Breathing Easier

from Children's Magazine, Fall 2005

Story by Melissa Howell 

Photography by Steve Kast

Running, Jumping and Playing Make Up Much of a 2-Year-Old’s World.

When TJ Ilaoa would start wheezing simply walking from the couch to the loveseat in his family’s living room, his mom, Ann Marina, knew something was wrong. After countless sleepless nights, numerous doctor visits and several hospital stays, Ann Marina finally heard the word that would help her understand what was inhibiting her son’s ability to be the active little boy he wanted to be: asthma. A year and a half later, with the help of The Children’s Hospital’s Asthma Management Program, Ann Marina now describes TJ as “rambunctious; a ham; always on the go.”

Fighting For Air

TJ was 6 months old when Ann Marina first heard him wheezing. Wheezing turned into bronchiolitis. In the following months, Ann Marina said, TJ was constantly sick.

“We were in the doctor’s office at least once a week after that,” Ann Marina said. “Our doctor suggested we wait on it and it would probably go away. It’s hard to see when they’re so little like that. He couldn’t do anything the other kids were doing.”

But it didn’t go away – it got worse.

One night in December 2004 started out like many other nights. Ann Marina woke up at 2 a.m. and heard someone wheezing; she didn’t know right away if it was TJ or his sister, Briana, who also has asthma. She went into the bedroom and found TJ wheezing.

“I woke up my husband and said, ‘something’s going on, TJ is wheezing bad,’” Ann Marina said. “We brought him in bed with us and saw his little stomach just sucking in (for air). I knew we had to go now. It was so scary.”

Soon after, they arrived at The Children’s Hospital’s Emergency Department.

“TJ was quite ill when he came in,” said Diane Herrick, a registered respiratory therapist and coordinator of the Asthma Management Program at Children’s.

TJ had a pediatric asthma score of 13 out of 15 possible points, Herrick said. His respiratory rate was in the high 50s; a normal respiratory rate for a boy TJ’s age is less than 34. His oxygen level was 87 percent to 90 percent; 93 percent or greater is normal at Denver ’s high altitude.

“This was considered to be a severe exacerbation,” Herrick said.

Doctors in the Emergency Department stabilized TJ with oxygen, steroids and Albuterol, a medication that provides quick relief for asthma. He was then transferred

to the fourth-floor inpatient unit on continuous nebulization, a device that administers high doses of Albuterol, and oxygen. The next morning, a team of caregivers arrived in TJ’s room with a diagnosis of asthma.

“TJ’s parents had been told a lot of different things about his condition, but hadn’t been told he has asthma,” Herrick said. “The Asthma Management Program diagnosed his asthma and provided the appropriate management.”

‘Education, Medication and Monitoring’

The Children’s Hospital Asthma Management Program was implemented in 2002 to better coordinate asthma care for all patients, from the very severe Emergency Department patients and inpatients to the milder outpatients who visit Children’s Asthma Clinic. It is the only comprehensive program in the Rocky Mountain region that provides coordinated care for acute and long-term management of pediatric asthma. In 2003, the Asthma Pathway was implemented as part of the program. This program dictates proven clinical guidelines for Children’s caregivers to follow, resulting in more consistent and appropriate treatment for patients. The program consists of a multidisciplinary team of caregivers throughout the hospital who care for asthma patients, including care providers from inpatient, outpatient, Children’s Child Health Clinic, the Emergency Department, Pulmonology, Respiratory Therapy, Nursing and Pharmacy.

Following implementation of the Asthma Management Program at Children’s main campus, program director Gwen Kerby, MD, and other Children’s care providers are working to bring the program to Children’s Care Centers in Aurora, Littleton, Broomfield, Exempla Lutheran Medical Center in Wheat Ridge and The Children’s Hospital at Parker Adventist Hospital.

Getting all caregivers on the same page is important, Dr. Kerby said, considering that Children’s treated more than 7,200 asthma cases in 2003. Asthma remains the No. 1 medical diagnosis at Children’s.

“We’ve tried to encourage caregivers to be more vigilant in using the correct diagnosis,” Dr. Kerby said. “We’ve also encouraged everyone who’s seeing asthmatic children to classify their severity and level of control. That helps decide what kinds of medications the patients should be on if they have persistent asthma.”

Herrick said, “Asthma has been called all kinds of things: bronchitis, pneumonia, bronchiolitis, reactive airway disease. One of the ways I explain it is to compare it to diabetes. We don’t call diabetes ‘pancreatic insufficiency syndrome,’ we call it diabetes, and we need to give the right education and treatment. With asthma you need education, medication and monitoring.”

Education is one of the biggest components of the Asthma Management Program, both for health-care providers and for patients and families. Patients and their parents receive education throughout their hospital stays.

On the morning of TJ’s diagnosis, Herrick arrived with the information, tools and education Ann Marina had been seeking: inhalers, a booklet full of information, and answers to her questions. Herrick explained what happens to the lungs in asthmatic patients, how different medications work to combat those symptoms and how TJ’s parents could monitor and treat his symptoms.

“We teach the families that there are three things happening inside the lungs when you have asthma,” Herrick said. One component of asthma is irritation, redness and swelling in the lungs, Herrick said. The airways of children and adults with asthma are sensitive to triggers, which are anything that make asthma worse. Triggers can include something an asthmatic is allergic to, such as pollen, pets and foods, or things that irritate the airways, such as cigarette smoke, perfume, strong odors and viruses. Viruses and infections are the No. 1 trigger for asthma in younger children, Herrick said.

“The No. 1 complicating factor by far is secondhand smoke exposure,” she said. “We can do a huge amount to manage kids’ asthma by never exposing them to smoke. People with asthma almost always have a little bit of inflammation, and that is what leads to the other problems in the airways.”Another component of asthma is that the muscles squeeze in and around the airways, called bronchospasms. Albuterol, an inhaled medication, relaxes the muscles in and around the airways so they return to a more normal size. But Albuterol alone doesn’t do the trick, Herrick said.

“Sometimes we see patients using lots of Albuterol, but all they’re doing is helping with the muscle relaxation,” she said. “They’re not helping with the underlying problem, which is the inflammation. The inflammation causes bronchospasms, so we really want to home in on the inflammation.”

For an acute asthma flare-up, an initial treatment in the Emergency Department, inpatient unit or sometimes even the asthma clinic is a burst of oral steroids, Herrick said. The steroids quickly relieve the inflammation.

“But to control the asthma, we really want to have less exposure to triggers and smoke, and use a control medication (such as an inhaled steroid) if the child has persistent asthma,” she said.

Asthma is considered persistent if symptoms occur more than twice a week or if the child wakes up at night more than twice a month.

“Inhaled steroids work directly in the airways to reduce the inflammation and to make them less sensitive,” Herrick said. “They are considered to be safe in low to medium doses over long periods of time.”

The third thing that happens in the airways of asthmatics is increased mucus production. Plugs of mucus can block the airways, and that can create problems, such as increased oxygen requirements and pneumonia.

“Not only do we want to give kids medications, we want to work with them on trying to take really big breaths and cough that mucus up,” Herrick said.

With asthma, air can get into the lungs, but it can’t get out very well, she said. Herrick does an exercise with parents where she has them take in a series of breaths without ever blowing out, which gives them the feeling of what that “air trapping” feels like. Sometimes she has parents breathe in and out through a straw, and then they pinch the straw to feel even more resistance.

“Ann Marina had lots of really good questions,” Herrick said. “It’s not unusual for us to take 45 minutes to an hour for discharge education in addition to the time that the bedside respiratory therapists spend teaching throughout a patient’s stay. Asthma education is not reimbursed by insurance, but we believe it’s part of the whole community of care. And it can reduce readmission rates and Emergency Department visits.”

After three days at Children’s, TJ’s asthma was stabilized, and he was able to go home.

“I felt more comfortable when I left Children’s,” Ann Marina said. “As a parent you know there’s something wrong with your child, but you don’t know how to care for them if you’re not familiar with the disease. When I left Children’s I could sleep at night – I knew TJ would be OK if I’d stay on top of it and teach him to stay with his medications, that he could be a normal kid like everyone else.”

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