Alavert (Loratadine)
Other names: Claritin
BRONCHODILATORS TO TREAT ASTHMA ATTACKS IN CHILDREN
As the spasm precedes the swelling, most initial treatment is aimed at the former. The group of substances used for this purpose is known as bronchodilators, and the large measure of success achieved in the control of asthma attacks centers on these remedies. A daunting array of products has been produced, mostly for commercial reasons, but I have found that there are two – namely Ventolin and Bricanyl – that are most effective and, as they have been used for many years, are known to be safe.
The dilemma with bronchodilators is by which route they should be administered. All of them are most effective when injected, but this is neither desirable nor practical. For general use there are only two reasonable ways – by mouth or by inhalation.
Since’ most drugs in this country are given by mouth there is a time-honoured custom in favour of this route. There is one major drawback – as the drug has to pass all round the body to reach the lungs, large doses must be taken. Bronchodilators which are inhaled pass directly to the organ in trouble, and so are not absorbed into the rest of the system. Taking Ventolin as an example; one inhalation contains 100 micrograms of the drug, whereas one tablet contains two milligrams – twenty times the dose of the inhalation. Thus, the potential for side-effects is many times greater with tablets. In my own practice -except in children under the age of two who are too little to master an inhaler – I never now use oral bronchodilator therapy. This is partly due to the possible unwanted effects, but also because their action is so much slower and often speed of treatment can be vital during an attack.
The main drawback with inhaled bronchodilators is that, because the airways are narrowed, insufficient of the drug may actually pass into the lungs, although this only really occurs when the wheezing is very severe. The most popular way of giving either Ventolin or Bricanyl is by pressurized inhalers. A jet of the drug is released by pressing the canister into its plastic casing. To inhale the drug the canister must be triggered just as a breath in is being taken. Some children find this difficult and therefore the treatment will be ineffective. Drug companies have tried various methods to overcome this problem and have devised a type of inhaler where a capsule is inserted full of powder and this is then inhaled. This comes in two forms, either as a roto-haler or as a disk-haler; this is similar to the way Intal was inhaled for the prevention of an attack.
More recently two new forms of inhaler have been produced which are proving very useful. Firstly, there is an Aerolin auto-haler, which is similar to the pressurized inhalers but is breath-activated, so does not require precise co-ordination of pressing the base of the inhaler as you breathe in. The drawbacks are that if your child is very wheezy the reduced force of inhalation may not be sufficient to trigger the device. Secondly, there is the Bricanyl turbo-haler, which, like the auto-haler, is breath-activated but a powder is inhaled and not a spray. It also has the same drawback of needing sufficient force of inhalation to fire it. However, both the auto-haler and the turbo-haler have removed the problem of coordinating the pressing of the inhaler with the breath in and for this reason have become my first choice in treatment.
Pressurized inhalers, however, are by far the commonest in use so I will concentrate on these. The pressurized inhalers, the turbo-haler and the auto-haler can all be carried easily in pockets and taken to school without the worry of breaking open capsules and whether the powder is dry or damp. One of the major reasons for worsening of an asthma attack is poor inhaler technique, but I have found that nearly all children can learn the correct method if sufficient time is taken to teach them. At my own surgery we run an asthma clinic and much of each appointment is taken up in teaching the correct technique for these inhalers.
Just occasionally a child may find it impossible to co-ordinate their breathing while pressing the canister so there are some ‘tricks of the trade to overcome this situation. First, Bricanyl can have a plastic tube fitted to the end of it, known as a spacer. Instead of the puffed drug going straight into the mouth it first fills this tube and can then be inhaled into the lungs. Both Ventolin and Bricanyl can be first squirted into a large plastic container called a volumatic and then be inhaled more slowly over several breaths. The disadvantage of this method is that the containers are large and cumbersome so cannot be carried in the pocket.
If the attack is severe, and the child too distressed to use the inhalers properly, or if the bronchial tubes are so narrow that the powder will not reach the lungs, then a new technique involving a nebulizer can be used. A measured dose in liquid form is poured into a small container and this solution is then vaporized using an electric current. The child inhales the vapor via a mouthpiece or facemask over a period of ten minutes.
The nebulizer is very effective and has completely changed the outlook of severe attacks, as now nearly all children can be managed at home and do not need the trauma of hospital admission. These nebulizers are inexpensive and every home with an asthmatic child should have one. It may be the best buy you ever make.
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