Is childhood asthma becoming more prevalent?

Dr. James Swift: We’re seeing a larger increase in the number of cases of asthma, and that is partly due to environmental concerns because of the amount of the kind of particulate matter. We have less smog in some of these major metropolitan areas, but the reality is we have higher particulate matter that does affect children.

The problem we’re seeing is that there is a much greater severity of the asthma presentation, whereas we talk about asthma being that kind of systemic disease with wheezing or coughing. We see now children coming in early on -- one or two years of age -- up to 18 years of age, and the degree to which they come in and how sick they are is much greater. When we look at it from a standpoint of age distribution, really the severe cases of those children between the ages of five and 18, it’s really a life threatening feature and it’s a dismissive feature for families. They go, ‘Oh well, yeah, he’s got a cough, so it must be a cold.’ That cough then becomes more severe airway obstruction to where they can’t even breathe, and when they come in they are really almost cut off in terms of their ability to move air in and out of their lungs because of what we call, bronchoconstriction, or constriction of the airways.

What can happen if it’s not treated?

Dr. Swift: If we look at just subtle signs -- if we say, gosh my child has nighttime cough and my child doesn’t do well out on the playground and running around -- it’s really just what parents would concern themselves with, mild symptomatology. The problem with that is over time, those airways remodel and the lungs remodel, meaning they become damaged, and on top of that, the blood vessels going to the lungs become what we call reactive. The blood vessels say, I need to try to get oxygen in, so I’m going to constrict down somewhere else to get more oxygen over here, and that can result in really higher pressures in the heart and heart failure.

People don’t think about it. People think about heart failure in adults as a result of having a heart attack or having end stage heart disease, but in children they can develop what we call cor pulmonale. It’s a fancy term for meaning they can have heart failure from a very subtle, yet longstanding disease process.

How young are you seeing kids with this type of heart failure?

Dr. Swift: We have children who have longstanding, what we call, pulmonary hypertension, as a result of some of these diseases that can be as young as one year of age. Some of these diseases, when we think of reactive airway disease, it’s kind of a mixed bag. We call it reactive airway, meaning the airways are very reactive and constrict and they have wheezing, and this can be a provocative element that can be some of these respiratory illnesses in the winter. One is called respiratory syncytial virus – RSV -- that can set children up for asthma later in life or asthma soon after having that illness. We know that very young infants can have these repetitive wheezing episodes that, if untreated, can result in some of these longstanding issues.

What is the traditional treatment for it?

Dr. Swift: If we look at it being the bronchoconstriction, we look at it being the inflammation, and we look at it being the issues with having too much mucus in the airways, the primary treatment is what we call bronchodilators. Those medications are generally inhaled and will open the airways up. When you think about it, you think about these things you see on TV of the little inhaler or the nebulizer that missed the medicine into the mouth and that gets into the airways, that’s a predominant medication that people utilize.

Then there are steroids. There are both inhaled steroids, there are steroids that can be given by a pill, and there are steroids that can be given by IV, in the severe cases that decrease the inflammation. Then there are those medications that help stabilize patients from having these repetitive outbreaks. We talk about those, not treating the acute symptoms, but treating the symptoms long term to prevent those outbreaks, so it’s really a multi-pronged approach.

This last one, are they shots or are they pills?

Dr. Swift: They’re pills. There are pills and there are also some inhaled medications that they can utilize that will stabilize the membranes that lead to the inflammation and what we call, bronchospasm, so that can prevent things. The problem and the feature that we see is that this is really not related to our current economic crisis in the country, but it’s related to somewhat of the psyche of the American population of hey, I have a medicine and I can use that medicine to treat, so children with asthma and families with children with asthma go, well I have my inhaler. Rather than saying, ‘I’m going to seek care, oh Johnny’s wheezing, I’ll go ahead and use not just two puffs, I’ll use four puffs. Well, not just four puffs because he seems to wheeze more, I’ll use six puffs.’ They start to use the medication in an inappropriate fashion or they don’t use the medications as an ongoing therapy. They use the medication when sick and that leads to this almost unsuitable situation where they have this false sense of security and the children come in with really very severe symptomatology.

That’s our biggest concern. Amplify that now where families probably aren’t filling some of these medications or are probably trying to stretch these medications and only using when sick, and you have the setup for these children coming in. What we’re seeing is in the area that we look at and that we study is, in chronic severe asthma and what we call respiratory failure, where children come in and they’re not breathing anymore and they have to be put on an artificial breathing machine to help them breathe with their asthma.

How does the treatment with helium work?

Dr. Swift: There are some novel therapies for asthma once they get to such a severe point where they cannot breathe. We know there are children who come in and we put them on really a constant flow of this inhaled medicine, the bronchodilator that gets into their system, that we know that part of the problem with asthma is the narrowing of the airways, and the mucous in the airways creates what we call turbulent flow. Think of it as looking at a stream running down in the mountains, and with the rocks in there you have these little eddies that are created. If you take the rocks out of that stream and let the water run down, it’s what we call laminar flow. When the rocks are in there, you have these eddies that cause turbulent flow. That’s just like in asthma in the airways. You have mucous secretes turbulent flow where the patients cannot breathe in and out effectively, and it becomes a problem of trapping air in the lungs and not being able to get air out of the lungs.

We all think of helium as a fun gas. It inflates balloons, it’s used by people to suck in after a party and make their voice squeak really high, but part of the reason a voice becomes very high with helium is because it creates greater laminar flow in the airways or increases velocity so air moves in and out very easily. In asthma, we can have the patients inhale a mixture of oxygen and helium. That helium layers out and allows the oxygen and the CO2 to get in and out of the airways in a much more efficient manner.

Is the helium treatment only used in the hospital in extreme cases?

Dr. Swift: Correct. It can be used in really two facets. One is for children who come in who might own one of those nebulizers and we can use that gas in the nebulizer to help get that medication down the airways more efficiently. Predominantly, we use it when we’re in those severe situations where we’re using multiple medications -- the patient’s on a ventilator, they have a tube in place, it’s helping them breathe, we have them sedated, and we have them on a mixture of this gas to settle the airways out, but more importantly, to prevent trauma to their lungs, so we can get the gas back out, but we can get the medications in.

Are there any risks to using helium?

Dr. Swift: Helium is a great gas because it is in our atmosphere. It’s in a smaller concentration than what we use here. The danger to helium is that you displace more of the oxygen. If you have too high a helium concentration, you aren’t getting enough oxygen in.

Can that cause brain damage?

Dr. Swift: It’s manifested mostly because we can see that their oxygen content in their blood drops, so we would not let that happen, and most of these concentrations we give are not straight helium. There’s a mixture of 60/40 or 80/20, meaning there’s a mixture of 20 percent helium, 60 percent, or 40 percent, depending on the mixture of oxygen and helium. The issue is not so much in the side effects, it’s in whether we can apply the therapy because some of these patients need a very high oxygen concentration to keep the oxygen content in their blood up, so there are those instances where we can’t use the helium mixture because we need to use more oxygen.

What are the risks of using steroids?

Dr. Swift: We try to match the treatment with the symptomatology and try not to over utilize. Families are concerned always with steroids. When we think of the negative effects or the side effects of steroids, we think of those over time. There are those children who unfortunately need repetitive doses of steroids in the outpatient setting that we can see manifest some of those side effects -- weight gain, problems with their metabolism, problem with their electrolytes, things like that -- but generally, the families are concerned when they’re in the hospital with us and we have them on high dose steroids. Generally, the risks are very low because we’re using them for a very defined period of time -- maybe only for days, and so those high doses really are immaterial. There are side effects. We recognize that probably the biggest side effects are stress ulcerations in the stomach because steroids have that effect. Especially in critical illness, they lead to some stress ulcerations, so we usually have the patients on medications to protect their stomach from having those stress ulcerations, but steroids, in the short term, are relatively safe.

How long would kids be on the helium treatment?

Dr. Swift: Generally, we would have them on heliox, as we call it, maybe for a matter of a few days. It could be a matter of just a few hours once that laminar flow becomes apparent and we’re getting medication in there and the airways relax, but we have had them for as long as two or three days on the heliox concentration.

Do patients have to come back for more treatments?

Dr. Swift: We use it for a defined period of time. We then turn it off and put them back on just a normal oxygen concentration that they need to be on to either come off the ventilator or come back to spontaneous breathing. If they get sick again, we can reapply it, but it’s generally not. People ask sometimes, ‘Well gee, will you get a rebound effect? Turn off this helium and all of a sudden the airways will be much more severely constricted?’ And the answer to that is, ‘No.’ Sometimes when you turn the helium down or off, we realize that there are turbulent flows still there and we need to keep them on it for a number of days more.

Does the helium just clear it out?

Dr. Swift: Correct. It just leaves.

Can you tell me a little bit about Zachary, one of the patients you have treated?

Dr. Swift: Here’s an example of a patient who came in who was at a referring hospital. Many times we will get a call from a referring hospital with a very sick asthmatic, a patient who has a rapid respiratory rate, who is wheezing, who can’t move air, who is very frightening for the ER staff in an adult setting where they go, ‘My gosh, this kid looks very sick.. One of the things we make the recommendation on -- we have a transport team that will go pick up these critically ill children and we’ll make the recommendation for them to put them on helium along with that inhaled medicine. That’s the situation that he was in where we had them apply that therapy and then once here, we continued to apply that therapy. That was a great example of a kid who got the medication, the bronchodilator, inhaled and inhaled continuously that wasn’t improving, and they got the helium applied with that medication, and probably because of that, really allowed that medication to get in so that by the time he was here in our intensive care unit, he did much better.

Did he already know he had asthma?

Dr. Swift: He was a patient who had bouts of what we call reactive airway, but that many times families don’t want to view that as asthma.

He was never diagnosed with asthma?

Dr. Swift: Correct, but what is asthma? Asthma is repetitive episodes of wheezing. I think that we couch things sometimes so we can say to each other, ‘Oh, my child doesn’t really have asthma, my child just wheezes when they’re sick.’ The most common thing you hear from families, they say, ‘My child doesn’t have asthma, but in the winter when they’re sick, they wheeze.’ Well, that’s asthma. The provocative issues -- whether it be exercise, whether it be a cold or having the flu or whether it be cold weather and those cause wheezing episodes -- that is asthma.

How did Zach respond to the helium?

Dr. Swift: Just fine. Again, we fill up a chamber, and in that chamber comes an oxygen tubing, and we can either hook that to the wall to one of our oxygen outlets on the wall or we can bring in a tank of helium and oxygen mixture and hook it to that and let them breathe. They tolerate that very well. There are some patients who can’t tolerate it because, again, their oxygen drops, so they have a low oxygen content in the blood so we can’t utilize it, but in this situation, it worked very well.

How would you explain Zach’s condition when he got here?

Dr. Swift: For families, it’s important to use the one to ten scale in many regards. On a scale of one to ten, ten being the sickest, he was probably about a six or seven. Those patients who are kind of above that are patients who are in a pending respiratory failure who end up on ventilators, and unfortunately, we have a number of those every year and every winter and spring season. Those can be very challenging cases where we’ve thrown the kitchen sink at them, everything but the kitchen sink and then put them on the helium. We have those rare circumstances where we have children with such severe asthma that we actually put them on a heart/lung bypass machine to allow their lungs to rest. Those things are, again, advanced therapies that we can use, but once we get to the helium, those things work very well.