Imagine going out on a boat. Trouble begins and the boat starts to sink. You are some distance from shore. You think about how good a swimmer you are which leads you to consider a few other options. Where is that life preserver? The recommendations (and hopes) are that it be within reach or that you are wearing it. That life preserver would be of little use if it was left on the dock.
Now think about asthma. You are out there and because this is an unpredictable condition, trouble starts. Where is your life preserver? Where is your inhaler? Should it be on your person just as that life jacket? This is a real concern and an issue that affects life and the quality of that life for those with asthma.
In the world of managing asthma we have two basic categories of medications: the long-term controller medications and fast-acting rescue medications. I like the use of the term ‘rescue’. These agents work fast and when used in a rescue fashion they help open the airways. The rescue medication will work usually within 15 minutes of application. A few examples of what would be considered asthma rescue medications frequently used for children include:
- Albuterol- available as ProAir, Proventil, and Ventolin HFA
- Pirbuterol- available as Maxair
- levo-albuterol- available as Xopenex
These agents can be effectively given by a metered dose inhaler (puffer) or through nebulization. Everyone who has asthma, regardless if it is intermittent or one of the three types of persistent asthma (mild, moderate, or severe), must have a rescue inhaler! This has been spelled out since the first edition of asthma guidelines (1991) and is an important part of the most recent NHLBI Guidelines for the Diagnosis and Management of Asthma. This is a well established recommendation, but how do we see it in real life situations?
I have always wondered where the rescue medication is kept, and how long it would take for someone to find and use their rescue medication when symptoms began. Recently, I had a chance to investigate that question.
I just finished a Masters in Public Health program at Indiana University Purdue University Indianapolis (IUPUI). (As an aside, anyone interested in conditions that affect the health of the population would find the pursuit of this type of a masters program most rewarding.) Some courses required doing field projects, especially in the epidemiology and biostatistics courses. I decided to do a project that involved the use of rescue medications by children with asthma.
In biostatistics you need to have a hypothesis, i.e., a statement that will be supported or found to not be true. My hypothesis was that all children with asthma have a rescue medication with them (or have immediate access). I was also interested whether or not a number of variables such as age, severity, or duration of asthma had any relationship to rescue medication availability. The questionnaire was answered by 124 children with asthma. I found that only 28% either carried their inhaler with them or had immediate (within 2-3 minutes) access to rescue medication. That means 72%, over two-thirds may have had to hustle to find rescue medication.
I asked this question of children who were about 10 years old. Just over half were boys. The group was representative of a suburban population. They severity of the asthma was as follows:
- Intermittent 10%
- Mild persistent 29%
- Moderate persistent 55%
- Severe persistent 6%
These children were asthma-experienced: the duration of having asthma was 6.6 years. This is where the inhalers were with this asthma-savvy group:
- Inhaler in a pocket (on them) – 14%
- Inhaler with a parent – 15%
- Inhaler at home – 55%
- Inhaler at school – 14%
- No inhaler – 2%
The next question was how long would it take to find and use your rescue medication?
- Immediately (optimal response) – 28%
- At 5 minutes – 40%
- At 15 minutes – 18%
- At 30 minutes – 7%
- Longer than 30 minutes 7%
The perfectionist in me felt that 5 minutes may be a concern, however there is a real issue with the 32% that needed 15 or more minutes.
There are a number of possible reasons for what I would consider a delay in rescue medication application. Our habits are that when things are going well, we tend to not be as vigilant. A well-controlled child with asthma would have very little additional need for a rescue medication so the lack of immediate access may be due to the success of other therapies. In fact, only 25% had used their rescue inhaler within the preceding month.
I was surprised by the results of my biostatistics project (not the grade, but the findings). As a specialist in the area of asthma care I learned something new and something that will help me to help my patients with asthma. I did not have to read this in a journal about some other population of children, this was a group of kids here at home, in my own backyard. My lesson learned is to be sure to ask the question and to use that basic principle of pediatrics- prevention. Prevent disasters but emphasize the concept of rescue and support any opportunity for the easy and quick access of that life preserver. I do not hesitate in writing those permission slips so medications can be carried at school. Yes there is concern about ‘medications’ and the possibility of misuse/abuse I fully understand that. I also hear about and see children who are very scared with these sudden, acute attacks of respiratory distress. Acute asthma events are not predictable, they are serious, and they need to be addressed urgently. The rescue inhaler needs to be readily available.
Respectfully submitted,
Fred Leickly
Leickly Stories 