Expert: Marc Rubin, RPh Asthma Educator - 4/5/2011

Question
QUESTION: my 7 yr old has nightcoughs for 2yrs now.zyrtec before bedtime helps, then last year flonase was added as well(we used albuterol with every cold coz he'd cough bad).he recently had pneumonia & even after it cleared ,there's a lingering cough that starts as clearing the throat during daytime & worsens around bedtime.so now pulmicort respules have been prescribed.i'm not sure if he really needs it?plz advise..
also if steam inhalation will help & whats the best way to do it, in the shower or directly over a pot of boiling water? your insight would be helpful

ANSWER: Hi Kebhisha,

The Pulmicort Respules are ideal, but the onset of improvement is a few weeks. Unlike the albuterol, this is a controller drug which needs to be taken on a continuous daily basis, not just a flare-up. Used that way, it has no value. In asthma, an inhalation steroid, such as Pulmicort,is the Gold Standard of care. Your doctor should be re-evaluating your child in 4 to 6 weeks for improvement.

Please be aware that lung function goes down in the night, which explains what you are seeing.

Regarding the steam, if he is trying to cough up phlegm, it helps to increase his fluid intake during cold, dry winters. A shower can be beneficial, as well as a clean humidifier. I'd be cautious about the pot of water due to the risk of accident. The cool mist humidifiers with the fans have a greater tendency to develop mold, so maintaining cleanliness with these and the other units is imperative. Mold is a strong lung irritant.

For great parental guidance and education in asthma, look towards the site of Mothers of Asthmatics:

http://www.aanma.org

Always timely and informative.

Let me know how everything goes.

Please note, I'll be leaving for vacation in the morning, and returning April 3rd.

Sincerely,

Marc

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

QUESTION: thnks for your prompt & informative reply, his symptoms improved on pulmicort in 2-3 days, but he's coughing again after 7 days.should I be alarmed or is it acceptable? I'll call the peds office tomorrow for the same.I would highly appreciate your insight on a few more points-
1) shall we switch to an allergist as you recommend in your other responses(we've been comfortable under the care of our pediatrician up until now),but we'll switch if it means better care for him there. our peds office doesn't have spirometry & other options?
2) would inhalers be a better choice for him if we have to continue this treatment beyond 4wks, although i really hope this is just something temporary after the pneumonia ,are lungs scarred & extra susceptible to asthma symptoms after pneumonia?

3) do we have any non steroidal options for the treatment with less side effects?

4) have you personally come across children who need asthma treatments for sometime & then grow out of it for good?
I really appreciate your time in answering this & thnks for helping me better understand things .

Answer
Hi Kebnisha,

1)It appears that there may be something in your environment that needs to be put in check. I would certainly like to see your son at an allergist to evaluate what the triggers are, so that it will be easier to eliminate the culprits from your son's surroundings. Medications are great, but are of limited benefit it there is a constant inflow of irritating factors. Also, once under control, the specialist should keep your pediatrician up to date with what is taking place, and once stable, can potentially resume with your pediatrician being your primary point person.

2)In regards to the inhalers, if he can master the proper technique which, with training, should be doable, it will simplify both his and your lives. Proper training is key, with regular follow-up on technique to insure the technique is being correctly implemented. Pneumonia does not present a scarring issue. Long-term asthma can lead to permanent changes in the lung tissue over time(decades). Be aware that the level of severity can be variable in individuals. Some have a more seasonal variety, like early spring through summer, yet fewer problems in the fall and winter, and the medications can be reduced. Others may only have a problem when they get a viral infection, and others still may be severe all year round.

3) Steroids are the Gold standard, and when used properly, have minimal side effects. The dose may be adjusted up and down during the year based upon symptoms, and at times, may be discontinued for a period of months, and started up again beginning a month before the seasonal variations bring on the difficult time of year.

4) There are children that do grow out of it, usually around the ages of 5 to 7, and more likely boys. I see more girls where in their 20's and 30's it seems to return again. Hormonal relationship.

5)...and newer approaches to therapy are constantly under development. A study just came out where the rescue inhaler (albuterol) was used in conjunction with a steroid inhaler (beclomethasone) just for a short period after a sudden attack, and then the steroid stopped after a week or so. The patients had mild asthma, and were able to go back to just using their rescue albuterol only after the lungs calmed down.

Hope this helps!

Sincerely,

Marc