Last week, we began the series on asthma with the basics, as it is important for everyone to understand how asthma affects children and what are the common misapprehensions about it. This week, Dr Tanmay Amladi focuses on the devices that asthma requires a pateint to have with him all the time - inhalers. The doctor differetiates between this and nebulisers, the other device, and how their uses have different approaches.
Q) What is a nebuliser? How does it work?
A nebuliser is machine that is capable of taking any liquid in small quantity and converting it into a fine spray of tiny particles (aerosol) which can be inhaled (taken into the lung) – imagine it to be somewhat like the spray that emanates from, say a perfume bottle but the particles are usually much smaller. The machine is generally electrically operated.
Nebulisation, in medical parlance, means delivering a medicine or combination of medicines, together or in sequence, using a nebulizer machine. The medicine(s) is (are) in liquid form, which are converted to aerosol(s). These aerosol particles of the medicine(s) then settle down on the surface of the entire airway from the nose and mouth, down the throat, the windpipe and the lungs’ airway tubes.
Medicines given for nebulising a breathless child help in 3 ways:
1. They loosen the mucus trapped in the airways and ease it out, making the airway tubes clean
2. They dilate the constricted tubes by relaxing the muscles in the walls of the tubes
3. They reduce the swelling of the walls of the tubes.
These effects, in total, clear and widen the airway tubes and make it easier to breathe.
An inhaler is a hand-held device which sprays an asthma medicine in the form of aerosol through the patient’s mouth, down the airway tubes and directly into the lungs to produce its effect. It doesn’t need an electric supply source, is compact and is ideal for home use or when on the move, say travelling in a bus or train. There are also dry powders in capsules which can be inhaled. Inhaler sprays with spacers can be used for asthmatic children of any age while dry powders and their devices are used by children 8 years and older.
Q) When a child gets breathless or wheezes very often, what should the parent keep at home – a nebuliser or an inhaler?
Nebulisation provides temporary relief; it does not control asthma. The relief lasts for a few hours. Nebulisation is therefore used in 2 settings:
1. To provide immediate relief to a child to visits the clinic or hospital for breathlessness/wheeze.
2. Children hospitalised with breathlessness or wheezing.
Inhaler devices such as metered-dose inhalers with spacers and masks or dry powder inhaler devices, are more suited for personal use at home or when travelling.
If your child needs frequent nebulisation, it is necessary to delve deeper and in more detail into the contact of the child with certain foods or environmental objects likely to be causing the wheeze, past illnesses, associated illnesses, family history etc – nebulisation should NOT be viewed as a panacea for all children with cough and breathlessness
Q) If the child has frequent coughs without wheezing or breathlessness and it is, what the doctors term, “respiratory infections’, should the child be nebulised?
The doctor needs to examine the chest with the stethoscope to confirm whether your child has wheezing and then advise nebulisation. That is why nebulisation is best left in the hands of a doctor in a clinic or hospital setting.
A cough, or even a repeated respiratory infection, may or may not be associated with wheezing, even in a known asthmatic child. Therefore, whether to give nebulisation needs to be decided from case to case and with each individual infection.
Q) Adult asthmatics often use inhalers daily. Is this also necessary in children?
There are two types of inhaler medicines – relievers, which are used to relieve symptoms fast, when the patient is acutely breathless, and controllers which are given daily to control the asthma and help repair the lungs even when the patient does not have any symptoms. Relievers are used on a need-only basis while controllers need to be used daily over a longer period of time.
Q) Do inhalers cause physical dependency? Do they stop having any effect after prolonged use?
This is a wrong perception. Inhalers do their work only as long they are being used and can be stopped whenever they are no longer needed. However, airways which have been damaged from episodes before the start of treatment, need time to heal, hence, inhalers containing controller medicines need to be given over a longer period of time.
Q) Older persons, and sometimes even young adults, may either use the wrong inhaler or repeatedly use the wrong technique. Is this a likely cause for the inhaler to not work, so the patient gets “dependent” on it.
Asthma control does not mean only inhaler treatment or nebulisation when needed – it means also controlling and avoiding triggers and treatment of co-morbidities to make the patient holistically back to health, giving the child quality of life.
Q) Do inhalers contain steroids which interfere with the growth of children?
All inhalers don’t contain steroids. And steroids are medicines just like any other medicines with both, good effects if used correctly and side effects if used incorrectly.
Used correctly in the right dose and duration, they will not disturb growth permanently and the patient will show excellent improvement from asthma symptoms and in fact live a healthier life, take part in sports, improve appetite and this will improve growth as compared with asthmatics whose treatment is neglected and have to undergo repeated treatment with syrups, tablets and injections and are unable to take part in sports and have poor appetite due to repeated illness.
However inhaled steroids are to be used under doctor’s supervision only and a regular follow up with the doctor will prevent any side effects.
Q) How do you monitor a child’s progress if she is on daily inhaler treatment?
Within about 4-6 weeks of daily treatment with inhalers, your child will stop coughing and be able to play and exercise more freely and sleep better at night, which now won’t be disturbed by cough or breathlessness. Overall, there would also be improvement in appetite and catch-up growth if your child has been lagging behind. Also sudden worsening episodes, which we call exacerbations, will stop occurring.
This is provided, the inhaler is used as instructed with the correct technique, illnesses associated with the asthma are also controlled, and the items in food and environment triggering the attacks are also avoided as advised.
Q) Can inhalers be stopped once the child is feeling better?
No – the inhalers given daily are controllers, not relievers – they are not for relieving symptoms - they are for repairing the airways and reversing the swelling and narrowing of the airways. This repairing needs to continue till the airways are normal long after the child is actually feeling better. Do not stop the treatment until the doctor has advised you to stop.
Q) After the child is symptom-free, how long can one expect the treatment to be continued?
On an average inhaler therapy takes at least 18 months – if the patient is well controlled early during this period and remains almost symptom-free all through the treatment can be reduced gradually and stopped at the end of 18 months or so. This is may be longer in a few children.
What if the child misses a dose? Should the next dose be doubled?
No there is no need to do that. You can simply continue from the next dose. But if you have forgotten, let’s say, the morning dose and remembered in the afternoon, you can give it in the afternoon and give the night dose at the usual time.
Q) Are dispersible tablets, given nightly, a good option?
There is such a medicine available in tablet form. It is very effective in children under five years of age who have infection-associated wheeze and in older children, in exercise-induced asthma. It can also be used as a replacement for inhalers.
However, in practice, it is generally advised as an add-on therapy with inhalers in those who don’t respond to inhalers well. As per currently available international guidelines, inhalers are still mentioned as the first choice of treatment of asthma in children. Inhalers are often refused by parents because of fears, misconceptions or a stubborn child who has some fear about the device. A doctor needs to counsel parents and the parents need to first be convinced themselves, and also reassure their child about the spacer-inhaler. The issue is what is more appropriate as per current guidelines rather than what is more ‘convenient’. And then....what is to say that a stubborn child, who refuses inhalers, will not refuse a tablet after a few months? The easiest way out is not always the best way.
Q) What should be done in an emergency even if a child is on daily inhalers?
Such a situation is less likely to occur provided you are giving the inhaler dose correctly, with the right technique taught to you and you are careful to avoid the triggers from the list given you by the doctor.
But you have to be prepared – if your child becomes breathless suddenly, please keep her propped up on the bed, loosen her clothing, keep her in a warm surrounding and give her a dose of the separate inhaler prescribed specifically for immediate relief. If she is finfs relief, you may repeat the doses every 2-4 hours till you can reach the doctor or hospital emergency room.