Dr. Emily Greenwald (Host): Hello, and welcome to Pediatric Voices, a conversation with the people who make up the healthcare team at Duke Children's Hospital. I'm Emily Greenwald, a Pediatric Emergency Medicine physician and Assistant Professor at Pediatric at Duke Children's and one of the hosts of the show. And I'm here to bring you insights about children's health from my expert friends and colleagues. And as a emergency department physician who works with children, I am very excited to share Dr. Jason Lang, and our topic this month will be pediatric asthma.

Dr. Lang is an Associate Professor here at Duke in the Division of Pediatric Pulmonary and Sleep Medicine in the Department of Pediatrics. And he has both clinical and research expertise in a lot of important aspects of asthma, such as the pathogenesis of lung disease in early life, particularly early-onset asthma, obesity-related asthma, and bronchopulmonary dysplasia, which affects many children coming out of the NICU or who are born very prematurely. He's involved in designing and implementing large multi-center clinical trials in children and just a real expert and leader here at Children's in the care of children with asthma. And so, without further ado, let's jump right into it. Dr. Lang, thank you so much for being here today. Tell us what is asthma exactly and who gets it.

Dr. Jason Lang: Yeah, sure. Well, first off, thanks for having me, Emily. It's great to be on the podcast. Yeah, asthma, it's a real challenge for lots of families. It's, as you know, a very common respiratory problem in kids. So, the way I like to think of it is it's a condition that really affects the lower airways. So, it usually causes a lot of chest symptoms.

There are a lot of misconceptions around asthma. People often think that you have to be older to get the diagnosis, and that it's a condition that really is just characterized by wheezing. But that's really not the case, and we can get into that.

Generally, it's caused by swelling and inflammation in those little airways of the lung that just kind of plugs up the airflow leading to wheezing, yes, but also lots of other chest symptoms like coughing, chest tightness, and shortness of breath. So, I'm sure you've seen a lot of kids acutely ill in the emergency room with those symptoms.

Host: Absolutely. Especially this time of year where we're recording this just in February, for those of you who might be listening later. And, boy, we're seeing a ton of respiratory viral illness right now: flu, RSV, all sorts of things. And there are kids who are coming in wheezing who even don't know that they have an asthma diagnosis and might not. So, I'd love to hear from you about those types of patients and thinking that through.

Dr. Jason Lang: Yeah. You say one of the things that can be tricky about making the diagnosis of asthma is that asthma symptoms are symptoms that lot of times otherwise healthy kids can have. I mean, we all cough here and there. Sometimes little kids have wheezing when they get a respiratory cold and differentiating that from asthma can be tricky, and that's why we have specialists at Duke to try to figure that out.

So, one of the things that people often think of along with asthma is wheezing. And I just want to take a time out and just define what wheezing is. So, wheezing related to asthma is really from the lower airways. It's not from throat or the upper airway. And that can be a diagnostic point of confusion. So, conditions like croup, which have that real barky, seal-like cough or the inspiratory sound that often comes along with viruses. So, that's upper airway, that's not asthma, and that's not wheezing. Croup can really be scary and bad, but it's kind of a separate phenomenon.

Asthma related with wheezing, again, lower airway is usually breathing out, and it's usually kind of a whistly sound. So, I'll sometimes even say like chest wheezing, chest whistling. And so, that can be helpful, I think, for everybody to keep in mind. You know, our trainees, my colleagues, pediatricians, parents, if they're worried about their child's asthma, but the sound is coming from the neck and the upper behind the nose, then that's really not asthma and isn't something to be as worried about. I think that's just one important thing.

As you mentioned, now in wintertime, there are a lot of respiratory viruses out there. Folks have probably heard of RSV, certainly influenza, but other viruses like the common cold virus; rhinovirus, for example, or parainfluenza, all of those viruses that in adults, healthy adults, just cause a little bit of a cold, maybe sore throat, maybe a cough that usually clears quickly and has mild symptoms. In young kids infants and toddlers, just a little bit of that mucus that the virus causes in the lung can really plug up the little airways in infants and toddlers and cause wheezing and respiratory distress.

So, that's why we often tell trainees that sometimes a third to a half of infants will have maybe one or two episodes of wheezing during their life, but most of those kids as their body grows and their airways grow, they tolerate those viral infections. So, the wheezing problems and the shortness of breath problems with viral infections goes away. It's usually by around kindergarten, first grade, that if you're still having lots of wheezing in the wintertime, then you really should be considering whether or not you have chronic asthma.

Host: And so, how would you coach a pediatrician or even a parent on, you know, let's say they have an infant who had RSV bronchiolitis as, let's say, a 12-month-old and had some wheezing associated with that, and then went on to have another respiratory illness in a year or so that had wheezing, you know, at what point prior to kindergarten should they be evaluated for could they have asthma or at what point as a school-age child would you think of starting that evaluation?

Dr. Jason Lang: Yeah. I would advise families to be in touch with their pediatrician, to have a pediatrician and going to their well-child visits because pediatricians have a really good understanding of asthma and early wheezing and can be a great resource. The way I think of it kind of in two ways, if you've had a RSV or another wheezing virus that's severe that lands you in the hospital, lands you in the ICU, then that's a bit of a red flag. I'm concerned that the child may have something underlying like asthma.

The other big factor is, does the child have respiratory symptoms separate from colds? That's a big predictor. And that can be tricky to sort of tease that out because again some of the subtle symptoms of asthma are symptoms that healthy people often have, a little bit of cough, a little bit of congestion. But the pearls that I would advise are, is there coughing a lot at night with sleep, like, so it's disrupting sleep? That's one concern. Is there coughing, congestion with activity, exercise? Is it predictable that that's triggered? And the other is with emotion. So, we'll often ask families, you know, does your child get congested or cough when they laugh? And oftentimes, the eyes will get big and say, "Oh yeah, she always coughs with laughter" or the reverse, you know, when kids get teary and emotional, does that cause coughing spells?

Host: Yeah. And this is outside of the setting of illness, where you're asking these questions, right?

Dr. Jason Lang: Exactly. And then, the other is just-- well, two things-- the connection with allergies. So, we think of atopy or allergy predisposition related to, do you have environmental allergies, hay fever, pollen allergies? Do you have eczema of the skin, which is kind of an allergic skin rash or food allergies? All of those conditions are kind of part of the allergic conditions that are related to asthma. So if you have those, then that makes me a little bit more concerned that the child may be also developing the respiratory component of allergies, which another way to think of it is asthma.

Host: And parents thinking about these things, I agree that partnering with their pediatrician is the best first step, absolutely. I wonder if you could talk a bit about how the asthma diagnosis is actually given, either by the pediatrician or a pediatric pulmonologist. Are there tests that can be done? And then, at what point would a parent or a pediatrician want to refer a patient to a pediatric pulmonologist who they are either suspicious, may have asthma, or may even have poorly controlled asthma?

Dr. Jason Lang: Yeah, those are great questions. So, I mean, we're always available. Sometimes we get just a consult or a consultation from a pediatrician and for confirmation. And then, it really just needs to be a one-time evaluation. And then, care is continued with it, with a pediatrician, or we're also happy to do the sort of diagnostics and continue. But I would say if there's a concern about the diagnosis, is it asthma, is it something else, we're happy to evaluate. If there's clearly recurrent episodes of wheezing, then I would suggest that the diagnosis of asthma needs to be entertained.

For younger kids, meaning before kindergarten, that's where it can be tricky because you can't do breathing tests. And kids are a little bit not as good at describing the symptoms that they're having.

Host: And is it you can't do breathing tests because they just aren't old enough to understand how to cooperate?

Dr. Jason Lang: That's right. Yeah. So, the main test that we do is called spirometry. So, you have to take a big deep breath and blow out as hard as you can, as fast as you can. And it requires some discipline to do. And generally, if given a lot of time and a lot of focus and a lot of patience, a lot of four-year-olds can do it. But, you know, in a busy clinic, it's getting good results. It's often age five or six sometimes before we can actually do good reproducible spirometry.

Host: So, age five or six, and then does that spirometry make the diagnosis for you?

Dr. Jason Lang: Well, not by itself. So, that's where it's tricky that we really say that to make the diagnosis of asthma is really a clinical diagnosis. So, we have to look at everything. We have to look at family history. Asthma does run in families. And so, if a young child is having recurrent wheezing and they have a first-degree relative with asthma, that's definitely a risk factor. So, brother, sister, mom, dad. Oftentimes, we'll talk about family history and then we find out that a great aunt had asthma. It's really that first-degree relative connection, I think, is helpful.

Then, you know, as I mentioned, if they have other allergic conditions, and so those are all kind of risk-based or probabilistic, but in terms of making the diagnosis in terms of symptoms, it's really those symptoms that I've mentioned, wheezing, coughing, chest congestion, chest tightness, that are recurrent, so it happened multiple times and that are triggered by known asthma triggers.

Host: Do you have a sense of how many kids get a diagnosis before age five where they can't participate in the actual testing, but they have these constellation of symptoms and complaints where you're able to make that clinical diagnosis? Is there some percentage?

Dr. Jason Lang: Yeah. I mean, I will just say that it's very common. So, I would say the majority of kids with significant asthma will have a presentation before age five. And that's because the most common sort of type of asthma is that allergic type. And I would say probably more than half of cases will present in those first five years of life. So, it is really important that we're talking about how to make the diagnosis early on.

And the triggers, I think, that's a really important clue. What are triggering the symptoms? So, one is really commonly colds, but also exposure to allergens and emotion and sleep, like we talked about, and exercise.

The other clinical part is, do they respond to asthma therapies? So, I think we'll probably get into some of the therapies that we're using, but it's actually a good sort of confirmatory test. The most common we call them bronchodilator medicine, albuterol, if kids respond clearly to that or if they respond to a steroid medicine, and when they do, it's usually pretty clear, that's a good confirmation for the diagnosis as well.

Host: Agree. So, it's sort of piecing all these pieces of the puzzle together. And I think for the pediatricians who are listening, we all know that talking about these other sort of non-ill symptoms with the family and the child are really important, like coughing at night, despite illness, and these other triggers, that you don't think of as a virus, right? The laughing or being upset, causing coughing or wheeze, et cetera, and these other allergens. "Every time I go to grandma's house, I'm coughing for a few days afterwards, and she has a cat," for example. Those things are really important.

So, once you get this clinical diagnosis and, you know,, you're thinking back in your history and thinking, "Oh, yeah, there were several of these times where I was treated with albuterol in the emergency room and that helped," and these things, all this comes together to a clinical diagnosis. Now what? So, how does the pediatrician proceed with the family or, if you're seeing this patient already, what are the next steps and how do you think of treatment?

Dr. Jason Lang: Yeah. What I'll often do, if I'm convinced that the child really does have asthma, then we start talking about things that we're talking about here, like what's the underlying process. The two main classes of medicine are the controller anti-inflammatory medicine, and then the bronchodilator acute fast-acting medicine. And those really make up sort of the asthma action plan. So, we really talk about that we need to have an asthma action plan, both for acute remedy, but then also prevention.

So if I'm talking to a family for the first time and we really need to make the diagnosis, I'll talk about screening for allergies oftentimes, because if a child appears to have allergy symptoms, but we don't know exactly what it is they're allergic to, knowing that can be really helpful and empowering. And we can start to use avoidance of allergen triggers as really an effective management approach. If we can do breathing tests through spirometry, we'll do that. And then, if I think that they have persistent asthma, then we'll usually recommend starting with an inhaled controller medicine. So, that's usually an inhaled corticosteroid.

Host: Is that something that you would use every day, is what I'm thinking of that I've seen?

Dr. Jason Lang: If they have persistent asthma, then that's generally the most effective approach is to do an inhaled corticosteroid daily for a trial. And that's an important point that I usually make. If we're just making the diagnosis, I'll say, what we really want to do is do a trial, usually of at least two to three months, and confirm that they're taking away the symptoms. Your child's now sleeping better at night. They're tolerating activity much better. If they get a cold, the cold isn't lasting three weeks now. And I think that's a way, rather than labeling the child with your child has asthma, let's do a trial of this medicine. I think it's going to help them feel better, but I think it's also going to confirm the diagnosis. And then, what's really important is for them to come back and reassess, and then together in sort of the shared decision-making model, figure out what the best next step is.

Host: Yeah. And, you know, I've seen a number of patients in recent years on using one of these daily controller inhaled medications. And then, when they actually have wheeze or symptoms, they use their albuterol or bronchodilator to help open up those airways in moments where they're being challenged, whether it's with grandma's cat or a new virus or something like that.

But could you talk a little bit-- this is sort of brand new that I'm seeing in the emergency department, some kids who are on a combined type of therapy where they're getting a bronchodilator combined with an anti-inflammatory steroid daily and how that's new and what the thinking is behind that new approach.

Dr. Jason Lang: Yeah. That is brand new. So, the Global Initiative for Asthma, GINA is the acronym, is a great organization. It's international. It's a group of Pulmonary, Allergy experts giving guidelines for the care of asthma. There have been a couple of large trials, first in adults and more recently in children showing that you can combine the two therapies and actually achieve better long-term control if you give both the bronchodilator and the inhaled steroid together with symptoms.

So, one of the problems that we've run into is that, particularly in kids, where kids are well most of the time, but they just get sick with colds, a lot of families don't want to be giving the everyday inhaled steroid for weeks and weeks and weeks at a time when they feel like they probably don't need it. They only get a cold a couple of times a year. There's evidence that giving both the albuterol and the inhaled steroid together just with illness or just with symptoms can reduce the total inhaled steroid dose while improving control.

There are some details around if you have intermittent asthma versus persistent asthma. And I can get into that if you have questions, but it's when insurance companies cover those medications, it can work out quite nicely. It sometimes creates a little bit of confusion. So, I think we're still in that period of time where, we're working out what the best approach is.

Host: Yeah. And it's neat that one of the things that I thought was sure was how to treat asthma in my training and moving along. So, it's very encouraging to see that there are new approaches, you know, based on the research being tried and that leads me into my next question, and families I'm sure will also be curious.

I know that there's a new biologic agent for eczema, which as you mentioned, it's sort of an allergic type skin condition. And oftentimes, children with eczema may also have asthma. And so, I'm curious, are there biologics being developed for asthma that could really almost cure, if you will, a patient's asthma, or how far away from that are we?

Dr. Jason Lang: Yeah, actually, we're there for kids with asthma age six and up. There are three now biologic medicines that are approved in kids six and up that are very effective for asthma. And where I think that that's really important is there are many kids out there who despite taking an inhaled steroid medicine every day still have breakthrough asthma still have to go to the emergency room several times a year, still get hospitalized. These biologic medicines can be life-changing and life-saving.

Host: That's fantastic. Out of curiosity, how often are they given, or how do they work compared to daily?

Dr. Jason Lang: The nice thing about them, whereas traditional medicines you have to take usually two puffs twice a day, these range from every two to every four weeks, they just get a single dose. That's the upside. The downside is that's an injection. But truthfully, I think, once people realize how effective they are and that they're so infrequent, people are able to manage and put up with the inconvenience of the injection.

The way they work is, you know, we mentioned all the symptoms that kids with asthma get, the swelling and the inflammation in the airways come about because of different chemical signals that we have in our body because of the inflammation. There are molecules that trigger in the airways the swelling and the inflammation and the twitchiness of the airways. These biologic medicines basically go the body and neutralize those inflammatory chemicals so that it completely avoids and cures all the swelling and the airflow obstruction that result.

Host: Wow. That's incredible and really great to hear because, working in the Pediatric Emergency Department, I've certainly taken care of many patients that despite, you know, trying to follow their asthma regimen, just have really severe asthma. And I think kind of prior to these biologics, there may not have been as many options. And so, that's really wonderful to hear and very reassuring for me too as a physician because those older patients with very severe asthma can be really tricky to take care of. And so, I think partnering with a pediatric pulmonologist when you've got asthma that that's severe sounds like a very great idea. And then, understanding with your pediatrician if you've got asthma that's easier to control, to work through some of the other options you talked through. Sounds like as a parent, what I would be thinking.

The other thing I'd be thinking though, as my child was getting an asthma diagnosis is, you know, what's next? Is he or she going to outgrow their asthma? Is this going to limit them and trying out for the high school basketball team when they get older? How hard is it going to be to give the asthma medications that I'm supposed to give? You know, all those questions I think would be going through my head. And I'm sure you've had lots of those questions from your patients and families.

Dr. Jason Lang: Yeah. That's one of the more common questions. So where that came from, I think, "Will my child outgrow it?" or "I had asthma as a kid and I outgrew it," a couple of things there to unpack. The most common, we say phenotype we referred to earlier was the kids that you know, have a lot of wheezing from viruses in the first few years of life.

Depending on the specialist you talk to, some people would label those kids as just having viral-related asthma. And if it's just viral-related asthma, they're well otherwise in between colds and they don't develop allergies, those kids typically "outgrow" their viral-induced asthma by around kindergarten. Now, if the child presents early like that, but then develops allergies, those kids typically won't outgrow it, unfortunately, by kindergarten. And we typically assume that they'll continue to have some degree of asthma indefinitely.

Host: So, the kids with allergies are more likely to continue on with asthma than those that just have asthma symptoms with illness or viruses before they're five.

Dr. Jason Lang: That's right. Yeah. Yeah. So, I mean, we can't really say absolute that you'll have it forever or that you won't outgrow it, but I just caution families that it should always sort of stay on the radar. Asthma can go away for a period of time, but it doesn't mean that you're completely out of the woods. So, it's something that families really need to keep vigilant about.

Now, so say the child has eczema, has allergies, has family members, I'll say, "Well, the bad news is I don't expect that they're going to quickly outgrow it. The good news though is that the vast majority of kids, we can control it. And you can run marathons, be on the high school basketball team." And I 'd cite that there's actually a higher percent of people on the Olympic team with asthma than just in the general population. So if you control asthma, you can have excellent lung function. I mean, there are many professional athletes that have asthma. So, it doesn't mean that your lungs are less able or have lower lung function in many cases. You can definitely control it and you can definitely perform at a high, high level provided that you stay on top of it.

Host: Yeah. And along those lines, we know that exercise is important for maintaining health, especially as an adult. You know, you hear about the way exercise mitigates against getting heart disease and things like that. How does that intersect with asthma? Because I imagine if you go out in the soccer field and you don't have well-controlled asthma and it's hard to breathe, it's not going to be the most pleasant experience. And so, how do you think about that? And is there any connection between exercise and having an ideal body weight as a child and asthma?

Dr. Jason Lang: Yeah. All of these are really important. So, I would say if you're in the throes of an asthma attack or an asthma exacerbation, generally focus on getting better and probably not go to basketball practice, because exercise is going to be a trigger and where that comes from is just, when you exercise, you hyperventilate, right? You breathe hard. You breathe fast. The process of breathing hard and breathing fast often dries out the airways. And that triggers bronchospasm and triggers coughing and wheezing. But if you get your asthma controlled by taking your biologic or taking your inhalers every day and reduce that inflammation, then exercise is really important for general health and it's really important for maintaining healthy airways. 

And that actually happens for, I think, from a couple of mechanisms. One is when you exercise, you take really deep breaths and you bronchodilate, you stretch the small airways open. And they stay open more easily. So, I definitely recommend all of our kids with asthma to get their disease controlled and then, do sports, do daily activity, to keep their airways healthy.

Host: Yeah. I love that. So, you know, as a parent thinking through, my goal for my child should be to get his or her asthma controlled to the extent that they aren't limited in sports really in any way, it sounds like.

Dr. Jason Lang: Yeah. And it's great. We talked about an asthma action plan before. One part of your asthma action plan needs to be exercise. So, anticipate they're going to be doing a lot of exercise. Take your controller, whatever your controller plan is every day. And have your fast-acting rescue medicine available. Sometimes we recommend taking two puffs of albuterol, that's the bronchodilator, 10, 15 minutes before you start exercising, and to have it available for any emergencies during your activity.

Host: Yeah. That sounds like a great goal. As a pediatrician, what do you recommend to keep kids safe during winter when we know there are going to be all these viral triggers?

Dr. Jason Lang: So, I would say most folks with asthma, winter can be a challenge because pretty much everyone, no matter what type of asthma you have, respiratory viruses are a trigger and respiratory viruses are really more common late fall to early spring. So, we're right in the middle of it.

Simple stuff, hand washing, most respiratory viruses aren't passed exclusively by aerosol. It's more touching surfaces, so handshakes, touching other folks. So, good hand washing and staying away from sick contacts seems really simple, but is really effective. We recommend flu shots for all our kids with asthma because influenza can certainly be an asthma trigger. And then, getting a lot of rest and staying hydrated are important in the wintertime.

And then, lastly, I would say going into-- you know, we talked about winter, I should actually back up and say one of the peak times for kids getting asthma attack is during the back-to-school time. And we're not sure exactly why that is, but probably some of it is just being back in a small area with lots of other kids and sharing germs. So, it's generally a good idea right before back to school time to have a check in with your pediatrician or your asthma doc to update the asthma action plan.

Host: That's a great idea. So, late summer, huh?

Dr. Jason Lang: Late summer. Yep, it's sort of the start of the cold and flu season. Making sure you have, refills, that you have a spacer for your inhaler, maybe retraining on inhalation technique, all of those sort of basics and then updating the asthma action plan, making sure you're going into fall or winter with an updated plan.

Host: Yeah. All those are great suggestions. And we often have families coming into the emergency department that didn't realize they were out of a medication until illness sort of strikes and then it puts them a bit behind because they're coming in not being able to use their albuterol at home. And so, we definitely see that. And then, the value of certainly vaccination for flu and other viral illnesses. Absolutely. We often see kids who still may get those illnesses despite having the vaccine, but it's more mild than not being vaccinated. So, absolutely.

Dr. Jason Lang: Yeah, I was going to say a lot of times, families are busy and they've got it covered for sort of the typical routine. It's when families are busy and they get out of their routine. Maybe they're traveling to grandma's or they jump on a plane. And my advice is to kind of know who your go-to resources are. So, you know, your pediatrician, if the pediatrician's controlling or helping manage the asthma or the specialist, you know their phone number. Here at Duke, we say our myChart messaging system, but just know how to get in touch with your resource, because it's easy to forget, "Oh, we need an extra spacer," "We forgot the albuterol." Making sure that all of those things are packed and available if you're traveling or doing things out of the typical routine.

Host: So Dr. Lang, absolutely wonderful having you on the podcast and absolute wealth of knowledge about asthma. I feel like we could do an asthma version two of the podcast or probably all the way up to 10 with all there is to discuss. But I want to highlight a lot of what you said here in the end about being prepared, thinking about the end of summer, what you can do to optimize your child's risk or your patient's risk if you're a pediatrician listening in for winter, and going back through those treatment options and making sure that children are so well treated that they can participate in any sport that they want to. That should be the goal. Thank you to you.

Dr. Jason Lang: Yeah, thank you so much. It was great chatting with you, Dr. Greenwald. And we're always available for consultation. And I love working with families with asthma, kids with asthma. They can really do anything they want to do.

Host: Yeah. And apparently, even have a higher chance of making it to the Olympic games. Don't forget that. That was great.

Dr. Jason Lang: No guarantee.

Host: Fair, fair. Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center in St. Louis. Sunny, Durham, North Carolina. Thanks to Courtney Sparrow, who keeps us on track and organizes our work. Special thanks to Dr. Anne Reed and to the wonderful people at Doctor podcasting. Please connect with us online and give us feedback. We love feedback and we want to direct the show in the direction the listeners want. You can connect with us on our website, pediatrics.org.duke.edu/podcast, or through all your usual media channels, such as Apple Podcasts or your favorite podcast app. Give us feedback, and until next time.