From Benchwarmer to Scoring Star: A Victory Over Asthma

Signs and Symptoms of Moderate Persistent Asthma

Many people, including some doctors, believe that a child must wheeze to be diagnosed with asthma. However, this is not the case. While wheezing is important, its absence does not rule out asthma. Persistent coughing and shortness of breath are also hallmark indicators. Breathing difficulties can worsen during physical activity or at night, disrupting sleep. Other symptoms may include chest tightness, rapid breathing, and the inability to speak in complete sentences due to breathlessness. Sara experienced all these symptoms, particularly when she tried to play soccer. She also coughed every night. Her parents had become so accustomed to Sara coughing at night that they began to feel like it was a normal part of her life.

Asthma Runs in Families

I asked Sara’s mother about the family history. Since asthma often runs in families, gathering information about relatives can provide clues to a diagnosis. Sara’s mother told me that she also had 'chronic bronchitis,' meaning that whenever she had a cold, it 'went into her chest,' and she would cough for weeks. Sara’s older brother had experienced the same, but he outgrew his symptoms by the time he went off to college.

I suspected that Sara’s mother was describing asthma, not chronic bronchitis, and I also suspected that Sara’s older brother had asthma. It is important to note that chronic bronchitis is rare in healthy non-smokers who do not have diseases like cystic fibrosis or other genetic conditions.

Allergies and Medications

As part of any visit with a physician, a review of allergies and medications is conducted. Seasonal allergies and skin conditions like eczema are common in people with asthma. Sara had no allergies; this is an important piece of history, but it does not rule out asthma. Her pediatrician had mostly treated her with antibiotics, but she also prescribed a 'rescue inhaler' (albuterol), which Sara said provided relatively brief relief from her breathlessness.

The Physical Examination

As part of any visit with a physician, a review of allergies and medications is conducted. Seasonal allergies and skin conditions like eczema are common in people with asthma. Sara had no allergies; this is an important piece of history, but it does not rule out asthma. Her pediatrician had mostly treated her with antibiotics, but she also prescribed a 'rescue inhaler' (albuterol), which Sara said provided relatively brief relief from her breathlessness. When I examined Sara, she appeared perfectly normal—no signs of allergies, inflammation, wheezing, or other abnormal breath sounds.

Pulmonary Function Tests to Diagnose Asthma

A doctor’s office does not need fancy equipment to help diagnose asthma; it only needs a spirometer, which looks like a hairdryer attached to a laptop. I had one of these in my office, so I taught Sara how to perform pulmonary function tests after the physical examination. This is straightforward and requires very little time to learn.

I asked Sara to take a deep breath and exhale into the 'hairdryer' part of the spirometer for as long as possible. The spirometer created a readout of the speed with which Sara exhaled. We repeated this process several times until she produced two breaths that were very similar to each other.

Sara’s breathing tests showed that she had a significant narrowing of her small airways, which is typical of asthma. But the test was not over. Sara took a couple of puffs of an albuterol inhaler, and we repeated the test fifteen minutes later. The repeat test showed a significant opening of Sara’s small airways. The diagnosis was made: Sara had moderate persistent asthma.

Moderate persistent asthma is defined by daily symptoms, with flare-ups lasting several days. Persistent coughing and wheezing can disrupt the child's routine, hindering normal activities and causing sleep difficulties. Nighttime flare-ups may occur more than once a week. In this classification, spirometry typically shows between 60% and 80% of normal values before albuterol treatment and a 10–15% improvement after treatment. Sara met all these diagnostic criteria.

Treatment Plan: Fluticasone/Salmeterol Diskus

To treat Sara’s moderate persistent asthma, I prescribed a fluticasone/salmeterol diskus inhaler and taught her how to use it. This medication combines an inhaled anti-inflammatory steroid and a long-acting airway dilator, similar to albuterol, but designed for asthma symptom maintenance, not rescue from attacks. I also asked her to take two puffs of albuterol thirty minutes before soccer practice or games for extra protection.

Follow-up: a Star is Born

I asked Sara’s mother to contact me with any questions or concerns and to bring her back for a follow-up visit in three months.

When I saw Sara three months later, she was excited to tell me that she could play entire soccer games on the field. Not only that, but Sara played forward and became the top scorer on her team!

Equally remarkable were Sara’s follow-up spirometry results. Her numbers were as good as or better than those of any typical 12-year-old without asthma. I followed up with Sara intermittently until she graduated from high school. She traded soccer for theater and pursued acting in college. She gradually weaned off her inhaler and was never bothered by asthma symptoms by her final follow-up.

Living with Asthma

If you suspect that you or someone close to you has asthma, please consider talking to a healthcare provider. Keep in mind that fluticasone/salmeterol is a maintenance medicine and a preventive meant to control asthma symptoms, not to be used during an asthma attack.

An otherwise healthy girl like Sara should be able to play soccer at a high level and engage in any activities her peers do, despite having moderate persistent asthma, as the signs and symptoms are controllable. Your healthcare provider can address any questions or concerns you may have.