifnotused correctly, they can harm the body. If used correctly, they are good fortreatingasthma.Theycanhelpyourchildstayoutofthedoctor’sofficeandtheEmergencyDepartment. •SteroidsgivenbymouthorinanI.V.canonlybeusedforashort time.Ourbodiesmakesteroidsforus.Extrasteroidsputintothe bloodfortoolongstopourbodyfromdoingthisjob.OralorI.V. steroids are used for several days to get an attack under control. Theyhelpthelungsbegintoheal.Oraldoseswillbeweaned slowly by your doctor, then stopped.

•Inhaledsteroids(inhaledcorticosteroidsorICS)aredifferent.They canbeusedsafelyforlongperiodsoftime.Thedosesaremuch smallerthanthosegivenbymouthorI.V.Thesesteroidsare

inhaleddirectlyintothelungs.Verylittleofitcrossesoverinto theblood.Thislessensitseffectontherestofthebody. - Many studies support the safety of inhaled steroids.

Some children on high doses of ICS may have a bit of growth slowingforatime.Thesechildrenalmostalwayscatchupin growth. Children who are sick a lot may also grow more slowly thannormal.Donothesitatetodiscussconcernsyouhave aboutusinganICSwithyourdoctor.Thismedicinecanbea very important tool for treating asthma.

- If you give ICS to your child, have them brush their teeth afterward. Rinsing the mouth or taking a drink will also work. ICS can allow thrush to grow in the mouth andthroat.Thrushis a fungus, and is quite irritating. Its most common sign is a white coating of the tongue or throat

that will not wash off.

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What is the best way to give breathing medicine to a child?

Therearetwomainwaystogivebreathingmedicine: •Nebulizer •Metered dose inhaler (MDI)

Bothworkequallywell.Thecorrectdevicewillbetheonethatworksbestforyouandyourchild.MDIsareeasytousewhenyourchildisawayfromhome.SomefamilieshavebothanebulizerandanMDIfortheirchild.Discussyourneedswithyourdoctor.

Tips for using a nebulizer • Anebulizerisoftenreferredtoasabreathingmachineoraneb.It

is a small air compressor and a plastic cup to hold a liquid medicine. A thin plastic tubing connects the medicine cup to the compressor. A jet of compressed air breaks up the liquid medicine into a fine mist.Thismistofmedicinecanthenbe breathed directly into the lungs.

• Youngchildrenneedaclose-fittingmaskto getagoodtreatment.Olderchildrencanuse a mouth piece. Blowing a mist of medicine intheopenair(blow-by)nearachild’sface willnotgivegoodresults.Verylittleofthe medicine given this way makes it to the lungs where it is needed. Work with your child on wearing a mask and taking good treatments.

• Nebulizingamedicinecantakesixto eightminutes.Thiscanbealongtimefora small child. Some children are so restless they seldomgetagoodnebulizertreatment.If this is what you find, ask your doctor about tryinganMDI.Mostchildrenquicklyget overanyfearoftreatments.Letthemplay withtheirmask.Letthemgivetreatments

to a favorite stuffed animal or doll. Children often learn that they feel better after getting a treatment.

• Treatmentsarebestwhengiventoanawake,calmchild.Tryto make treatments fun. Play games with your child. Read or sing to your child. Watch a video. If needed, treatments can sometimes be given to a child while napping or sleeping.

• Achilddoesnotgetmoremedicinewhencrying.Acryingchild maybreatheinshort,shallowgasps.Theymayexhaleforseveral secondsatatime.Nomedicineisdeliveredtothelungsduring much of a crying session.

• Rinsetheplasticmedicinecupwithtapwateraftereachtreatment. Letitairdryonacleantowel.Washitinwarmwaterwithregular dish washing liquid once each day when it is being used. Some cups are safe to wash in a dish washer. Read your instruction booklettofindout.Donotwashthetubingthatconnectsthe medicine cup and compressor. It is very hard to dry and may grow harmful germs.

• Medicinecupswearout.Theyhavetinyairholesthatcanwarpor getclogged.Thisdefinitelyhappensifacupisusedeveryday.You may not see any visible change in the mist your

cup puts out, but the medicine particles can betoolarge.Largeparticlesoftendonot

make it into the lungs. Your instruction booklet will tell you how often your cup

needs to be changed. Contact your supplier to get a new one.

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Tips for using an MDI• ThereareseveraltypesofMDI.Themostcommonisasmall,

pressurizedcanister(puffer).Youmayalsoencounterdrypowderinhalers(DPIs).DPIscontainmedicineasadrypowderthatisnotunderpressure.MostpressureMDIsaretriggeredbyafingersqueeze.SomeMDIs(andmostDPIs)aretriggeredwhen a user inhales. Be sure to use any device exactly as the instructions say.

• MDIsallowforveryshorttreatmenttimes.Thiscanbeabigbenefitwithanactivechild.MDIsmayseemtobealesseffectivedeviceduetotheirshorttreatmenttimes.This

is not true. If used properly, they are very effective.• EverypressurecanisterMDIshouldbeusedwithaspacer

(holdingchamber).Thisis a plastic tube that fits betweenanMDIandtheuser’smouth.MedicineexitsfromanMDIat

high speed. A spacer provides time for a puff of medicine to slow down before it hits the backofthethroat.Thethroat is wet, and a mist of medicine can stick there. Any medicine that sticks will not make it intothelungs.Children’sHospital advises that all pressureMDIpuffsbegiven using a spacer. Thisadviceappliestoall adults as well as to children.

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• Spacersalsoallowapuffofmedicinetobebreathedinoverseveralbreaths.Thisisgoodforyoungchildrenwhocannottimeasinglebreathtoinhaleapuffofmedicine.AspacerallowspressureMDIsto be used even for infants.

• Spacershaveeitherasoftmaskora mouth piece. Children younger than age 5 usually need a spacer with mask. It is important that the maskbecorrectlysized.Havingagood seal over both mouth and noseisimportant.Olderchildrenwill be able to inhale when told, and hold a breath for a count of ten.Theycanuseaspacerwithmouth piece.

• MostMDIsnowcomewithadosecounterbuiltin.Ifyourdevicedoes not have a counter, carefully track the doses used. It is very important to never have an empty rescue medicine MDI. If you useanMDIorDPIeveryday,simplywritetherefilldateonyour

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calendaroronthedevice.This

works well for many daily controller medicine. Rescue medicine is not normally used every day. Make a markontherescueMDI’sbox,orona slip of paper kept with the device every time you use it.

• Never use an MDI or DPI for more doses than it is said to contain. EmptyMDIsmaystillproducevisiblepuffsofpowder.Thatpuffmaycontain little or no actual medicine, however. Be safe rather than sorry. Being sorry can carry a high price when dealing with asthma.

When will my child’s MDI or DPI be empty or need to be replaced? Youcaneasilyanswerthatquestion.MostMDIsorDPIsnowhavecounters,butnotall.UsethesestepsifyourMDIorDPIdoesnothave a counter.

1. Read the label or package insert.FindthetotalinhalationstheMDIorDPIcontains.(Example:120inhalations)

2. If the medicine will be used daily, figure the total inhalations you are to give eachday.(Example:Ifyourchild takes two inhalations twice a day, that is a total of fourinhalationsaday.)

3. Dividethenumberyoufoundin the first step by the total inhalations you give your childeachday.(Example:120inhalations divided by four inhalations a day equals 30 days)

4. Make a note on your calendar about one week before your child’sMDIorDPIwillbeempty. Begin the process to get a new one on the date you marked. You may need to talk toyourchild’sdoctorabouta new prescription. If you do, you will have the time to do so.

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How to use a canister MDI1. Shake the canister well for

10 to 15 seconds.Donotskip this step. Shake either before or after connecting anMDItoitsspacer.Shakingis needed to deliver the right amount of drug.

2. Prime the device, if needed. Priming means delivering one or more drug puffs into theair.Dothisifadevicehasnot been used recently. Read the specific instructions for your device.

3. Exhale fully.(Skipthisstepwith children using a spacer withmask.)

4. Seal lips on the spacer mouth piece (or place mask onto face). In either case, make sure there is a good seal. If using a mouth piece, make sure the tongue does not block the mouth piece opening.

5. Tilt chin slightly upward. Lookwheretheceilingandawallmeet.Thisopensourairway as wide as possible.

6. Activate the MDI one time. Deliverasinglepuffofdruginto the spacer.

7. Inhale slowly and steadily. Takeinafullbreath.Donotstop till the lungs are full.

8. Hold the breath for 10 seconds, then exhale. If a 10-second hold is not possible, hold as long as possible. Shortness of breath and coughing are sometimes a problem during anattack.Forchildrenusinga spacer with mask, keep the mask in place till they have taken six breaths.

9. Wait one minute before giving a next puff. Repeat all steps as many times as ordered by your doctor.

10. Mark the number of puffs given on your tally sheet. (Skipthisstep if a device has its own built in counter.)

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What should I do when an attack starts?

Some attacks get bad very quickly after exposure to a trigger. Some attacks progress slowly, but become severe quite suddenly. Your plan of action should be built on two principles. •Neverignoretheearlysignsofanattack. •Beginusingyourrescuemedicineasquicklyaspossible.

Attacksthataretreatedlatecanbeveryhardtocontrol.KeepawrittenAsthma Home Care Plan to guide you and all others caring for your child.Mostactionplansarebrokendownintothreezones.Seethenexttwo pages for an example.

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What you will see:Yourchildiswell.Therearenosignsofanattack.

Green zone action:•Allcontrollermedicineshouldbegivenexactlyas

ordered.

Green zone

What you will see:You see one or more early signs of an attack.

Yellow zone actions:•Increaseyouralertness.Watchforworsening.

Watch for other signs to appear.•Continuegivingallcontrollermedicineasordered.•Begingivingrescuemedicineasneeded.Each

rescue treatment should provide relief for at least four hours.

•Ifrescuemedicineworksforlessthanfourhours,thinkaboutcallingyourdoctor.Donotgiverescuetreatments at home every two hours without getting help.

•Ifarescuetreatmentgivesnoreliefin20minutes,movetoredzoneactions.Youmaybenearinganemergency.

Yellow zone

Here are the three zones of an Asthma Home Care Plan:

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What you will see:A child is having obvious signs of distress. Rescue medicine is not working well. You need help quickly.

Red zone actions:•Givearescuetreatmentifyouhavenotalready

done so.•Callyourdoctorifyouhavenotalreadydoneso.•Giveanotherrescuetreatmentin15to20minutes

if the first has not improved the distress.•Ifyourchildturnsblue,orhassignsofsevere

distress, call 911, then give another rescue treatment. You may choose to go to the EmergencyDepartmentyourself.Youcangiveanother rescue treatment on the way. Choose the quickest and best way to get your child to the help they need.

•Everychildneedingredzonetreatmentmustseeadoctorassoonaspossible.Thisistrueevenifextrarescuetreatmentsbegintowork.Donotassumethat the attack is over.

Red zone

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How can I keep my child safe at school?

Sending a child back to school after an asthma attack can be scary. Workwithyourchild’steacherandtheschooltomakesureyourchildwillbesafe.Thefollowingtipsmayhelp. Meetwithyourchild’steacher,theschoolnurse,ortheprincipal.Yourteachercanhelpyoudecidewhoyouneedtomeetwith.Themeetingistodiscussfullyyourchild’sasthma.Itistodevelopanactionplanatschoolincaseofanattack.TakeyourAsthma Home Care Plan to the meeting.

TheTennesseestatelawcoveringprescribedmedicineatschoolisT.C.A.49-5-415.OlderchildrenareallowedtocarryarescueMDIinhalerontheirpersonatschool.Theyshouldbetrainedtoselfadministerthe

medicine if needed. Your school system may have several forms that you and your doctor need to complete. Some children may not need tohavearescuemedicineatschool.Thisisadecisionyou,yourdoctorand possibly your child will need to make.

If your child is young, his rescue medicine should be kept as close to him as possible. In his classroom is the best place. Rescue medicine should not be locked away and out of reach if needed.

If your child is given their rescue medicine at school, make it clear that youneedtobecalled.Explainthatifyour child says they need their rescue medicine, it should be given, and a call made to you. You will then decide what should happen next.

Stress that your child should never be left alone if having an attack. If an attack appears severe, make sure the schoolknowstocall911.Theyshouldalso give a rescue treatment to your child without delay.

Some children may have extra breathing trouble at school. Work with the school to see if mold, dust, class pets, or strong odors might be present as triggers.

Form No. 30680 (02/14)www.etch.com