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While the theory of asthma is easy to understand, it is equally important to be able to recognize an attack in practice, so treatment can be commenced rapidly. No doubt some people will be well aware of how it affects their child, but others may not be so certain. Asthma can present in two different ways: as a chronic low-grade shortness of breath; or as a severe breathlessness of much faster onset. These are well illustrated by two patients of mine, Richard and Simon. Richard’s mother had become increasingly worried about her 12 year-old son as he kept arriving home from school in a miserable state. He had always enjoyed playing football but recently had lost all enthusiasm for it. To make matters worse at a parents meeting she was told that Richard was falling behind with his schoolwork. He denied that anything was wrong and on several occasions had been angry with his mother for keeping on at him about it. She decided that it was probably a phase he was going through, although lately he did seem to be coughing more than usual at night. Richard had tended to be ‘chesty’ when he was younger, and had often been given antibiotics by his GP. Matters came to a head one day when Richard was asked to rush to the post office to send off an urgent letter. He arrived home, very short of breath saying that he had just missed the post, at which his father became very annoyed because of the importance of the letter. Richard was very upset and over the next hour he became increasingly short of breath and distressed. His parents were worried when his breathing became noisy and he started to wheeze, so they called me out to visit.
Richard’s main symptoms were a persistent cough, wheezing and a fall-off of performance, all of which are very typical of chronic asthma. Happily after examining him I was able to instigate the appropriate treatment using an inhaler and his breathing difficulty quickly settled.
I have found with my own three children that a troublesome cough is a warning that an asthma attack is threatened, and a sign temporarily to increase their medication. However, I am often asked by parents whether there is a single symptom which will confirm that their child has asthma – that sign is undoubtedly ‘wheezing’.
In asthma there is more difficulty breathing out than breathing in. This is mainly because during inhalation there is a pull on the airways which tends to widen them. During expiration the reverse is true and the airways become relatively narrower. The child, therefore, in an attempt to breathe out sufficiently has to try and expel the air through the narrowed tubes. This produces the characteristic whistling sound known as a wheeze. In listening to Richard’s breathing it was easy to see that inhaling was quite comfortable but each exhalation was prolonged, required much more effort, and was accompanied by the typical wheeze. This one feature is itself virtually diagnostic of asthma.
Richard’s attacks were low-grade ones which built up over a period of several weeks. Simon, however – in similar fashion to Julie – developed a much more sudden and savage attack during a freezing winter night. He had suffered from a common cold for the previous three days but this was not unusual as his mother commented that he always picked infections up very easily. He was now 10 years old and this was the first time he had been in such distress. When I arrived, to a very worried household, Simon was sat up in a chair and looked extremely ill. The dominant feature was the violent wheezing with severe shortness of breath. He was pale and his facial expression was anxious with beads of sweat on his brow. He was cold to the touch, with a clammy skin. His heartbeat was very fast and increased every time he tried to force a breath in. The soft tissues around his neck and the muscles between his ribs were sucked in every time he inhaled. Simon was sitting forward with his elbows on his knees gasping for breath. Speech was almost nonexistent save for short phrases, and he was extremely restless.
At this stage it is almost impossible to reassure either child or parents and management is aimed solely at relieving the breathing difficulty. Up to a few years ago this would have meant admission to hospital, but apart from causing further anxiety, vital minutes would be lost before treatment was started; the wait for an ambulance, even though they come quickly, can seem to last for an eternity and many is the time I have taken an asthmatic child up to hospital in my own car.
Fortunately a great deal of progress has been made in the treatment of these severe attacks, and now, with the use of a machine called a nebulizer, relief can be obtained very rapidly Simon used the nebulizer for ten minutes and it became possible for him to breathe out more freely. He still had a wheeze but it was not so forced. In only a short space of time the tension relaxed and the mood of the whole house was lifted. It took Simon another twenty-four hours to become free of his wheeze, but during this time he was quite happy and was able to move about virtually as normal.
In all three of the cases I have just described the parents were most anxious to know the cause of the attacks and whether they could be prevented.

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