Vol. 11 •Issue 1 • Page 14
Life in the Big City Presents Challenges for Children with Asthma
Anna, an 11-year-old New Yorker with asthma, showered the clinic’s tabletop with inhaled corticosteroids, long-acting bronchodilators and leukotriene receptor antagonists. Despite the cascade of medicine, she recently experienced three hospital admissions and innumerable missed school days due to her asthma. Apparently, having all the right medications wasn’t getting the job done.
As is the case with many urban children facing chronic illness, Anna had other problems standing in the way of her good health. Limited access to treatment and medications, a lack of communication, understocked pharmacies and an environment of fumes and dust are all hurdles of the city that need to be overcome.
ACCESS TO CARE
Too often, urban children’s asthmatic symptoms may simply be accepted as part of “life in the big city.” This acceptance of sickness is the first of many challenges facing health care professionals when trying to provide patients access to care.
A girl such as Anna who coughs and wheezes every time she plays basketball might be told by her mother to avoid the playground rather than to seek treatment. Missing two or three weeks of school a semester because of asthma may even be seen as par for the course for a school riddled with chronic absenteeism. The girl’s intensive care unit admission might not cause undue alarm because “that’s what her father also went through at her age.”
To combat these perceptions, doctors and nurses need to get the word out that symptoms, such as the ones described above, are not something that have to be lived with. For example, the New York City Health and Hospitals Corp. partners with the city’s Mayor’s Office to do mass advertising about spacers. They regularly send out a fleet of brightly colored vans on weekends to local schoolyards and playgrounds for asthma screening and education. Asthma admissions are now down citywide, although the reduction could be within the boundaries of an average year-to-year fluctuation. More time will be needed to truly gauge the program’s effectiveness.
Beyond a commitment to communication, medical care needs to be available when children can use it. Clinics should be open outside of school hours so as not to compromise any precious time meant for learning. Health care professionals also must consider parents’ schedules. On one occasion, Anna visited the doctor’s office with her non-English speaking aunt while her mother was at work. Getting information to and from Anna’s mother in this secondhand fashion was not an ideal situation.
The best health care access allows a doctor or nurse to be reached during an exacerbation of asthma, rather than letting symptoms progress to the point where an emergency room visit or hospitalization is necessary. Too many local medical facilities have inadequate night and weekend telephone coverage. For many families, there is simply no choice but to call 911 for an ambulance.
In these situations, a written asthma action plan can help guide families when an emergency is occurring. The action plan should be easily accessible to all caregivers so that the instructions aren’t misplaced or forgotten in the heat of the moment.
MEDICATIONS: HOW AND WHEN TO GIVE
While asthma medications must be given on a regular basis to prevent exacerbations, many times they’re misused. First and foremost, doctors must make clear to an asthmatic’s family the difference between acute and chronic medications. Because it’s human nature to only seek treatment when one is feeling poorly, it’s no surprise to hear from a patient that a bronchodilator is “the only drug that works for me.” Taking an anti-inflammatory medication every single day, up to three or four times a day, is a hard routine to maintain. This is especially true when the patient perceives no immediate benefit from the drug, as she does with a beta2-agonist.
Medical counseling can help. In 23 sites across the country, in-cluding New York City, the Centers for Disease Control and Prevention have started a pilot program that assigns a social worker to act as an asthma counselor to each asthmatic’s family. This counselor not only acts as a go-between for the patient and physician but also constantly reinforces the need for chronic, preventive medication. Through weekly telephone calls, the family is encouraged to stick with the asthma care plan they have been given, which can be a tricky thing to do.
Anna, who is enrolled in the program, had three asthma medications in her bag that she needed to use every single day. Taking into account extracurricular activities and an active social life, along with a mother who works long hours, the medications may not have always been at the top of her agenda.
In addition to remembering to take medications, children with asthma must be able to use it properly in the first place. Simply prescribing a spacer, something essential for the vast majority of patients using a metered dose inhaler under the age of 12, isn’t enough.
Spacer usage is the first therapeutic intervention for any pediatric patient who is doing poorly. The use of mouthpiece devices requires the child to be able to take and hold a deep breath for at least five seconds. This is usually possible by 5 to 6 years of age. Younger children should use spacers with masks.
If a spacer is prescribed, proper usage must be demonstrated in the medical office, ideally with a placebo MDI. Unfortunately, prescribing and demonstrating spacer usage is only half the battle. In New York City, parents of children with asthma have had difficulty obtaining spacers from their local pharmacies. Most often, pharmacists point to inadequate reimbursement from insurance companies as the reason. Inner-city druggists may not be as well stocked as those in more affluent neighborhoods, forcing mothers to go to as many as three or four pharmacies in a valiant but ultimately failed attempt to find spacers. To alleviate this problem, New York City doctors have begged supply companies for samples and loaners to give out on a case-by-case basis.
It’s a good idea to ask the parent to bring in the spacer at the next office visit, both to check for fit and technique as well as for leaks and tears. This also ensures that parents have obtained the MDI in the first place.
As for what medications to take, patients under the age of 5 to 6 may be prescribed inhaled medications via compressor-nebulizer. It’s helpful to have such a machine, complete with tubing, masks and sample medications, in the office for demonstration purposes. It also comes in handy for the children who frequently come to the office in status asthmaticus.
A common error made by pediatricians, however, is to prescribe 0.083 percent unit dose albuterol to those patients receiving nebulized cromolyn or budesonide. Administering 2 cc of cromolyn followed by 3 cc of albuterol can take as long as 10 to 15 minutes, an eternity for the average toddler. Concentrated 0.5 percent albuterol is meant to be combined with other medications and can easily cut the time required for each treatment by 50 percent.
Many inhaled medications are now available in dry powder dispensers as well. Doses are deposited in a holding chamber (rather than blasted via propellants into the air) where they wait for the patient to deep breathe. Both inhaled steroids and long-acting bronchodilators are available in these devices. Like MDI’s and spacers, proper technique must be demonstrated face-to-face with the child and his or her family. Relying on pharmacists and drug inserts almost certainly will lead to improper usage.
The environment that surrounds the inner-city asthmatic can trigger exacerbations even in those patients well versed in medication delivery. New York City children have been inundated with irritants ranging from diesel fumes to cockroaches, dust mites to cigarette smoke. Up to 50 percent of the 11,594 children in New York City’s homeless and battered women shelters have some asthma symptoms. Of these children, 33 percent have no medication whatsoever for asthma, and only 54 percent have bronchodilators.
To combat the environmental hazards of the urban environment, vigilance is required. Many patients find themselves busy just trying to get family members to stop smoking in the living room or ridding their apartment of mice so that the neighbor’s cat doesn’t come in and go hunting. Garbage needs to be removed. Leaks and drips need to be stopped. Exposure to dust mite allergen needs to be controlled using snug-fitting mattress encasings.
Cockroach antigen, though, is more difficult to eradicate, requiring removal of both food and water sources. High efficiency particulate arrestors (HEPA), filters that remove dust, pollen and various allergens from the air, also may help to control environmental allergens.
Needless to say, addressing the many issues inherent in an urban setting, whether concerns about environment, medication or access to care, can’t be done in a 10-minute office session. Simply reviewing the medications and technique of a patient such as Anna could take that long, leaving the performance of pulmonary function testing or the exploration of what’s going on at Anna’s home unaddressed. Care needs to extend beyond office visits.
Staying in touch, however, can be difficult. After all, the average medical office clearly does not have the personnel needed to devote to this aspect of asthma care. The CDC’s asthma-counselor initiative may offer a solution. A study under way is examining the program’s effect on asthma admissions, ER visits and missed school days.
As the best course for the future is laid out, Anna continues her fight to stay healthy. Her latest hospital admission for an asthma exacerbation was triggered by flu symptoms and a 103-degree fever. Luckily, an intensive care visit wasn’t needed, and she was discharged after two days. n
Dr. Ting is an assistant professor in the division of pediatric pulmonary medicine at Mount Sinai Medical Center in New York City. He is co-director of an asthma outreach clinic at Queens Hospital Center in Jamaica, Queens, N.Y.