Results of the study, published in the Annals of Allergy, Asthma and Immunology, show there are missed opportunities to intervene early and thus relieve a child’s symptoms, possibly reduce the extent of the attack and prevent visits to the emergency room.

The study stems from comments received by two lay asthma coaches employed by Washington University School of Medicine. The coaches are trained to help educate families dealing with asthma by offering information and social support. They also have asthma themselves or a family member who has it.

While talking to parents of children with asthma, the coaches noticed that parents were often unsure of exactly how to use albuterol, a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs, when they noticed signs that their child’s asthma symptoms were worsening. The study followed up on those observations to determine if they are true among a larger group.

Asthma is one of the most common childhood diseases in the United States. Every year, two of every three children with asthma have at least one attack, or exacerbation. These exacerbations often result in missed school days, visits to the emergency room and hospitalizations. But researchers at the School of Medicine say some of these exacerbations could be prevented with early home treatment with albuterol.

For the study, the coaches telephoned 101 parents of children ages 2-12 who had recent visits to the emergency department at St. Louis Children’s Hospital with an asthma exacerbation or who had called the hospital’s After Hours Call Center. More than 60 percent of the families had Medicaid insurance. The coaches surveyed the parents about how they detected that their child was about to have an asthma attack and what they did to prevent or treat it.

Parents reported noticing signs such as coughing, wheezing, shortness of breath, chest tightness or pain, cold or allergy symptoms, or even behavioral signs such as becoming quiet or more temperamental.

“Every time the child had an exacerbation, many parents noticed the same medley of signs preceding it,” says Jane Garbutt, M.B., Ch.B., associate professor of medicine and of pediatrics. “But even though they noticed the signs consistently, they often didn’t do anything about it. If parents had known to give albuterol earlier, they may have been able to manage things at home and avoid a trip to the emergency room,” says Garbutt, also director of the Washington University Pediatric and Adolescent Ambulatory Research Consortium.

Garbutt says one of the reasons parents may not begin treatment is that they believe they are following doctor’s instructions.

“The asthma plan from the doctor often says to start using albuterol when parents notice the child is wheezing or coughing or short of breath, but the doctor may have a different definition for those symptoms than the parent,” Garbutt says.

Another problem the researchers found was that parents may not notice some of the early signs that predict an exacerbation. One in four parents who was interviewed reported seeing late signs of an exacerbation in the child, including gasping for breath or sucking in the rib muscles when breathing.

“Those kids have to go to the emergency department because they are too far along in their exacerbation to do anything at home,” Garbutt says. “If we can talk to parents and find out that’s the issue, we can teach them to take action sooner.”

In some instances, parents knew they needed to give their child albuterol, but weren’t sure how much or how often.

“Parents varied in terms of how often they used it, if they used it with a nebulizer, how often they repeated it and how they determined if it was working,” Garbutt says. “A careful assessment of exactly which medicines are used and how they are administered and dosed could identify problems. We think that is something that can be addressed with education.”

Prednisone is a corticosteroid that prevents the release of inflammatory-causing substances in the body. Many parents said they kept the drug on hand at home in case of an asthma attack, but few parents in this study used it, instead calling the doctor’s office or going to the emergency room.

Garbutt and fellow researchers are conducting a follow-up study in which the asthma coaches are working with physicians to promote earlier use of albuterol as well as other effective self-management behaviors. In addition, the coaches are working with parents to help them identify the early signs of an asthma exacerbation by giving parents a symptom diary to help parents see symptom patterns.

Source: Annals of Allergy; Asthma and Immunology, Washington University in St. Louis (2/10/2010)

Analyzing data from interviews with 262 mothers of African-American children with asthma — a population disproportionately affected by this inflammatory airway disorder — the Hopkins investigators found that children whose mothers had more depressive symptoms had more frequent asthma symptoms during the six-months of the study. Conversely, children whose mothers reported fewer depressive symptoms had less frequent asthma symptoms.

Researchers tracked ups and downs in maternal depression as related to the frequency of symptoms among children.

“Even though our research was not set up to measure just how much a mom’s depression increased the frequency of her child’s symptoms, a clear pattern emerged in which the latter followed the earlier,” says senior investigator Kristin Riekert, Ph.D., a pediatric psychologist and co-director of the Johns Hopkins Adherence Research Center.

But while maternal depression appeared to aggravate a child’s asthma, the opposite was not true: How often a child had symptoms did not seem to affect the mother’s depressive symptoms, an important finding that suggests maternal depression is an independent risk factor that can portend a child’s symptoms, researchers say.

Past studies have shown that children with chronic health conditions fare worse if their primary caregiver is depressed, but none have teased out the exact interplay between the two.

“Intuitively, it may seem that we’re dealing with a chicken-egg situation, but our study suggests otherwise,” Riekert says. “The fact that mom’s depression was not affected by how often her child had symptoms really caught us off guard, but it also suggested which factor comes first.”

Researchers did not study why and how a mother’s depression affects a child’s asthma status, but because depression often involves fatigue, memory lapses and difficulty concentrating, it can affect a parent’s ability to manage the child’s chronic condition, which can involve daily, and sometimes complex, drug regimens and frequent visits to the doctor.

“Mom is the one who must implement the doctor’s recommendations for treatment and follow-up, and if she is depressed she can’t do it well, so the child will suffer,” says lead investigator Michiko Otsuki, Ph.D., a behavioral medicine fellow at Johns Hopkins at the time of the study, now at the University of South Florida St. Petersburg.

Investigators say their findings should prompt pediatricians who treat children with asthma to pay close attention to the child’s primary caregiver — whether or not it is the mother — and screen and refer them for treatment if needed.

“We ask these parents if they are smokers all the time, so maybe it’s time to start asking them if they are coping well emotionally,” said co-investigator Arlene Butz, Sc.D., a pediatric asthma specialist at Johns Hopkins Children’s Center. “Doctors are trained to pick up on subtle clues, so if they see a red flag in mom, they should follow-up with a depression screener and referral if needed.”

Treating depressed mothers whose children are at high-risk for asthma complications will likely benefit both mother and child, researchers say, while providing a clear treatment target to help reduce the burden of asthma in the United States. Asthma is the country’s leading pediatric chronic illness, affecting 6.5 million children under the age of 18, according to the CDC.

The Hopkins study included only mothers but investigators believe a similar pattern would emerge regardless of who the primary caregiver is.

Researchers caution that the mothers in their study were screened for depression with a standard questionnaire, which is a reliable detector of symptoms but not a firm diagnosis.

The Hopkins findings came from a high-risk, inner-city population and thus cannot be statistically extended to other ethnic and socioeconomic groups, but researchers say the effect of caregiver depression on a child’s asthma likely transcends demographics.

The research was funded by the National Heart Lung Blood Institute.

Source: Johns Hopkins Medicine, 11/19/2009

You’d had bronchitis before. It was annoying, but nothing to worry about. You knew what to do: You took a cough suppressant, sipped herb teas, made a big pot of chicken soup, and upped your daily dose of vitamin C. But your coughing continued, and not just during the day. You also developed a symptom you’d never had before, terrible coughing fits that kept you up at night.

“The Bronchitis from Hell,” your doctor sighed, as he scribbled a prescription for antibiotics and a codeine cough syrup. But they didn’t help.

Four days later, a call to your doctor’s office got you a referral to a lung specialist. He listed to your story and had you blow hard into a strange tube. “You don’t have bronchitis,” he said. “You have asthma.”

“Asthma?” you gasped. “At my age? I’m a 53-year-old woman. I thought asthma was a childhood illness. And I though it caused wheezing. My problem is coughing.”

“Asthma is best known as a childhood disease,” the specialist replied, “so few people know that the majority of Americans who have it are adults. Many people, particularly women, get diagnosed in their thirties, forties, and fifties. And asthma doesn’t necessarily cause wheezing. A classic symptom is persistent coughing at night.”

What’s Going On?

Asthma is the “childhood” illness that affects more adults than kids. Some 15 million Americans have it. About 5 million are under 18, while 10 million are adults, according to the American Lung Association (ALA). In other words, adult asthmatics outnumber kids two-to-one. In addition, few children “outgrow” asthma. The condition persists into adulthood in 72 percent of men and 85 percent of women.[i] Regardless of asthma sufferers’ age, it’s a serious condition. Childhood asthma is the leading cause of school absences caused by chronic illness, and it accounts for one-sixth of all pediatric emergency room visits. Adult asthma costs 3 million lost work days a year.

To make matters worse, the asthma rate is rising. In 1982, 3.5 percent of the population had it. Today, the figure is 5.6 percent. Asthma deaths are also rising: 2,600 in 1979, more than 5,100 today.[ii]

Until the mid-1980’s, doctors believed that you developed asthma when your bronchial tubes (or airway), suddenly narrowed (broncho- constriction), limiting your ability to move air in and out of your lungs. Doctors treated asthma with drugs that re-open the bronchi (broncho- dilators). Physicians still view bronchoconstriction as a key element in asthma, and still prescribe a variety of bronchodilators to treat it. But about 15 years ago, researchers discovered that another process is even more fundamental to asthma–airway inflammation–which, in turn, leads to bronchoconstriction.[iii]

What causes your airway to become inflamed? Many things:[iv]

• Inhalant allergies. “Allergies are the leading asthma trigger,” Homer Boushey, M.D.,[v] chief of the Asthma Clinical Research Center at the University of California’s San Francisco Medical Center. Allergic triggers include: pollens, dust, molds, pets (especially cats), cockroaches, and house dust mites (microscopic bugs that are ubiquitous in carpets, upholstered furniture, and bedding).

• Occupational exposures. A persistent cough and trouble breathing at work suggest job-related asthma, especially if symptoms get worse toward the end of the day and the end of the week. Triggering exposures might include: dust, molds, cleaning products, and work-related chemicals, including those in copy machines.

• Irritants. The major offender is cigarette smoke. Others include: volatile chemicals released from fireplaces, wood-burning stoves, and gas stoves and grills.[vi]

• Air pollution. In a study of childhood asthma attacks treated at emergency rooms throughout London over 12 months, British researchers documented a clear link between air pollutants–ozone, sulfur dioxide, and nitrogen dioxide–and asthma attacks.[vii] The good news is that in the U.S., sulfur dioxide, and nitrogen dioxide are much less of a problem than they were a generation ago.[viii] But ozone continues to fill the air, and exposure to ultra-fine particle pollution has increased, which, the ALA says plays a role in the increase in asthma.[ix]

• Strenuous Exercise. As workouts become more strenuous, risk of bronchoconstriction increases. Scientists are not sure why, but “exercise-induced asthma” is quite common. About 6 percent of the population has asthma, but 15 to 20 percent of people develop asthma symptoms during sustained workouts.[x] Many people with exercise-induced asthma experience no bronchial symptoms except when exercising.

• Weather. Cold weather is a respiratory irritant that can cause asthma attacks.[xi] Thunderstorms can also trigger asthma. In June 1994, a thunderstorm struck London, England, and immediately afterward, area hospitals reported 10 times the usual number of asthma admissions. The electrical activity of thunderstorms apparently breaks pollen particles into smaller pieces, increasing their respiratory irritation.[xii]

• Infections. Colds and flu are well-known for aggravating asthma. Sinus infections can do the same.

• Heartburn. For reasons that remain unclear, heartburn is associated with asthma, particularly night-time symptoms.

• Drug sensitivities. Aspirin, other drugs, and food-preserving sulfites may trigger asthma symptoms in sensitive individuals. Sulfites are found in beer, dried fruit, and processed potatoes and shrimp.

• The menstrual cycle. “Asthma is a major unappreciated women’s health issue,” says Emil Skobeloff, M.D.,[xiii] an associate professor of emergency medicine at Allegheny University of the Health Sciences in Philadelphia. His studies show that 75 percent of adults hospitalized with severe asthma are women, and that almost half of women’s asthma attacks occur around the time of their menstrual periods. Menstrual-related asthma attacks are often quite severe, Dr. Skobelloff says, which explains why women account for most asthma deaths—62 percent.[xiv]

Mainstream medicine treats asthma by encouraging trigger avoidance and with drugs, primarily anti-inflammatories and bronchodilators. “Drugs help,” says life-long asthma sufferer Richard Firshein, D.O., an assistant professor of family medicine at the New York College of Osteopathic Medicine and author of Reversing Asthma,[xv] “but they’re not The Answer. Mainstream medicine undervalues traditional health wisdom: diet, exercise, breathing re-education, and complementary therapies. I’m not opposed to drugs, but with my own asthma, I’ve had tremendous success with a comprehensive program that includes alternative approaches. The same goes for my patients. Within six weeks, 95 percent of them are able reduce their medications, and about 60 percent cut them in half.”