Expert: Marc Rubin, RPh Asthma Educator - 2/8/2011

Question
QUESTION: Hi, Thank you in advance for helping me with my confusion! My son(6) has had asthma his whole life. We treat him with Xopenex.  I am very used to it acting up with a cold and know to go to the treatments every 4 hours to help him get through. He also takes Pulmicort 2x day.  Now normally my son doesn't have any cough with his asthma. He also will not normally tell me he needs his inhaler until its obvious. There has been many times where I could hear wheezing and ask if he needed the inhaler and he will tell me no. He gets it anyway.

So on Monday he woke up with a fever of 100.8 and wheezy. I could hear it standing next to him. So I started the xopenex every 4 hours...wasn't overly concerned at this point. I gave it to him before bed and then 4 am Tuesday morning he woke up coughing and in a panic that he needed his inhaler. He sounded pretty goopy at this point.  Around 6:30am it happened again. At 9:45 am he needed the inhaler again and I called the doctor. He still had a fever and she told me to go to the ER.

We went and he had 102 fever by that time. They treated him with back to back treatments of Xopenex and something that starts with an "a"(atavan?). They started him on oral steroids(which we have done before).  We hung around for hours waiting to see if it worked. He was doing well by the time we left. They also did a chest xray and found it suspicious for "walking pneumonia". They also sent me home with a prescription for Zithromax.

So Wednesday he woke up at 4 am again with the fear and a coughing attack. Gave hiim a treatment. We went for the follow up visit with his doc and she told me she was very close to admitting him. So the plan was that I continue the Xopenex every four hours around the clock.  So I gave him one at 2am . This worked because he didn't wake up in the morning with a major attack.

Yesterday, things seemed to be improving. He spent the day coughing up a lot of gunk and doesn't seem to have a fever anymore. He was still wheezy.  Last night he seemed  to be sleeping pretty sound.

That is the background..here is my confusion.  Throughout the day yesterday..I could tell he was still having issues. His nostrils are flaring and he is out of breath when he talks. I thought I heard the wheeze so I put my head on his chest and could hear the high pitched sound when he breathed out. But, he had already had his nebs an hour and a half before. .. Does this mean he is still having an attack and needs the inhaler again?  Today his cough is barely there. ..a little if he runs around.  I gave him the Xopenex at 7am and at 9 am  I sit him down and listen and I hear the wheeze.

I am confused if I should let it go and stretch it until the four hour mark..or does this mean he needs another treatment.  He isn't asking for the inhaler. But like I said, he normally doesn't. ..But it might be because he is getting by and feels ok?  He had the dose of steroids in the ER on Tuesday. He has had 8ml two times a day on Wednesday and Thursday. He has today and tomorrow left. Do I need to tell my doctor about this...or just wait out the course of steroids and continue the nebs every four hours?

If I can't hear it by standing next to him..does that mean it isn't as bad?  Should I just stop listening to his chest to see if he is wheezing?

I am very comfortable with the care my son got. I feel the doctors have done a great job..I just don't know if this is something I should talk to them about?

Thanks so much!!

ANSWER: Hi J,

Is your physician a pediatrician, or a pediatric allergist? If she is not an allergist, considering your description how he is presenting symptom-wise, he needs to be seen by a board certified specialist.

Do you have a peak flow meter? Has the doctor created an Asthma Action Plan with you? The dosing of the steroid is supposed to be based upon reaching 80% of projected peak flow numbers. It is given daily until that point is attained, and generally occurs in 3 to 10 days. You then just stop the steroid, with no need to taper. If you have never seen an Asthma Action Plan, go to:

http://tinyurl.com/AsthmaActionPlan

Not only does it show you impairment based upon peak flow results, but also what symptoms develop as the asthma worsens.


Has your son had any asthma training, aside from living with it? Often, an asthmatics perception of good lung function is a long distance from reality (this applied to my wife as well). There is an educational game online at http://asthma.starlight.org
Although it is for 7-15 year olds, I'd advise you to play it with him, and he should be able to acquire more knowledge.

Does he have any sinus symptoms? Is he taking any other asthma meds, like Singulair? In the AllExperts bio of me, I request information about where you live, type and age of housing, pets, meds, etc. Please review this, and give me more background so I can better ascertain issues which may be trigger related.

Look forward to hearing from you shortly.

Thanks,

Marc

---------- FOLLOW-UP ----------

QUESTION: I followed up with the info for you...and I wanted to update you on my son's progression. Hopefully you will see this with my other follow up!!

Over the weekend he still was wheezing slightly after using Xopenex. He was done on Saturday with all his meds. On Sunday he was really out of breath all day. He ran up the stairs and couldn't finish his sentence. He got very pale and scared me a bit.  

He has been like this today also(Monday). He also has a headache  and been exhausted. He went back to the doc today and they put hiim on flovent and said he had a double ear infection. ..so now he is on Amoxicillin also. He just finished the Zithromax? I asked about the out of breath and the doc just told me not to expect him to just bounce back.(which I understand).  She also told me that most kids are out of breath when playing. I tried to explain that he was just coming up the stairs ..not playing.  She told me to start using the Xopenex on an as needed basis. ..Thanks!

ANSWER: Hi J,

I just saw this post (crazy weekend!).

Did the pediatrician run any blood tests, such as a CBC (complete blood count)?
Did she advise you of any parameters to monitor?
I understand you are passing on to me what you sense she is telling you, and if you are accurate (of which I have little doubt), it just confirms to me she is not up to date on asthma therapy and troubleshooting his issues.

Please, get him to a specialist..

Marc

---------- FOLLOW-UP ----------

QUESTION: Thank you so much..I will definitely move on to a specialist. He has been skin tested...and all I recall "popping" was milk. I probably need to do it again. I have not been advised of anything. That was my frustration today. The doctor was more interested in explaining to me what flovent will do for him and how NFL players have asthma and live full lives. I was well aware of the maintenance medicines and what they do(my older daughter has asthma also). It's different than my son's and she is controlled right now.

I like my pediatricians ..just wasn't nuts about this particular one in the practice. She was the same one that I went to the day before we had to go to the er. I told her I heard wheezing and she told me he was clear..I am not saying she missed it..but it's possible.  Today, She listened to his chest and only heard a little wheeze...which definitely was an improvement to last week..but being out of breath is an asthma symptom for him..She said she could hear all the way down to the bottom of his lungs ..so he was good. But I never got my answer about it shortness of breath. How do I know he isn't in a little distress? She advised me to stop the Xopenex and just use when needed. Again...my question .. he is short of breath...he is still wheezy..doesn't that mean he needs it?

Albuterol sent him bouncing off the walls and we were switched to Xopenex.  I didn't know that about the asthma cups..I don't think his are disposable..

Thanks for all the info..it is much appreciated!

Answer
Hi J,

For starters, this particular pediatrician, in addition to listening to his lungs, did she do a peak flow test? If not, she is solely relying on her hearing without measurable information. The purpose of the peak flow meter is to provide objective information for making a correct assessment, and to allow the observation of improvement vs. increased impairment. I'd strongly suggest picking up a peak flow meter soon. They generally run $20-$30 tops. They come in full range meters and pediatric range. I'd prefer the peds, but either will do.

Thank you for the explanation of the albuterol.

If you'd like to talk with me tonight, reply to this, but make PRIVATE, and I'll send you my pharmacy phone number. I begin work at 9pm (10pm your time).

Sincerely,

Marc