Here's a scary statistic: One in three life-threatening asthma attacks happens in people with mild asthma.
"You're just caught in that terrible moment where you're sick and there's wildfire smoke and somebody just asked you to pat their cat and you went for a run," describes Dr. Anne Hicks, associate professor of pediatric respiratory medicine and Canada Research Chair in Children's Lung Health. "It can all add up and send you in the wrong direction."
That statistic is why Hicks recommends that everyone who has asthma - one in 10 children in Canada and 6.1 million kids worldwide - should have an "asthma action plan" so they're ready for that no good, very bad day when it happens.
"Asthma is a condition of loss," Hicks explains. "You can't go outside for recess, you're not picked for sports teams, you miss being in the school play."
Hicks, who is clinical lead for the Children's Environmental Health Clinic and also runs her own Children's Lung Health Lab, aims to help children have safe play experiences, participate in sports and go on summer vacation without a crisis.
"How do we get people prepared so they can control their asthma and live just like somebody with no asthma?"
In honour of Asthma Awareness Month in Canada, Hicks shares some expert advice on how parents can keep their children safe and healthy every day of the year.
Find an asthma educator
As soon as your child is diagnosed with asthma, Hicks says the first step to preventative care is finding a certified asthma educator - a specially trained nurse, respiratory therapist or pharmacist - who can teach you all about the disease and how it affects your child.
Hicks' recent study of a Calgary asthma education program looked at 3,589 children with mild asthma from 2016 to 2019. Their risk of asthma attacks was reduced by 15 per cent in the two years following the education session, and they also saw a reduction in emergency department visits.
"A certified asthma educator works with a family for 60 to 90 minutes, teaching them about asthma and their medications and how to read their own body, what they should expect from their medicine and how long it'll take to work," Hicks explains.
"This supports parents and children to make informed decisions about how to control what's happening in their body."
An asthma education session may include taking a clinical history, spirometry (for children age five and up), a prescription review, and teaching on how to use asthma devices such as inhalers.
Each patient should come away with a personalized asthma action plan that outlines preventive actions, control medications and exacerbation management, Hicks says, so you can stay on top of the disease and avoid a serious attack.
Know your child's triggers
Asthma is a chronic inflammatory disease triggered by external factors like smoke, infections or allergens, causing symptoms such as shortness of breath, chest tightness, coughing and wheezing, according to Asthma Canada.
"Basically asthma is an obstruction of air flow in the small airways because they are swollen and the muscles become tight," says Hicks. "But it's a waxing and waning disease. Everybody's asthma is different. It belongs to them."
"Inflammatory triggers" such as dust mites, animal dander, moulds and pollen set off an allergic reaction that causes inflammation. "Symptom triggers" such as smoke, exercise, cold air or perfume are not allergic, but they can provoke symptoms all the same.
In about one in 20 children with asthma, it is severe or difficult to control, with a different disease process in the body, according to Hicks, who is a member of the Women and Children's Health Research Institute.
Hicks says people with asthma are much like the proverbial canaries in the coal mine when it comes to environmental pollutants, providing an early warning of danger.
"When we're exposed to a respiratory irritant like wildfire smoke, everyone will eventually get sick," she points out. "But people with asthma know about it before others."
Know what good control looks and feels like
The good news is that people with mild to moderate asthma can plan for these challenges by taking regular medications and staying on top of their disease.
"People want to take medicine and get better and have it go away," she says. "That's not how asthma works, but it's incredibly frustrating to take medication when you feel well."
She says accepting that asthma is a chronic illness that means taking medication every day is the first step to good control. Think of it like wearing glasses for poor vision.
"When you have the right asthma medicines in your body, your lungs work beautifully and you can run and play. You can even catch a cold and it feels crummy, but you're not sitting in the emergency department needing medications to get you out of an asthma attack," Hicks explains.
Every person's asthma will require different treatment, but most people will have two kinds of medication: The first is a controller medicine, taken daily, that will take two to four weeks to start working. Much like your skin after a scab comes off, it takes up to three months for inflamed and irritated lung tissue to completely return to normal after a severe attack.
Then there are reliever medicines, for when your child has a flare-up. These are often inhaled medications. They should work within 30 seconds to two minutes and last for two to four hours. Some people may also need to carry an EpiPen to take first if they have severe allergies, depending on their triggers.
Older children should be able to tell you when they're not feeling well, but you may need to watch small children to see the first signs of trouble.
"If a little kid is suddenly quiet, and you can see their neck muscles working, or you lift up their shirt and their little sides are pulling in between their ribs, you know they're struggling to breathe, so give the reliever and consider an emergency visit if needed," Hicks says.
If you find new medications don't work as you expect, go back to the doctor and let them know.
Find the right balance
Using asthma medications effectively is all about balance. Though the medications should ensure that your child's asthma is well controlled, it's also important to consider side-effects. You're aiming for the lowest dose possible with the most benefit and the least harm.
"One of the main reasons kids may not use their puffers, other than inconvenience, is that parents are really worried about side-effects," Hicks notes. "That's where the asthma educator comes in. They can answer questions and talk about risk factors you should be watching for as a parent."
Reliever medications will increase the heart rate, for example, so it might look like you've given your two-year-old a pot of coffee. Using a puffer can give you a sore throat. Some puffers use aerosols, which contain greenhouse gases, a concern for some families. You can talk to your doctor about greener versions that work for many people, although children under 5 may not be able to activate them.
Controller medications generally contain a steroid, which at low doses has minimal side-effects but can sometimes promote yeast growth in the mouth. To avoid more severe symptoms like thin skin, brittle bones and immune suppression, it's important to stay below a maximum total steroid exposure from all sources, including nasal sprays, puffers and skin creams. This varies by age and should be carefully evaluated by your pharmacist, asthma educator or doctor, especially in young children.
Expense can also be an issue for families, with some puffers costing as much as $150 each. Hicks encourages parents to seek out programs that can help, such as the Alberta Child Health Benefit.
Create an asthma action plan
Hicks advises every person with asthma should have an "asthma action plan" that spells out exactly what to do when things are under control, when it's getting worse and when it's time to get help. There are lots of templates for the plan online, or your doctor may give you one.
Build this plan with your child and their care team. Once it's complete, take it everywhere your child goes, along with medications and a list of triggers. Camp counsellors, teachers and babysitters all need to know about it.
"Think about Murphy's law and bring the puffer along. Hopefully you never need it, but if you have it with you, you don't have to worry," Hicks says.
When your child has an asthma attack that can't be controlled by their usual reliever routine, then it's time to head to the hospital.
"If you're having to give the medication frequently, you either drive into the hospital or you call an ambulance because when you can't breathe, it's an emergency," Hicks underscores.
At the hospital, staff will administer steroids and other medications to decrease swelling and relax tight airway muscles, and may also provide oxygen and other breathing supports. Then begins the long process of stabilizing the asthma again. As well as resuming controller and reliever medications, a severe asthma attack should trigger a medication review and potential changes to prevent future issues, Hicks says.
Reasons for hope
Children with asthma in Alberta have the opportunity to take part in research projects that aim to make life better, thanks to researchers like Anne Hicks and others.
One, called the Mobile Health for Kids With Asthma (MoKA) study, is using cellphones to "listen in" on patients and measure their symptoms in real time. The goal is to train a predictive model that can be individualized for patients to help them see an asthma attack coming well before it happens and take action early enough to prevent severe attacks.
"Imagine if your colds mailed you a postcard and said they were coming. You'd be able to plan for them, and you'd be able to prevent viral-triggered asthma attacks," Hicks says.
One of Hicks' studies, called ADAPT, monitors indoor air quality in a child's home to measure total exposure to chemicals and analyze their impact on asthma control, sleep quality and skin health. It includes a randomized control trial to learn whether HEPA filters in the home can help.
"We'll follow those kids for one year so that we capture all four seasons. And we'll see if that HEPA filter changes chemical uptake, inflammation, asthma and sleep outcomes," Hicks explains. "We are hoping that with more of a cause-and-effect link, we can help people figure out how to make changes in their homes that can decrease asthma symptoms."
Another project in collaboration with the University of Calgary has an engineering master's student building an app that will collect local weather, air quality and transportation data in real time, so people with asthma can plan their day based on what they know about their triggers.
Hicks also supports primary care providers in giving asthma care. Her Children's Environmental Health Clinic, a WHO Collaborating Centre in Children's Environmental Health, just completed a companion document to the PAHO Climate Change Pocket Book, focused on pediatric needs.
For Hicks, the ultimate goal is to ensure children with asthma can get the most out of life.
"We all want families to have a fantastic summer. Let's plan ahead a little bit extra and as well as bringing a swimsuit, pack your water bottle, pack your puffer and … go play!"
