Reactive Airway/Wheezing/Inhaler tips

PLEASE SEE THE MOST UPDATED VERSION OF THIS POST  AUGUST 2021 We get calls all the time from parents worried that their child is wheezing. I am always going to pay attention to this complaint but not all breathing noises are the same. A whistling noise from congested nasal passages is not always something that we need to worry about. The wheezing that is going to get my antenna up is the noise from down in the lungs. Any squeak, crackle or wheeze can be a sign of inflammation. When a person is well, air can move easily in and out of the lungs through a network of airways. There are several things happening during a wheezing attack. The airway becomes irritated and inflamed; this produces mucus which can clog up the airway. The inflammation also causes the lining of the airways to swell and the muscles around these airways tighten; this is called a bronchospasm. Wheezing is actually quite common in infants; it is estimated that up to 25 to 30 percent of infants develop wheezing in their first year of life. Wheezing may be more common in babies because of their smaller airways. Also, children under two are susceptible to a common, but easily treatable condition called bronchiolitis. This is caused by a viral respiratory infection and is a frequent cause wheezing. If your child has multiple episodes of wheezing they may get diagnosed as having a reactive airway. Reactive airway is exactly what is sounds like. Something is “triggering” the lungs, and the airway gets inflamed. Triggers range from a new cold, a change in the weather, secondhand smoke, dust, pets and or other allergens. Having a season or two of wheezing does not mean they have a lifetime of asthma ahead of them. Some kids can grow out of this. If your child is wheezing it is important that they get prompt medical attention. If this is a first time event it is even more critical to get educated about medications and treatments so that you are prepared to recognize and deal with it in the future. In general, having a doctor take a good listen with a proper stethoscope is a good idea, but you will have important clues if you know what to look for. Pay close attention to the patient’s breathing. Is it faster than normal? Getting a sense of what normal looks like when they are well is a good idea. Age Category Age Range Normal Respiratory Rate Infant 0-12 months 30-60 per minute Toddler 1-3 years 24-40 per minute Preschool 4-5 years 22-34 per minute School Age 6-12 years 18-30 per minute Lift up the shirt and watch. Do the respirations appear labored? Look for the tummy going in and out, or any retractions. How are they feeding? If your baby needs to take more frequent breaks from eating that can be a warning signal that they are ill. For older kids, can they take a big deep breath without it triggering a coughing fit? If a patient is wheezing they are likely to get some special medicine prescribed. Albuterol (Ventolin/ Proair) and levalbuterol (Xopenex) are the common “fix it” medications. These help open up the airway by relaxing the tight muscles. Unfortunately it is not uncommon for patients to get a little amped up from the treatment. These medications should start to work within 6 minutes or so. Some parents report that the kids seem to cough even more after a treatment. Remember that this medication is loosening up an airway that was previously very tight. All of a sudden there is more room for the mucous to rattle around. A productive cough is normal. We would use either albuterol or Xopenex, not both at the same time. Some folks find that Xopenex is less likely to make them jittery. Insurance companies will often need to see documented failure with albuterol before the Xopenex is covered. These medications can be given through a nebulizer machine or through an inhaler. Most young kids do better with the machine, but as soon as they are old enough to cooperate with the puffer it is a quicker and much more convenient way to give the medication. If this is a short little illness, sometimes a few days of the albuterol-type medication will see you through. If you are requiring albuterol for longer than a week or find that you need to use it more than several times a month, it is a sign that the situation is not well controlled. An absolute key treatment for a reactive airway is the use of inhaled steroids and other anti-inflammatory drugs. In our office we use something called budesonide (Pulmicort) in the nebulizer, but switch over to an inhaler when the kids are old enough. Common brands are Flovent and Qvar. These can control and prevent future attacks. The steroids work by reducing the inflammation, swelling, and mucus production in the lungs. As a result a person is less likely to react to the triggers. All the studies agree, inflammation in the lungs is bad and can lead to scarring. The choice between allowing persistent inflammation or using proper dose of inhaled steroids is an easy one. Please don’t be reluctant to use the inhaled steroid if it is appropriate. The word steroid sounds scary, but when they are inhaled, they are not generally absorbed by the body, but are going straight to the lungs. If your child is given a prescription for inhaled steroids,It is not unusual for them to be on them for weeks or months, especially during the winter cold and flu season. Both of my kids had a few seasons of using the Pulmicort. As soon as I would try to wean off the daily dose, the dry hacky irritated cough would start right back up. Here are some tips regarding inhaler use: For younger kids, I start with some really basic teaching. Get a tissue and hold it up to their mouth. Have them practice blowing on it and then inhaling so that it sucks up to their mouth. This can help them to understand the difference between inhaling and exhaling. It is really important to shake the canister before each use. For the first use and any subsequent use if you haven’t used it for more than a week, the inhaler needs to be primed by spraying 2 to 3 puffs into the air. I know it seems wasteful, but it is necessary. If you child is having trouble, you want to make sure that you are actually giving the medication. Read the directions carefully for the specific information about each inhaler! Hold the medicine upright so that it doesn’t stick to the tongue. Breath coordination is difficult. Using a spacer will make the inhalation much more effective. For younger kids, the spacers come with a mask. Keep lips firmly around the mouthpiece. The spacers should not make noise. If there is a whistle, try to make the breath slower. Activate the medication and make sure to keep the spacer at the mouth for at least 5 breaths. Wait about 30 seconds in between puffs. If you are using albuterol and an inhaled steroid, give the albuterol first. It is a good practice to rinse the mouth out after the medication. This is especially true after the steroid. If your child has a history of wheezing, it is a good idea to keep track and make sure that you have un-expired medication on hand. If you are traveling have them with you! Most inhalers have counters now so you can see how many doses are left, but if yours does not there are some tricks for figuring out how much is left. Take the canister and place in glass of water. A full one will stay mostly upright. If it floats at a 45 angle, it is time to replace it. If it goes sideways, it is probably empty. Shaking it is not a reliable indicator because there is propellant inside, so it is hard to tell how much is in there. It is good practice to keep the inhalers in their box. When you come to a doctors appointment, please bring them with you so that you can show the doctors exactly what you have been taking. Please be aware that in February 2018 QVAR will be coming out with a new activation system that will not require a spacer or shaking of the cannister. It also won't require priming. The is approved down to the age of 4 years. Please make note if you have the old or new system. If you are using a nebulizer machine, make sure that you change the tubing at least every 6 months. If it is the disposable tubing, that should be used for no more than 15 treatments. I have found that a little tech time or videos are very useful in getting your child to sit still. This is one of those situations that bribery might come in handy. I shouldn’t have to add this, but please remember that the correct call for a child in true respiratory distress is to 911, not the doctor’s office.