March 6, 2018
Q: I’m currently very confused about whether the risks and benefits of treating with inhaled steroids for wheezing are well established. I’m also confused about what the literature means when they say ‘exacerbation’ of asthma.
A: Hoo boy. This is one of those questions that would get different answers to if you asked a room full of pediatricians. Different answers, and arguing, and maybe a thrown chair or two.
Heck, we’re not even sure if we should call this asthma. So I’ll back up to what we all can agree on, first.
A “wheeze” is a specific physical exam finding. It’s a whistly, almost musical sort of chest noise, the noise you hear when air tubes are constricted. Most (but not all) wheezing is heard during expiration. Children who are wheezing almost always cough, and cough is the main symptom of most wheezy illness. It makes sense-the airways are constricted, so the body tries to “pop” them open with a forceful expiration. Coughing can open airways and at least temporarily relieve the airway constriction and wheeze.
Lots of health conditions cause wheezing, and at least 25% of children will wheeze at least once. Mostly typically, it’s caused by a viral infection. Whatever you do or don’t do to treat it, the noise will go away and Junior will stop coughing. But recurrent episodes of wheezing, that’s when things get interesting. And controversial.
In older children, school age and up, the most common-by far-cause of recurrent wheezing is asthma. These kids usually have multiple triggers for their wheezing, including allergies, infections, cold air, and exercise (not all kids will have all of these triggers). Albuterol is the mainstay medicine to quickly stop wheezing and coughing once it starts. Inhaled steroids are the best medicine to use to prevent wheezing flare-ups (called “exacerbations”-that’s when kids with asthma have symptoms like coughing, wheezing, chest pain, and shortness of breath.) Inhaled steroids as preventive medicines work and they’re safe. Kids with asthma who use daily inhaled steroids have far fewer exacerbations, miss less school, and stay healthier.
But there’s another group of children in whom the usefulness of inhaled are less clear-cut. These are toddlers and preschoolers, little kids, who have recurrent wheezing episodes only triggered by one thing: viral infections. They get a cold, they start to wheeze. These kids seem to respond less robustly to both inhaled albuterol (which, especially in the youngest children, may not work at all), and less well to inhaled steroids, too.
Some people don’t even think we should label these little ones with recurrent wheeze as having asthma, because that can mislead us into using treatments that are less effective. A suggested label is to say these children have “WARI”, or Wheeze Associated with Respiratory Infections. Some docs say these kids have “RAD” or reactive airways disease, or “recurrent bronchitis”, or “viral pneumonia”, or recurrent “bronchiolitis”.
What makes this especially difficult is that we can never tell, from the first or second wheeze episode, if a child is going to end up with asthma (recurrent wheeze of many triggers) versus WARI (recurrent wheeze only triggered by infections.) Some suggest we look at family history, or whether the child has eczema or food allergies, but that history doesn’t reliably predict the future course of wheezing. What we really need is some kind of test or biomarker to predict who will really benefit from inhaled steroids. We don’t have any great way to know.
Inhaled steroids are safe, at least in ordinary low doses. In higher doses some growth suppression can occur, though that may disappear with long-term use. And we know out-of-control asthma, with frequent wheezing, will also stunt growth.
As always, risks and benefits have to be weighed. If a young child has infrequent flare-ups easily treated with albuterol I’m less likely to suggest a trial of an inhaled steroid; but if flare-ups are frequent or severe or land a child in the emergency department, daily inhaled steroids are worth a try. There’s some art here, and a lot we don’t know, and plenty of room for discussion between doc and parent about what’s best for each childs’ circumstances. The chair throwing, that’s optional.