Simple Advice that Will Simplify Your Life Part I: Asthma Treatments
Dear Readers,
First, I must apologize for the long hiatus I took from writing in the past few months. Every few days, a thought of a new topic crosses my mind, but I rarely have time to put it into writing. Today, being off for New Year’s, and spending half the day with family and friends, I felt that I was coming down with a “mini flu” some chills and bone pains, so after praying Mincha, I was allowed to retire into my bedroom to rest, and decided that I would feel better if I shared some practical advice with you.
To help you internalize and memorize the info, I decided to give a few real scenarios from my office. Today’s topic will be asthma treatments.
Scenario A
A few years ago a 1 year old toddler came into my office. His family recently moved back to the states from a few years of learning in Israel. I knew the family already well because their extended relatives were my patients for years and knew that Asthma ran in their family.
On this visit, the mother started with the following history: “Doctor Simai, I already decided that no matter what I do, this child will not stop wheezing”. On further questioning, I found out that for the past 2 months the child was persistently wheezing. He was started on an albuterol puffer, continued on to the nebulizer and was given a 5 day course of Oral Steroid at least twice. The mom was understandably very fatigued at this point. A quick look at the child revealed a well nourished, vigorous 1 year old that was having a mild chest retraction and a persistent cough. On exam, he had low grade temperature and a runny nose, fluid in the ears and impressive sounds of wheezing bilaterally on both sides of his lungs. There was no history of choking on any objects or foods. To treat him for a possible pneumonia, he was already given a course of a strong antibiotic.
I was truly concerned about him, in my experience so far, I did not encounter many cases of wheezers that I could not control fairly easily with albuterol nebulizations. I had a few cases of aspirated foreign bodies (a clove from Havdalah and PopCorn kernel both of which were already described in previous articles). I was truly perplexed by the fact that even with oral steroid for 10 days, there was no relief. I wanted to assume that maybe he had a few viral illnesses that triggered a few, separate episodes of asthma, but I decided to treat him as I would any new patient with wheezing. I asked my nurse to start a nebulization with albuterol at my office, and when I returned to the room, the mystery was easily solved.
Scenario B
A new patient walked into my office a few years ago. On her registration form, there was a check by the box “history of asthma”. When I asked the mother how severe the asthma was, she sadly stated that her daughter was admitted to the hospital numerous times for asthma exacerbations and she was taking oral steroids for months at a time. She was followed by a well respected pediatric pulmonologist. At that specific visit, she was asymptomatic without any complaints. Again, I was intrigued by her history. I was not used to seeing patients with such severe and persistent asthma. After a few months, she came into the office actively wheezing. Again, I asked my nurse to nebulize her with albuterol and once again, her mystery was solved.
Scenario C
Recently, a 6 year old patient came in coughing to my office on a Thursday afternoon. He had a mild history of asthma which did not require admission to the hospital, but did require a few Emergency Room visits. On the day of examination, he had a very mild wheeze, I could only hear it with my old trick squeezing his chest simultaneously with his expirations. I asked the mom if she owned a nebulizer and she happily nodded “yes”. I asked her to nebulize him twice a day with albuterol and pulmicort and said that he should be back to himself, Gd willing, by Sunday. On sunday morning, he returned to the office with a worsening cough and by now a loud, audible wheezing. Although perplexed, I asked the mom a few questions about his nebulizer and found my answer.
Solving the Mysteries - The simple answer to these interesting cases lays in the manner by which the parents were nebulizing their children.
Scenario A The young toddler that would not stop to wheeze.
When I returned to the room, I noticed that the young toddler was extremely irritated and his mom was struggling to hold the mask next to his mouth. I turned off the nebulizer machine and allowed the child and his mom to catch their breath. I asked if she has been nebulizing him in this fashion all along and she nodded “yes” that’s the only way he would allow. I smiled and said: “I have a feeling that little Yitzy will stop wheezing before shabbos”. I explained to mom that holding the nebulizer mask next to the face but not actually on the face, helps humidify the air at best. It delivers zero medicine to the lungs. From personal experience, I know that most infants and young toddlers dislike having a tight or loose fitting mask on their faces. They scream, throw their hands and feet in the air sometimes for the entire 10 or 15 minutes it takes to nebulize. But that is actually good for them. Yes, screaming and crying means taking deep breaths and by doing so, these children are inhaling the medicine deeply into their lungs. They are getting the medicine to the smallest part of the lungs called alveoli where the medicine act to reinflate these small structures. Rest assure, if you are persistent, by the second or third time you nebulize your child, he or she may actually like it (again, speaking from personal experience with some of my kids) and today, we have child friendly dragon masks or pacifier masks readily available. Little Yitzy received literally a few treatments at home with the mask tightly on his face and within 48 hours his lungs were crystal clear. He received albuterol (which relaxes the muscles in the lungs) and pulmicort (an inhaled steroid which decreases the inflammation in the asthmatic’s lungs with minimal side effects) only. There was no need for any oral steroids or oral antibiotics. in order to maximize the treatments and shorten the asthma attack, Yitzy was given some chest physical therapy with his nebulizations.
Scenario B New patient with history of severe asthma
When I came into her room, I noticed that she was getting the albuterol via the mouthpiece. This is a method we use for children older than 5 years. Something was suspicious though. At first, I noticed that she was definitely not taking deep breaths. A few moments later I noticed that there was a steady mist coming out of the nebulizer and then it hit me she was not inhaling any of the mist in!!!! she had a mouthpiece in her mouth but she was breathing from her nose. All the mist was just going through the “exhaust” and spreading in the room. I trained her to take breaths through the mouth while she was getting her treatments. Since that day, her asthma has turned around. She had no more hospitalizations and much less use of oral steroids.
Scenario C The mild wheezer who worsened over the weekend.
After seeing him worsen despite treatment with asthma medicine via his nebulizer, I asked the mom to demonstrate to me how she nebulizes him at home. She proceeded to show me that he was not using a mask or a mouthpiece, but just holding the canister a few inches away from his nose. When I suggested to use a mask, she said that when he was a young wheezer and visited the Emergency Room (a few years before I knew his family), the resident told her that if her son gives her a hard time, she could just use this method. It took a few minutes to convince her to change this approach but we both went home smiling and knowing that shortly, with Gd’s help, her son will be back in school.
I know that this advice may only seem relevant to a few parents out there of asthmatics, but the truth is that we use the nebulizer often to treat infants with viral bronchiolitis a disease that frequently causes hospitalizations. Throughout the years, my staff members and I have been treating hundreds of these infants with frequent nebulizations and with Gd’s help have an extremely low hospitalization rate.
On some occasions, I can easily sense that a parent is overwhelmed by holding a rambunctious toddler down for a full nebulization, which may take 15 minutes. I remind these parents that proper nebulization for 5 minutes is much preferred to 15 wasted minutes of “blow by” treatments.
A little advice can go a long way, so I hope that this simple advice may come in handy one day.
Wishing you a warm and healthy winter,
David E. Simai M.D.