A person might need one inhaler for prevention, a different one for rescue. Some patients get the two confused. Many don’t like to use them at all. (iStock photo)

There are so many tricky things about keeping kids with asthma healthy that it’s hard to know where to start.

At their worst, asthma attacks can mean a sudden trip to the emergency room. These can be scary episodes in their own right, but they also disrupt everyday life, interfering with sleep, school or work schedules. Preventing such attacks is a major goal of treatment.

Asthma — which affects more than 6 million American children, according to the Centers for Disease Control and Prevention — is a chronic inflammatory disorder of the airways. When airways are provoked — by allergens, infection or exercise, for instance — they narrow, which reduces airflow. Typical asthma symptoms are shortness of breath, coughing and wheezing, and a tightness in the chest.

Frequency and intensity of symptoms can vary widely, says Katherine Rivera-Spoljaric, a Washington University pediatrician at St. Louis Children’s Hospital. “Symptoms can be intermittent to persistent — that’s one continuum,” she says. “With intermittent symptoms — a few times a year, say — we look for triggers.” Are attacks related to allergies, perhaps, or stress? “We try to reduce those triggers and treat their symptoms.”

The severity of symptoms is another continuum, says Rivera-Spoljaric.

To manage the sometimes fickle condition, doctors recommend two strategies: to prevent serious attacks from occurring and to be prepared to nip an approaching attack in the bud.

“It’s a very complex illness, even though it’s really common,” says Kristin Riekert, a Johns Hopkins Medicine researcher who studies doctor-patient communication and medication adherence. With multiple possible triggers, a wide range of things can prompt an attack “even if you’re doing everything perfectly,” Riekert says. “People feel fine until they don’t.”

Ideally, people with asthma know what their triggers are and avoid them. This might work for a child who is allergic to dogs, but it is harder with dust-mite allergies. One of the most common triggers for asthma in children is the common cold. Another is cold air. Try avoiding cold air and cold viruses all winter long.

In reality, it can take time to identify triggers. And triggers can change as kids grow older, Riekert says.

There are medicines that dampen overreactive tissue in the airways and help prevent asthma attacks. Two common control agents are corticosteroid inhalers (such as Alvesco, Pulmicort and Flovent) and leukotriene inhibitors such as montelukast (Singulair), a once-a-day chewable medication.

Other medicines can thwart an asthma attack as it begins. The most common are inhaled bronchodilators such as albuterol (brand names include Proventil, Ventolin and ProAir). Properly used, the drug gets deep in the airways and blunts the overreactive inflammatory process.

In other words, a person might need one inhaler for prevention, a different one for rescue. Some patients get the two confused. Many don’t like to use them at all.

“There’s nothing appealing about respiratory medicine,” Riekert says. There’s a bothersome taste; there’s poor technique. And because of the capricious nature of asthma, she says, people can forget to use their control inhaler and still feel fine, thereby “reinforcing non-adherence.”

Managing asthma, Riekert says, “requires structures and routines in a spontaneous world.”

For severe allergic asthma, a newer and expensive treatment, an antibody treatment called omalizumab (Xolair), is approved for people age 12 and older. “It’s been helpful in some patients with severe asthma,” Durrani says.

Education is a mainstay of asthma management for anyone, says Sandy Durrani, an allergist at the University of Cincinnati, but perhaps especially when kids are the patients. He says health-care providers need to spend time with their patients and their parents to explain both the illness and its management.

“At first we see patients pretty frequently — maybe weekly,” Durrani says. In addition to taking a detailed history to identify possible triggers and to understand the frequency and severity of attacks, he says, “this time is used to prevent the patient and the parent from getting overwhelmed. It’s an iterative process.”

Giving patients and parents some say can lead to better asthma management, says Rivera-Spoljaric. “I tell the parent: Your child meets the criteria for daily medication.” Then she’ll explain the medications and write down the options, starting with Number 1: Do nothing. “It’s a choice,” she says.

Other options might be taking medications intermittently, using a daily steroid inhaler or taking a once-a-day pill. The pill may not provide the best protection, but it helps most patients and might fit hectic lifestyles better, she says. “I talk about lifestyle — work and day-care schedules, who’s in charge of the kid’s therapy.”

Kids might resist using an inhaler, saying they don’t want to be different from their friends. Riekert will reframe that concern: “Your friends don’t see you take your meds, but they do see you limiting your activity at school.”

Even with education and practice and frequent visits, sticking to an asthma management plan can be undermined by the temperamental nature of the illness. “The fact is, you can’t always anticipate when there is going to be a problem,” Riekert says. “Asthma’s unpredictable nature makes it really tough.”