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Column originally published Nov 1, 2000
Column last revised/updated on Oct 23, 2018

Check To See Whether A Child Is Using Spacer And Proper Technique When Using Inhaled Medicine For Asthma

Question: Our ten-year-old son has asthma since he was an infant. His biggest problem is in spring and fall. We have managed him with inhaled bronchodilator and steroid. This fall, he has been sick for three weeks already. His inhalers have not helped him very much. Our family doctor gave him an antibiotic, but after three days he is still not much better. He was coughing to the point of vomiting and losing his breath. A doctor in the emergency room wanted to give him a different antibiotic. We are concerned whether this is the right thing to do. Can you give us some guidance?


It looks like you have a fairly urgent medical problem. I hope the answer comes fast enough to help with your son’s asthma.

Your experience over the years has indicated that spring and fall are troublesome times for your son’s asthma. There are many reasons for this seasonal pattern.

In the fall, when temperature gets colder outside, children spend more time indoors, especially in cold evenings. Many families also start to close their windows. As a result, indoor air quality becomes a greater factor in your child’s health. If there are cigarette smokers, the smoke accumulates much more in the house than in summertime, and affects the bronchial tubes of children with asthma.

At the same time, the furnace starts to kick on for the first time. If the house has force-air heating, the hot air will circulate dust around the house. A lot of house dust can accumulates in the ducts of force-air system.

Another important problem is viral infections. When schools start in September in North America, children are crowded into classrooms. Respiratory viruses can spread from student to student very quickly. As you likely know, respiratory viruses are the best triggers of asthma.

The situation is quite different in spring. Other respiratory viruses can trigger asthma attacks at this time. But more importantly, some children can be allergic to the pollens of trees and shrubs that start to bloom in the spring. Different children may be allergic to different pollens.

Many people like to hang their sheets and clothes outside. This is very good to conserve energy and healthy for the environment. However, if your son is allergic to some of the pollens, you may bring large amounts of them indoors into his bedroom and on his clothes. Putting everything in the dryer may reduce springtime asthma problems.

When asthma is triggered, most children would develop cough. Some may get short of breath and wheeze, especially with exercise. Many children, however, have cough as their only symptom. When the problem is severe enough, some may start to vomit up mucus. Therefore, your son’s symptoms of coughing and vomiting may not signify an infection that requires antibiotic; they likely mean his asthma is getting worse.

Because your son is already using inhaled bronchodilator and steroid, you have to find out why he is not getting better. The first thing to do is to check whether his inhalers are empty or not. Sometimes it is hard to tell whether they are getting low on medicine.

Another important consideration is whether your son is taking the inhalers properly. Even though he has taken inhalers before, he may not be using the proper technique now, therefore not getting enough medicine into his bronchial tubes.

If he is using the puffer type of inhaler, he should use a spacer device. The spray of the puffer comes out at a very high speed. If no spacer device were used, most of the medicine would end up in the throat instead of in the lungs. The spacer device allows the medicine to be suspended as fine particles inside the spacer, and then inhaled into the bronchial tubes.

Many children would use the spacer when they were young. When they get older, they thought they could manage without it. The truth is that much less medicine would get to his lungs. If you find out that he is not using a spacer device, I would suggest that you insist he uses it with the puffer. This can increase the actual amount of medicine going into his lungs, and control his worsening asthma.  I suggest children and adults use spacer whenever they take puffer type of inhaler, regardless of age.

If he is doing everything right, and still doesn’t get better, it is quite possible that he needs more medicine. This can mean increasing the dose and frequency of his inhaled medications, both bronchodilator and steroid. You should do this under the guidance of your doctor.

Occasionally, asthma does not improve with inhaled medications. Your doctor may recommend a short course of oral steroid called prednisone. This is a very safe medicine. When used for a short time (like a few days), there is no long-term side effect. You should discuss any concern with your doctor.

Since viruses do not respond to antibiotics, there is no need to start one in viral infections. However, bacterial complications like sinusitis are fairly common. Research has also shown that people with asthma and sinusitis may not improve unless the bacterial infection is treated with antibiotics.

The symptoms of sinus infection include congested nasal passage, thick yellow or green nasal drainage, pain in the cheeks, and fever. These symptoms usually occur several days after the onset of a cold. You can prevent sinus infection by using local decongestants (either as nose drop or spray) to open the sinus passage. However, if sinus infection is already well established, an antibiotic would become necessary.

Finally, I would like to mention here that a few bacterial infections of the respiratory tract can trigger asthma, much like viruses. These include whooping cough, Mycoplasma pneumonia and Chlamydial pneumonia. In spite of their names, the last two bacteria can infect the respiratory tract and trigger asthma without causing pneumonia.

It is not possible for me to discuss more about these bacteria in this column. Your doctor can decide whether these bacteria are the likely culprit, and perform necessary tests to check them out. Fortunately, there are effective antibiotics to treat these bacterial infections.

I hope I have given you some useful suggestions here. Keep in mind that if your son does not improve within a few days (or if he gets worse), you should get in touch with your doctor for guidance. Sometimes a referral to a paediatrician may be necessary to sort out the problem. Good luck.

[Note to Readers: In the last few years, doctors have found that another oral steroid called decadron can be given safely to children with acute asthma attack. Decadron is much better tolerated than prednisone (it tastes better) and can be just as effective.]