Asthma treatment of children and adolescents : Strategies for a global approach

Strategies for a global approach to the management of asthma in children and adolescents are described. Such an approach requires the physician to explain to the patient the pathophysiology of asthma, to evaluate and, whenever possible, change predisposing environmental factors, to establish a written plan of action and to maintain a close follow-up of the patient to ensure compliance.

Le traitement de l'asthme de l'enfant et de )'adolescent : Strategies pour une approche globale RESUME : Les strategies pour une approcilc global t' de la prise en charge de l'asth me chez I 'enfant ct I 'adolescent sont dccri tes.Une relic approc he ex ige du medeci n qu ' il exp lique au patient la physiopathol ogie de l'asth me, qu' il evalue ct mod ifie.quand c'est poss ible, lcs fac te urs enviro nnementaux predi posants.II doit auss i etablir un plan d 'action ecrit et maintenir un suivi rigourcux du patient pour garantir sa fi delite au traitcmcnt.

EXPLAINING THE PATHOPHYSIOLOGY OF ASTHMA
The primary role of the attending physici;111 is that or educator.It is essential to expla in carefully the nature of asthma.dist inguishing clearly the two pheno111cna involvt:d -hronchospasm and inflammation.To illust rat e this dis tinction .it is very use l"Lll to draw an analogy with the nasa l phenomenon during hay fever season.One obserws mucosa!edema and secretions (the in flammatory nl1nponcnl) but also sneezing (the dynamic component).
Several factors are kno wn to cause bronchial inllammation and hyperreactivity.In genera l, res piratory viruses arc the first inductors of thL' asthmatic res ponses during th e l'irst kw years of life.Thu s. daycare centres become particu - Later, after infancy, speL•ific alle rgies dL'Vclop that may cause asthma: allergies to dust.mi tes , muul ds.cats.clog•, etc (2,3).Special attention must be g iven to atopic c hildren during the fir.,t months of life: their putcntial for becoming asthmatic is high .
It is also desirahk to discuss the characteristic symptorm of asthma ( 4,.5) -L•oug hing, shortness of breath and whcc1.ing.For a long time.the whee zi ng crisis that brought patiL'IltS to emergency rooms associated w ith the clinical improvement brought on by treatment with an adrcncrgic agent (s uhL•utaneou s noradrenaline or inhaled salbutarnol) was cons idt:•red the hallmark of asthma.Today .frcLJucnt.repeated .md persistent coughing is cons idered a symptom o f as thma.The shortness of breath associated with cough ing or wheezing is also part of the symptom triad.If. al one ti me , it was said that all pati e nts who were wheezing were not necessa rily asthmatic (referring to the poss ibility of an intrabronchi al fore ig n body, for example) , today it is recognized that every case o f wheezing or coughing should first suggest asthma.

EVALUATING ENVIRONMENTAL FACTORS
In an effort to e xp lain the recent dramatic increase m asthma cases.al!ention is now being paid more and more to the macro-environme nt and phcnorncn..i such as industri al pollution.acid rain and cha nges in the ozone layer.
However.other respiratory irri tant s are also present in the mino-cnvironment of the home.It is important to know how well the temperature is m..iintained in an asthmatic c hild 's home bet ween the e nd of September and the end of May. a period when thi s micro-environment is self-contained.Ideally, the ambie nt temperature should be mai ntained between l 8 and 20°C.It should also he remembered that.over the past 20 years.most housL'.S have been overinsu lated and they arc freque ntly overheated.Another importa nt aspect is the humidity level.For several years, it was thought th :tt mainta ining a hi g h leve l of humidity (greater than 50 to 60% ) was preferred for cver-y child with respi ratory problems.Since the mid '80s, the opposite has been recommended; the ick..il re la tive humidity level in ..i house should be betwee n 30 and 45% .Pare nts should therefore have at hand a thennome t r and a hy g romete r to monitor and control as e ffici ntly ..is possible the temperature variations in the house.
Cigarel!e smoke is another irrit an t than can and must be absolutel y avoiclccl.As physicians.we ofte n !'eel that our recommendations arc not always put into prac tice.but it has been proven that if we ins ist, during each visit.on the importance of L'liminating tob:J.L'L'O smoke , pare nts ft"el more respon.,ibleas far as as thma man age ment is CllllCernecl.

ESTABLISHING A WRITTEN PLAN OF ACTION
To optimize both pat ient and fa mily trea tme nt compliance. it is of the must utmost importance lo give them a treatment diary in which they will desc ribe symptoms and doses of medication for an objecti ve ~•valuation.Even ii' an asthmatic patient only suffer., episodic :tirway obstruction .it 44A is useful to note the se epi sodes on a calend;tr and to wrilL' down the meclicatinn taken.
For the l'hronic asthmatic it is very useful and e ffec tive to ask. at the start.for the symptoms and drugs used to be no ted each day in a diary to indicate clearly the evolution or the disease.Follow-up vis its should be used to rein force the overall management strategy (6J).
Mild asthma w ith frequent symptoms (cough, shortnc.,s or breath, dyspnea, wheez ing, more th:tn seven to IO days a month).w hich interfere very lillle with e veryday adivitics and rarely cause a visit to the emergency room or hospital admiss ions.Nonstero ida l age nts such as cromog lycate, nedocromil or ke totifen are recomme nded as fi rst-step treatment.
as are the in haled steroids in the dose range of 200 to 400 p g pe r day.Taken continuously for a few weeks (generally four to six weeks) these drugs will alkviatc symptoms in patients with mild asthma.Moderate asthma with more marked symptoms that require visits to the emergency room and some times admission to ho spital.Cort icosteroids al doses rang ing from 400 to 800 µg pe r day are used in th t" long term treatme nt of moderate asthma.Severe asthma with daily symptoms that interfere with the child's or tee nager's norrn:il life.These patients regularly have to be treated in the emergency room and arc ofte n hospita li zed.It is often difficult to defe r th e use ofbronchodilators.
Whatever the level of treatment , the signs of an effective control o f asthma are the absence o r symptoms.bei ng able to pursue e veryday activities and , finally. the greatest possi biL' reduc tion in the use of ad rcne rgie agents ( 12.1 3 ).
T he use of pul mona ry function measures (spirometry with or without bronchial challenge, peak exp iratory flow ) is limited in ordinary practice to school age children and adok•s-L'Cnls.In children less than fiv e years old, different tests (rapid chest compress ion in the case of newborn infants.oscillation test in childre n two to fiv e ye ars old) are ava il able in spec ialized ce ntres.
For m:my child ren w ith moderate to severe asthma, serial me asure me nts with a peak expiratory flow meter help both the pare nts and the doctor to e va luate the airway obstruc tion crisis objectively and to m ake more effective adjustments 10 the long te rm treatment plan ( 14.15 ).

CLOSE FOLLOW-UP AND ACTION PLAN
When starting tre atment.it is esse ntial to plan a close follow-up of the pati e nt.Prescribing inha led medi cation during the arntc phase and the period immediately following does not mean th at an adeq uate control of as thma will be automaticall y achieved.T oo many unpredictable !'aL'lors aml difficulties haw to bL'.faced , 111:1king it is impossi ble to achieve effective the rapy and prevention so e as ily.Educttion and support are of the utmost impurtan ce when the child and his or her parents undertake th e task of asthma self-managemcnl.Thi s effort must no! be undertaken in a context of crisis.
A good relationship has to be established at the beginning of treatme nt, and mus! be reinforced every four lu six week s and !hen at intervals determined by !he 4ualily of asthma contrnl.It is also nseful to see a patient again two weeks following a significant exacerbation 10 review the treatment plan.
The use of an action plan written dmvn by the clol'tor and given to the patient at the same time as the symptom diary increases patient L "ompliance and makes him or her feel more responsible for man:.iging the di sease.Moreover.because most drugs arc cklivered by different inhalers, it is essential to ask the patient to bring the medic:.itionsto the office and demonstr:.iterepeatedly that he or she m asters the inhalation technique.The im portance given to the effective use of medi-L•:.itionwill demonstrate how seriously the maintena11L-e treatment of the asthmatic patient is considered.Finally. it is a good idea to rlan in one office sess ion (cg. the same morning or aftnnoon each week ) all arpointments of patients fol - Can Respir J Vol 2 Suppl A March 1995 lowed for asthma; repetitive application of strategies in different types of a s thma will rei nfo rce the message that we value a coherent a nd continuous manage ment ur uur asthrna patients (l(J,17).

CONCLUSION
The global arproach 10 asthma treatment is much mure demanding than the simple p resc ribi ng of a specific drug: the essenti a l role of educating childre n with asthma and their fam ilies is the most important of these responsibilit ies.At the first e valuation and at each follow-up visit, the attend ing phys ici a n must give special attention to all the essential facto rs of successful control of asthma: explain clearly the pathophysiology a nd s ig nifican t symptoms of a thma ; eliminate systematically all avoidable environmental factors to which the child is exposed; write down a plan or action for long te m1 m anagement: check regularly the qnality of the patie nt's in h alat ion technique; and , fina lly, cons tantly reinforce the everyday trea tment strateg y. ror the asthma tic child.the ultimate g oal is to live a normal daily lik.