Darrell Sapp, Post-Gazette William Burchfield, 11, exhales as chief pulmonary technican Steve Walczak coaches him through nitric oxide testing at Children's Hospital. It is a new technology that is reliable and child-friendly in measuring lung inflammation in children with asthma. Click photo for larger image. Related article Asthma updates

Instead of being in class one spring morning, William "Will" Burchfield, a fourth-grader at O'Hara Elementary School, was playing a game with a friend.

OK, his friend was actually Steve Walczak, chief pulmonary technician at the Children's Hospital pulmonary lab. And the game, which tests the health of Will's lungs, is vital to the management of his asthma.

"When did you eat last?" Mr. Walczak asked the 11-year-old. "In the car," Will said.

Then the game began: A girl floated in a hot-air balloon on a computer screen. Mr. Walczak told Will to blow out, then inhale in a tube and breathe that air back into the tube. Three times he did it, keeping the girl floating high above the ground, crossing the screen.

"Blow all the way out ... breathe in, deeper, deeper. Keep going, all the way out. Keep going," the respiratory therapist coached.

According to Will's mom, Michele, the lab visits have paid off in controlling his asthma symptoms.

"Since we've been coming here, it's much more regulated," she said, adding that before the monitoring, they visited the emergency room several times a year.

Controlling asthma

Young Will's game is a relatively new, non-invasive test of lung inflammation -- exhaled nitric oxide (eNO) testing,

It's a highly reliable and child-friendly way to help manage asthma in children. Giving it high praise as a monitoring method is Dr. Daniel J. Weiner, director of the pulmonology laboratory at Children's.

Inflammatory cells give off nitric oxide, he explained, so measurements of the exhaled gas, together with symptoms and lung function, can give doctors more accurate and more frequent information on how a child is doing on his or her medication. "It's easy and we can do it as much as we want to," Dr. Weiner said. He's working on methods to apply the technique with infants.

Darrell Sapp, Post-Gazette Dr. Daniel Weiner talks about the new test for children and babies with asthma. Click photo for larger image.

In the Children's lab, Will is tested before and after his medication, to gauge its effectiveness. He goes on to take other pulmonary tests as well, including a check of lung capacity. He's an active kid who, in his mom's words, "does anything," such as playing hockey, golf and lacrosse, and shooting trap. Before recess, he takes a puff off his inhaler.

The idea behind the eNO game is that if they're having fun, children do a better job of exhaling to their fullest ability.

Nitric oxide testing was approved by the FDA for clinical use in 2003. With it, doctors can determine inflammation without invasive tubes or inducing methods to get a child to cough up sputum to be tested. Both Children's and Allegheny General offer versions of the technology.

The eNO test began as a way to refine the diagnosis of asthma in children, according to Dr. Jay Kolls, chief of Children's division of pediatric pulmonary medicine, allergy and immunology. Wheezing can have many causes, but if it's accompanied by nitric oxide, it indicates asthma. Now the testing is also a way to monitor the effectiveness of medications. Dr. Kolls said even more effortless eNO testing may lie ahead; right now children under 2 can't reliably take direction to blow into a tube.

Children's and Allegheny General also use oscillometry, a new method of measuring airway resistance for preschoolers. A young child can easily breathe normally into a mouthpiece for 15 to 30 seconds. Older children and adults can still use the conventional lung function test called spirometry, which requires them to follow instructions to take deep breaths in and out.

Dr. Kolls said Children's is trying to have spirometry offered in physicians' offices as well as the Oakland hospital, since most children rely on their primary care doctor to treat their asthma.

Fighting attacks

After being diagnosed with asthma, some children benefit from two types of medication: daily controller medications or inhalers to prevent attacks; and rescue inhalers to quickly relieve symptoms during an attack. For babies, a mask is attached to the inhaler.

Common control medications are Singulair and Advair (as well as corticosteroids and various drug combinations); quick relief comes in steroid inhalers and "bronchodilators" such as albuterol.

"If they take their meds, our goal is they can do all the things they want to do. If they're not happy with their care, they need to find a doctor that they're comfortable with," said Dr. David Nash, clinical director of allergy/immunology at Children's Hospital. A good working relationship between a child's primary care doctor and specialist is important, he said.

"The backbone of this problem is getting a regimen, getting a regimen that's manageable and having the patient follow the regimen."

The hope is that children will improve as they get older, he said.

Dr. Deborah Gentile, director of research at the division of Allergy, Asthma and Immunology at Allegheny General Hospital, said new aspects of the asthma care at Allegheny General, focus on asthma control, with the aim of reducing or eliminating symptoms.

"We use a predictive index in preschoolers to determine if they are likely to outgrow their wheezing by school age or not."

Dr. Gentile noted that a new medication, Xolair, can be helpful for patients with poorly controlled asthma: "It has really turned some patients' lives around."

Adding his support for Xolair, Dr. Kolls said he is currently investigating if scarring in the lungs, which narrows the airways in some children with asthma, can be prevented with the new medication.

He said Xolair can be used in children 12 and older, adding that he hopes to see if it improves children's long-term outcomes.

Dr. Gentile said clinical trials of Xolair for children under 12 are now being completed as part of the process toward FDA approval for that age group.

"Since the drug has come out, we have put several children under 12 on it," she said. "They are very severe asthmatics who have failed all other meds. Initially it was quite a bit of work to get it approved by HMOs but as experience has increased, it has become less of an issue."

She said doctors inform the patients and their families that it has not yet gained FDA approval and may have other risks and benefits, adding, "The most recent version of our national guidelines on treatment of asthma also recommend this as a potential treatment for children."

Dr. Kolls said other new products are an inhaler form of Advair, formerly only available in a diskus dispenser, now also with a spacer to get the medicine deeper into a child's airways; and Symbicort, a control medication for patients 12 and older, that combines a corticosteroid and a rapid-, but long-acting asthma-controlling drug.

Generally, there are many options available for treating asthma in children. At the same time, the number of cases is rising.

More than 5 percent of all children suffer from asthma, according to the American Academy of Allergy Asthma & Immunology.

Dr. Gentile noted that pediatric asthma admissions have more than doubled over the past two decades and asthma disproportionately affects inner-city children.

"Pittsburgh is a real hot spot in the country for asthma -- a lot of it is related to air quality," she said. She added that the city has a high smoking rate, which might account for a rise in child asthma numbers. "There is emerging evidence that smoke exposure in very early infancy changes the immune system."

See another Health & Science story about children with asthma: Home program finds friendly visits are helping families of children with asthma.

For advice from the Asthma Center at Children's Hospital, see www.chp.edu/clinical/03a_asthma.