Despite the development of effective medications for treatment, asthma and allergies remain a significant contributor of morbidity, mortality, and financial hardship to patients with the disease. Estimates from a skin test survey suggest that allergies affect more than 50 million people in the United States.1 While most people are aware that asthma and allergies are common in this country, many are surprised to note the profound impact that these diseases have on our society. 

The United States has the most advanced health system the world has ever known and its citizens have access to some of the most effective medications, best hospitals, and talented physicians.  Despite all of these advantages, 11 people every day will die from asthma, and over 40 people every year will die from insect sting anaphylaxis in this country.2, 3 On any given day, 10,000 American children miss school because of allergic rhinitis, for an annual total of 2 million lost school days.4 For the majority of people with allergies and asthma, proper recognition of risk factors, early identification of an attack, and appropriate management of the attack can prevent more lives being lost and lead to a better quality of life.

Attacks from allergies and asthma may appear to come out of nowhere and often seem completely random. A peak flow meter can be used to measure the velocity of air that a patient with asthma can forcefully exhale.  Many times, this value decreases even before the symptoms of an asthma attack are present, and may be a useful tool to use as an asthma early warning system.  Below are some helpful ways to identify some red flags that may alert you to an impending attack:

Asthma Warning Signs:
Asthma symptoms (cough, chest tightness, wheeze, shortness of breath) more than twice a week
Albuterol requirement more than twice a week
Frequent (more than twice per month) nighttime or early morning awakening from asthma
A decrease in the peak flow reading (less than 80% of the patient’s personal best)
Frequent (more than twice per year) refills of albuterol inhaler
Unable to participate in usual activities due to trouble breathing

There are many triggers for asthma attacks, and certain people may be more susceptible to one or more triggers than others.  The key factor for each child will be recognition of their potential triggers. 

Triggers for Asthma:
Allergens
Infection
Poor adherence to medication regimen
Failure to refill medications
Irritants such as tobacco smoke
Exercise
Exposure to cold or dry air
Poorly controlled allergic rhinitis
Aspirin
Acid reflux
Emotional anxiety or hyperventilation

Allergens:
Pollens
Molds
Animal dander
House dust mite
Cockroach droppings

Anaphylaxis is a potentially life threatening reaction that requires early recognition and prompt treatment once it occurs.  This immunologic reaction typically occurs within minutes following exposure to the offending allergen, and any delay in treatment may result in a fatal outcome.5 While there are many causes of anaphylaxis, the most common causes in the school setting are reactions to food or insect stings.  Food allergies are more common in children as opposed to adults, and the prevalence of peanut and fire ant allergy is increasing.3, 6

Most Common Foods That Cause Anaphylaxis5
Peanuts
Tree nuts
Fish
Shellfish
Milk
Eggs

Most Common Insects That Cause Anaphylaxis7
Fire ants
Wasps
Yellow Jackets
Hornets
Bees

Common Mistakes With Asthma Medication
The 2 primary inhalers used in asthma are either a metered-dose inhaler (MDI), or a dry powder inhaler (DPI).  It may be difficult for some children to properly time their inhalation after pressing an MDI in order to get the medication deep into the lungs where inflammation is present.  Older children can be taught to begin to take a slow deep inhalation within 1 second of pressing the MDI, whereas younger children will likely require the use of a holding chamber device (e.g. Aerochamber©) to accomplish this.  If the medication is a DPI, on the other hand, no spacer or holding chamber is required but the inhalation should be deep and rapid.

There are 2 primary types of asthma medications:  controllers and rescue medications.  Controller medications have anti-inflammatory properties and should be used every day even when asthma symptoms are completely gone, whereas rescue inhalers should be used only when asthma symptoms are present.  Some patients may need to use a rescue inhaler prior to beginning exercise if exercise typically triggers their symptoms.  It is a common mistake for patients to feel so good that they stop using their controller medication, or they only use it as needed—both are recipes for an asthma attack.  In contrast, rescue inhalers work best when they are used only when needed.

Because some of the asthma medications are expensive or inconvenient to obtain refills, many patients will try to decrease their use in an effort to conserve the remaining amount.  It is also tempting to try to “squeeze every last drop” out of their inhaler and use it until it is completely empty before refilling the prescription, but this practice may result in the patient not getting the full dose of medication with each use.  This is also a situation that frequently results in asthma flares and should be discouraged. Parents and older children should keep track of doses so they know when they’re low. Some inhalers have a built-in dose counter, but for those that don’t, estimate how many days the canister should last, and mark the date on the calendar.8

Common Asthma Mistakes:
1.    Incorrect inhalation technique
2.    Using anti-inflammatory asthma medications only when needed
3.    Using rescue medications when not needed
4.    Trying to stretch the medicine

Dr. Steven Cole may be contacted for more information about allergies and asthma at:
Park Lane Allergy & Asthma Center
9101 North Central Expressway, Suite 430
Dallas, TX 75231
214-363-8889
www.ParkLaneAllergy.com

References:

1.    Gergen PJ, Turkeltaub, P.C., Kaovar, M.G. The Prevalence of Allergic Skin Reactivity to Eight Common Allergens in the US Population: Results from the Second National Health and Nutrition Examination Survey. J. Allergy Clinical Immunol 1987; 800:669-79.
2.    Akinbami L. Asthma Prevalence, Health Care Use and Mortality: United States, 2003-05. 2006.
3.    Moffitt JE, Golden DBK, Reisman RE, Lee R, Nicklas R. Stinging insect hypersensitivity: A Practice Parameter Update. J Allergy Clin Immunol 2004; 114:869-86.
4.    Foresi A. A comparison of the clinical efficacy and safety of intranasal fluticasone propionate and antihistamines in the treatment of rhinitis. Allergy 2000; 55:12-4.
5.    The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005; 115:S483-523.
6.    Food allergy: a practice parameter. Ann Allergy Asthma Immunol 2006; 96:S1-68.
7.    Stinging insect hypersensitivity: A Practice Parameter Update. J Allergy Clin Immunol 2004; 114:869-86.
8.    Laliberte R. Get smart about asthma. Parents 2008:133-40.