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Dr. Tom Plaut's Asthma Guide for People of All Ages

Dr. Tom Plaut's Asthma Guide for People of All Ages. Thomas F. Plaut, MD. with Teresa B. Jones, M.A.
310 pages, 1999

ISBN 0-914625-22-5
$15.00 single copy, $5.00 in lots of 100

"A superb resource for patients..."

Journal of Asthma

"Straight-talking asthma asthma version of Dr. Spock." Advance for Managers of Respiratory Care

"First-rate help, indispensable for those with asthma."

Kirkus Reviews

"...speaks directly to those suffering from this chronic disease."
Annals of Allergy, Asthma & Immunology

Read excerpts from the Asthma Guide

Parents of children with asthma and adult patients will learn what to do in every asthma situation, how to get the best effect from their asthma medicines, how to track asthma with a diary and when to call for help. Includes special tips on managing asthma at school and while traveling, real-life asthma stories and detailed information on the use of inhalers, peak flow monitoring and home treatment plans. Also contains a resource section, medical bibliography, glossary and index.

Dr. Plaut wrote the Asthma Guide for People of All Ages at the request of physicians across the United States who wanted a practical book for parents and adult patients. The Asthma Guide contains 30 first person stories that describe the asthma experiences of patients from seven months to 65 years. It covers the basics of asthma and the medicines and devices used to treat it. The sections on monitoring asthma by peak flow, and by the four signs of asthma in young children, are more complete than in any book written for parents, patients or professionals. Use of diaries and action plans is described in detail. Templates in the book can be copied for personal use. There is a special section devoted to asthma in the school.

Book Reviews

David Tinkelman, M.D.
Editor, Journal of Asthma
January 2001

Physicians are constantly searching their offices for literature to give to patients about asthma. We find these from professional associations, lay associations, pharmaceutical companies, and others. In Tom Plaut’s Asthma Guide for People of Ages, physicians can reduce their searching time and find a single superb resource for their patients. This book is far more than a "guide." It has an excellent chapter about asthma pathophysiology, which is the basis for many of the other chapters dealing with the management of asthma. To help the family deal emotionally with this chronic problem, Dr. Plaut has included short vignettes from parents and patients regarding their own experiences with asthma that add to the basic what-to-do aspects found throughout the text. I am particularly pleased with the strong position that Dr. Plaut takes regarding the need for the patient to work closely with the physician. This book is not held out at all to be a physician substitute, but rather provides “the basic information you need to communicate clearly with your doctor." The Journal of Asthma salutes Dr. Plaut for his continued devotion to providing patients with the most up-to-date scientific information and guidelines in an affordable, understandable format.

Kirkus Reviews
November 15, 1999

Pediatrician Plaut, a specialist in asthma treatment (Children with Asthma: A Guide for Parents, etc.), makes no bones about it: A well-informed patient, working with a knowledgeable health-care practitioner, can control his or her disease so completely that "you will have symptoms no more than two days per week, will rarely miss school or work because of asthma, will rarely require an urgent visit to the doctor or emergency room, and will be able to exercise as long and as hard as anyone else." Plaut goes on to provide readers--even those suffering frequent severe attacks of the disease--with the tools and an action plan for reaching these goals. He explains the anatomy and physiology of the disease; what asthma medications are available and how to use them (the proper technique when inhaling a medication is vital); and how to monitor and interpret peak flow (a measure of lung function and the most important early indicator of trouble). Plaut then discusses treatment plans in depth and includes clear, well-designed forms for tracking the disease and its treatment, plus a short "asthma diary" for patients and their physicians.
First-rate help, indispensable for those with asthma.

Thomas J. Kallstrom, RRT, FAARC
Advance for Managers of Respiratory Care
March 2000

If patients are to gain control of their asthma, they must be better educated so that they can care for themselves as their physician intends. Asthma Guide for People of all Ages, written by Tom Plaut, MD, with Teresa Jones, MA, gives readers tools to accomplish this.
Dr. Plaut is a pediatrician by education and practice, but he has gone outside his specialty to write a most useful text that addresses key components of asthma care for all ages. His many years of experience in the field have made him a solid authority on this topic.

The book is presented in a straight-talk type of style. As Dr. Plaut notes in the opening segment of the book, his audience is the diagnosed asthmatic. Accordingly, his language is easy to read and comprehend. If he uses words not commonly uttered by the nonprofessional or are potentially confusing, a definition is provided.

The opening chapter, a compilation of true narratives written by patients, grabbed my attention. This is a great idea and a most unique approach. Unfortunately, I'm not sure what the authors' intention was by dividing the stories into the 1980's and 1990's. This format was not especially useful.
The following section presented pathophysiology of the disease, keeping in mind the audience's probably level of understanding. While this isn't an easy task, the underlying causes of asthma are presented clearly. In this section, Dr. Plaut discusses diagnosis, trigger and treatment of the disease. Clear and definitive figures help to reference the written word. The book is consistent with the recommendations of the Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma.

I noted an excellent analysis of how and why physicians may use terms like RAD (reactive airways disease) vs. asthma when they talk to patients. While well-meaning physicians may try not to worry their patient by using unfamiliar terms like RAD, such words can interfere with good physician/patient communication. I see this in my practice all the time. Dr. Plaut recommends that we call it what it is, if indeed it is asthma. I agree. His ability to get at the core of issues that concern most patients and parents of asthmatics is commendable.

The pharmacology section is well-written and covers the potential medications that patients are likely to be prescribed. It's up-to-date and offers useful information, such as common drug administration problems that patients may encounter. For example, Dr. Plaut lists remedial steps the patient can take if he or she misses a dose of medication.

The devices section logically follows pharmacology. Dr. Plaut presents details of all available delivery devices, including their efficacy, most analysis and ease of use. He rightfully states that while many home care companies can provide nebulizers without a prescription, the patient must be instructed by the physician, respiratory therapist or the nurse. This observation often is overlooked. Missing from this chapter was discussion of the two most common methods of nebulizer disinfection: white vinegar vs. quaternary ammonium compounds.

The peak flow and asthma diary chapters offer clear and concise information on these two important components of asthma monitoring. The author presents this information with the understanding that patients must be an active part of their care. If these techniques are done incorrectly, the patient is possibly basing care on erroneous information.

A chapter on school asthma confronts common problems that are seen within the pediatric patient population. Most of this information also is pertinent to the adult patient as occupational exposure issues. Dr. Plaut suggests well-reasoned approaches that the patient can use to intervene in areas that we sometimes think are out of our control.
A related chapter on family and travel addresses a wide variety of problems liked to asthma that rarely are discussed. These include divorce, babysitter care and support groups.

The Asthma Guide for People of All Ages can be likened to an asthma version of Dr. Spock's care of the baby and child books that have been a staple for decades. The cost is reasonable, and at 310 pages it's not too lengthy.
This book should be in the possession of all asthmatics, especially the newly diagnosed. It also should adorn the bookshelves of those health care professionals who wish to share accurate and timely information with their patients.

Kathleen R. May, M.D.
Annals of Allergy, Asthma & Immunology
February 2001

This latest asthma educational tool, for patients of all ages, by Dr. Thomas Plaut, incorporates current medical information while maintaining a personal tone that speaks directly to those suffering from this chronic disease. The guide is overwhelmingly positive in perspective and should motivate patients to take charge of their asthma. The importance of both personal knowledge and communication with all members of the health care team is underscored.

Vignettes, written by patients and parents, comprise the first chapter, "Asthma Stories." Selected patients and their stories are referenced in subsequent chapters to highlight important details. Use of specific, personal narratives heightens the reader's interest and promotes the logical unfolding of concepts.

Asthma pathophysiology is thoroughly reviewed in a straightforward manner for the lay person, including discussion in several places about the rote of allergy in asthma. Asthma details introduced in this chapter segue conceptually to the successive section about asthma medications. Various medication aspects are noted, including purpose, onset of action, timing of administration, potential adverse effects, and dosage. The dangers associated with using inhaled epinephrine, outlined briefly, could have been further emphasized.

Devices for inhaling asthma medications are given thorough coverage, including an essential overview of proper inhaler technique. Repeatedly and daily in our care of asthma patients, improper inhaler technique is detected. Arguably, the situation would improve greatly if all health care personnel, in addition to patients, were required to review this section! National Heart, Lung, and Blood Institute updated guidelines are heavily referenced in multiple chapters, especially with regard to use of home treatment plans. That all patients may benefit from written asthma plans is reiterated, with accompanying examples from selected patients. Additional contemporary clinical research is referenced appropriately throughout the book.

Sections on asthma in specific circumstances include school-based treatment and travel preparedness. A cornerstone of school asthma management is undeniably the school nurse, who is increasingly burdened with responsibilities in many school districts. Potential environmental issues within school buildings themselves are considered, with an illustrative patient vignette. Workplace environmental issues, perhaps beyond the scope of this text, are not specifically addressed. Emphasis is placed on children with asthma in discussing family issues and interaction with caregivers. Careful and organized travel planning for those with asthma is reviewed.

Physicians specializing in the treatment of asthma will undoubtedly agree with the tenets of this thorough work. Specific practices may
differ in the application of these tenets, but the author does recognize these differences and cautions readers to review management details with their physicians. One minor area of contention is the influenza vaccine recommendation: immunizing those who have had several severe asthma episodes yearly or receive daily medication- The implication is that patients with milder asthma or less severe exacerbations would not benefit from influenza immunization, which is perhaps not the author's intention here.

Resources for patients and parents are found at the end of the guide. An abbreviated list of contents includes sample asthma peak expiratory flow rate diaries, asthma treatment plans, educational books, pamphlets, and organizations devoted to asthma care. The medical glossary included here is a tremendous resource for patients and their families.

This guide is aptly dedicated “to patients, parents, and professionals who are willing to learn." In its entirety, this book gives the patient essential tools for understanding and managing asthma: at the same time it never presumes to obviate physician input. Long-term asthma control must be achieved through effective communication among all involved. Reading this guide is required of Dr. Plaut's patients. For our patients, primary care colleagues, and other health care professionals with an interest in asthma, the guide is recommended reading as well.

For excerpts from the book, click below:

Table of Contents
Working with your Doctors
How to Choose a Doctor
Seeking a Consultation
Asthma Stories
Luke, age 7 months
Nathan, age 1
Shoshana, age 3
Karen Warren, age 22
Jeffrey Wolfman, age 38
Cynthia Miller, age 65

Table of Contents
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Asthma Stories

The Basics of Asthma

What is Asthma?
Excellent Asthma Control
Basic Facts
Naming and Diagnosing Asthma
Natural Course of Asthma
Monitoring Peak Flow Scores and Asthma Signs
Asthma Severity
Asthma Triggers
Allergies and Asthma
Special Considerations for Diagnosis and Treatment of Asthma

Asthma Medicines

Understanding Your Medicines
Controller Medicines
Quick Relief Medicines
Quiz on Asthma Medicines

Devices for Inhaling Asthma Medicines

Inhaling Asthma Medicine Deep into Your Airways
The Right Medicine the Wrong Way
Metered Dose Inhalers (MDIs)
Holding Chambers
Dry Powder Inhalers (DPIs)
Compressor Driven and Ultrasonic Nebulizers

Peak Flow

Using Peak Flow at Home
Measuring Peak Flow
The Personal Best Peak Flow Score
Using Peak Flow to Guide Asthma Treatment
Interpreting Your Peak Flow Scores
Usefulness of Peak Flow
Learning from Peak Flow
Do Peak Flow Scores Always Tell You What Is Going On in Your Lungs?
Does Everyone Agree That Peak Flow Is a Helpful Tool?
Peak Flow Meters

Asthma Treatment

Effective Asthma Treatment
The Home Treatment Plan Based on Peak Flow
Treatment for Children Under 5 Years of Age
The Home Treatment Plan Based on Asthma Signs
Signs Based Treatment Plan for Young Children Taking Inhaled Steroids

Working With Your Doctors

How to Choose a Doctor
How Often Should You See Your Doctor for Asthma?
Achieving Excellent Asthma Control
Seeking a Consultation
Asthma Visits for Young Children
In the Emergency Room and Hospital

Asthma at School

Health Planning
Legal Aspects of Asthma at School
Indoor Air Quality
The Environment Plays a Key Role in Asthma
Health Problems Related to Indoor Air Quality
Understanding Indoor Air Quality in Schools

Family and Travel

Asthma is a Family Affair
Two Mothers' Stories about Living with Asthma
Role of Family Members
Asthma Education Groups and Asthma Support Groups

Introduction: You Can Control Asthma
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You are probably aware of reports that asthma emergencies and hospitalizations are increasing. My patients and my readers rarely have these problems. They have learned to control their asthma and you can, too. By "controlling your asthma" I mean that you will have symptoms no more than two days per week, will rarely miss school or work because of asthma, will rarely require an urgent visit to the doctor or emergency room, will not be hospitalized, and will be able to exercise as long and as hard as everyone else. To achieve this control, you will need to learn:

• how to deliver inhaled medicines
• how to check your condition using peak flow or asthma signs
• how to follow a written plan based on your asthma treatment zones

You could get the information in this book from your doctor, but it would take at least ten hours. It would be difficult for you to remember, and you would probably not want to pay for it. It makes more sense to use this book as a foundation that you and your doctor can build on. By doing so, you can become a skilled manager of your asthma care and continue your learning process.

My first book, Children With Asthma: A Manual for Parents, has helped hundreds of thousands of families since it was first published in 1983. Many patients and health professionals asked me to expand my writing to include adults. This book outlines the blueprint for achieving excellent asthma control for people of all ages. It is consistent with the recommendations of the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, a comprehensive report on asthma care published by the National Heart, Lung and Blood Institute in 1997.

Dr. Tom Plaut's Asthma Guide provides you with the basic information you need to communicate clearly with your doctor. It will help you understand asthma and its treatment so you can follow a plan designed by your doctor to control asthma. As you read, you will meet people who have overcome many of the problems you face. I am convinced that you, too, can improve your asthma control.

Most asthma books discuss the basics of asthma and the medicines used to treat it. You will find that important information here, but I believe that you need to learn more than that before you can fully control your asthma. I give serious attention to the following areas of asthma care:

The basics of asthma. Understanding asthma starts with learning how the lungs work and how they change during the asthma reaction.

Careful monitoring will tell you that an asthma episode is beginning and how severe it is. Allergens and other substances in your environment can trigger an asthma episode. It makes more sense to reduce triggers such as tobacco smoke, animal dander, or dust in your home than to increase your dose of medicines.

Asthma medicines. We now understand how important it is to control and prevent long-term inflammation in the airways. We also know a lot more about asthma medicines, who is most likely to benefit from them, and what adverse effects to watch for. You will read about the medicines currently available to treat asthma, how they work, what they are supposed to do, how long they take to act, what adverse effects may occur, and the usual doses prescribed for home use.

Devices for inhaling asthma medicine. Taking the right medicines, especially the ones needed daily to control persistent asthma, is an important part of your asthma treatment. Yet, many people who see me for an asthma consultation are taking the right medicines the wrong way. Their techniques for using a metered dose inhaler (alone or with a holding chamber), a dry powder inhaler, or a nebulizer are flawed. This prevents them from getting the full benefit from their medicines and may increase the adverse effects. You need specific instructions and demonstrations from a health professional to learn the proper use of each device. The descriptions and illustrations in this chapter will help.

Peak flow. For patients five years of age and older, tracking airflow is the key to successful asthma treatment. The peak flow meter, a portable and inexpensive device, has revolutionized asthma care because you can use it at home to monitor your airflow. Once you know how to blow peak flow scores, you can learn to judge your asthma status and adjust treatment at home. You can also discuss specific numbers with your doctor, instead of using vague terms. As a result, you will receive better advice

Using an asthma diary. A well-designed asthma diary helps you collect information in an organized and useful fashion. It aids you in learning about your individual asthma situation, keeping track of medicines, and figuring out when to change your treatment. A diary that displays the asthma treatment zones also helps you communicate with health professionals and family members.

Treatment plans. A one-page written treatment plan guides you in your daily routine and in care of an asthma episode. Based on peak flow scores or the four signs of asthma, it is easy to follow since the zones are identical to those in the asthma diaries. Once you have worked out an effective plan with your doctor, you will be able to manage most asthma problems at home.

An effective collaboration between you and your doctor requires that you do the day-to-day work of asthma management. It requires that your doctor guide you in learning how to use devices, diaries, and a treatment plan. He or she needs to prescribe the medicines and environmental changes that are essential for you to gain control over your asthma.

Using Dr. Tom Plaut's Asthma Guide

This is not a do-it-yourself book. It gives you the information you need to understand asthma and work with your health care provider. It does not give specific advice for your individual situation. If you were to read this book ten times, you would know more about asthma than most people. But you would still need the help of a health professional to manage your asthma effectively and safely. Your doctor will work out an asthma treatment plan based on all the individual information you collect, and will provide emergency care if you need it. The more knowledgeable and experienced you become, the more responsibility you can take on and the better care you will receive.

You will find clear explanations of the many areas of asthma management. Illustrations and first-person stories clarify the more complex aspects of asthma care. Step-by-step examples demonstrate how to use asthma management tools such as an asthma diary and a home treatment plan. Forms for your personal use are available at the back of the book. An extensive resource section and a medical bibliography can lead you to additional information…

Almost all of my patients gain excellent control over their asthma. There are no secrets or shortcuts. The day-to-day work is not exciting, but the results are dramatic.

Amherst, Massachusetts

Working With Your Doctors
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You must work closely with a competent doctor to control your asthma safely and effectively. That doctor will give you written instructions, teach you to use your devices, measure air flow at each visit, and treat you in a manner consistent with the 1997 NHLBI Guidelines.

I believe you can achieve excellent asthma control only when you and your doctor actively share with each other complementary knowledge, skills, attitudes, and behaviors. A good doctor brings a breadth of experience and medical knowledge to the collaboration. You bring the daily observations, insights, and growing understanding of your own asthma situation. It takes both of you to build and carry out a successful asthma management plan.

Your doctor needs to have comprehensive knowledge of asthma and the medicines used to treat it. He must recognize that you want to be the primary manager of asthma once you acquire the skills and knowledge you need. He must support you as you learn, and he must also be readily accessible toanswer your questions.

If you want to be a major manager of your asthma, you have to work, too. By reading this book, you have begun the process of building your knowledge and exploring your attitudes about asthma care. With the support and guidance of your doctor, you can become skilled in measuring and monitoring peak flow, observing the signs and symptoms of asthma, and using devices to deliver medicines.

Once you and your doctor have worked out an asthma management plan, you can make that plan effective by following its guidelines and continuing to observe how well it is working. Most asthma problems will be temporary, and you will be able to manage them at home. However, even after you have acquired extensive knowledge about your asthma, treating it still requires collaboration with your doctor. There may be some situations that you cannot or should not handle at home. Don't guess. Stay within the boundaries of your written plan.

Taking care of asthma is a shared responsibility. In the early stages of your learning, it is only safe to take on a small portion of that responsibility. As you grow in knowledge, skills, confidence, and experience, you will be able to take on more. A good doctor will help you judge your ability to manage asthma and transfer responsibility to you in an appropriate and timely way.

The approach I describe in this chapter is based on my experience and is followed by many asthma specialists. It works well for patients who want to take control of their asthma and to prevent or manage most of their episodes. Once you have high expectations for asthma control, you can make sure that you get the care you want. The following stories illustrate how two mothers found doctors that they could work with.

How to Choose a Doctor
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A doctor's particular specialty is not as important as his interest in asthma. It takes time and effort for a doctor to stay up-to-date in diagnosis and treatment, although the 1997 NHLBI Guidelines have made that job easier. If you have mild intermittent or mild persistent asthma, you may be able to achieve excellent control working with a good primary care physician (pediatrician, family practitioner, or internist). If you do not achieve excellent control, or if you have moderate persistent asthma, periodic consultation with an asthma specialist will be helpful in almost all cases (see "Seeking a Consultation," this chapter). Once you have worked out a good plan with a specialist, you can follow this plan with your primary care physician and see the consultant occasionally for review. If you have severe persistent asthma, you should be treated by an asthma specialist.

To judge whether your regular doctor will be able to help you achieve excellent control, you need to consider several issues:

Does the doctor employ currently recommended treatment?
Can the doctor communicate to you what you need to know to manage asthma?
Does the doctor listen well enough to learn about your specific asthma situation?
Does the doctor want to help you to learn to manage your asthma at home?

I will discuss each of these points to help you make an informed decision about whether your current physician has the qualities that will help you to
gain control of your asthma.


Use the following criteria to assess whether your doctor is up-to-date in his approach to asthma care. A competent asthma doctor:

Gives you written instructions. This means that your doctor provides you with a written home treatment plan (often called an asthma action plan) that you can understand. The plan should clearly list all of your asthma medicines and doses, when and how to take them, and when to add or stop taking additional doses. The plan should be based on peak flow or signs scores and the zone system.

Teaches and monitors your use of devices. The office staff or the doctor should teach you how to use each prescribed device (inhaler, holding chamber, nebulizer, peak flow meter) and observe you as you use each one. Even after your technique is perfect it will need to be checked at visits.

Measures your peak flow or FEV1 at each visit. At an office visit, your doctor can get important information about your airways by checking your peak flow score with a peak flow meter or your forced expiratory volume (FEV1) with a spirometer. This airflow information is essential to monitor your progress and adjust your treatment.

Approaches asthma treatment in a manner consistent with the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, in 1997. The Guidelines are the most comprehensive guide to effective asthma care currently available. Your doctor and the office staff should be familiar with this document, or with the more readable version, Practical Guide for the Diagnosis and Management of Asthma. Treatment consistent with its recommendations will almost always lead to good results.

Not all experts agree on every part of the Guidelines. A good doctor may suggest treatment that differs from the Guidelines and will be able to explain clearly why he recommends that approach for you. I suggest that you purchase the Practical Guide and become familiar with its key points (see Resource Section).

If your doctor meets the four criteria discussed here, he is up-to-date on asthma treatment and can help you take control of your asthma and live a fully active life. However, consider these additional factors before making your final decision.


Now you need to decide how well the doctor's attitude toward home management fits with yours. Please remember, no matter how good the doctor, you have the primary responsibility for your care. A good doctor will teach you how to provide this care within certain well-defined limits. He will help you learn the skills you need to manage asthma at home and help you judge how much you can handle as you become more skilled.

Home management of asthma depends on your ability to observe, score, record, and assign a zone to peak flow scores and the signs of asthma. Your observations guide the actions that you take based on your written plan. Effective home management also depends on your ability to take the medicines you need properly and promptly. It is your doctor's job, and yours, to make sure that you understand your asthma medicines and how to take them.


A doctor needs detailed information from you to develop the most effective treatment plan. Both his medical knowledge and your individual knowledge are necessary to reach the goal of asthma control. You need to write an account of your life experience with asthma similar to the stories (from the 1990s) in Chapter 1. Your doctor needs to read it. Does he supplement this information by careful questioning? Does he analyze the information you have collected in your asthma diary? Does he want to know about the environment you live and work in? As your doctor conducts an asthma visit, it will become clear how much he values your input.


A doctor may know everything there is to know about asthma. However, that knowledge won't do you any good unless the doctor can communicate the important information to you.

Doctors vary widely in their ability to communicate, just as patients do. If you feel that you are getting the information you need from your doctor, his communication style is probably compatible with yours. Patients often find that communication with their doctor improves greatly after they read this book. If you leave the office confused or frustrated, you might benefit from working with a doctor who can communicate more clearly with you.

Seeking a Consultation
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Even when patients and parents have had a good experience and work well with their doctor, they may want a second opinion from an asthma specialist on some prescribed course of action or to get a fuller understanding of their situation.

This is accepted medical practice, and you should not feel at all uncomfortable in asking for it. Involve your regular doctor in the process by asking that he provide a clinical summary and suggest a consultant. A competent physician will not be insulted by this request. In fact, he will want to be involved in recommending a consultant who would be particularly skilled to help with your care. Some patients prefer to make all the consultation arrangements on their own.

I recommend that you seek a consultation if:

• you limit your activity or miss school or work more than one day per year because of asthma, in spite of reviewing the situation with your regular doctor.
• your doctor suggests that you limit activities because of asthma.
• you have to go to the doctor's office or emergency room for urgent care more than once a year.
• you have recently been hospitalized for asthma.
• you have nighttime symptoms (cough or wheeze) that wake you up one night a week or daytime symptoms more than twice per week, despite reviewing the situation with your regular doctor.

Asthma Stories
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The asthma stories which follow are true stories which give real details of asthma care. They were written by my patients or by the parents of my young patients. They demonstrate that asthma, even when it caused severe problems in the past, can be controlled.

Luke, age 7 months
Wendy Fulginiti
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My son Luke is seven months old. Since his birth in August 1992, my husband and I have been telling the doctors that Luke coughs, sneezes and sounds very raspy, and occasionally spits up mucus. We were told this was normal for newborn infants.

At age 2 months, Luke developed a virus with a slight fever. After Luke was sick for three weeks, the doctor decided to run some X rays and lab work; all results were negative. At this time his coughing and spitting up mucus became much more pronounced. One afternoon my mother was watching Luke. He was lying in his crib in another room when my mom heard a violent cry. When she reached Luke, he was spitting up mucus and gasping for air. I called the doctor, who once again told me there was nothing wrong with Luke and that this was very normal for infants.

In early November 1992, we went back to the doctor, for a routine checkup. We discussed our concerns that Luke was still very raspy and coughing every few minutes throughout the day and night. I also voiced my concern that his eyes were awfully tearful. We were basically told that everything sounded clear and we should try not to worry about either of these concerns, because Luke was growing and appeared healthy. The doctor said, "If the coughing and sneezing continue when Luke is about a year old, we will run some tests on him." At this point I became so frustrated that I asked, "Could this be asthma or allergies?" I received no response other than, again, "I do not hear a wheeze. He really is too young to detect allergies." I decided to call the Second Opinion Clinic at Boston Children's Hospital. The doctor there agreed that the symptoms might be either asthma or allergies, but at Luke's age it was really difficult to determine. The doctor gave us some soybean formula to try.

At this point, we did not know where to continue in this battle, but we kept searching for the answers. During Thanksgiving, we discussed that we needed to find another pediatrician, one who would listen to our concerns and not make us feel like paranoid parents. Right after Christmas, my parents left for three weeks on vacation. When they returned in January 1993, my mother commented, "I can't believe Luke is still coughing and he sounds worse!" I agreed. I knew at this point that I had to find some answers to this grim situation.

Luke woke up the next Saturday much more congested. He was coughing non-stop (he could not catch his breath between coughs) and he was sneezing every few minutes. So we decided to take him to Boston Children's emergency room.

This visit became an eye opener. The doctor told us that Luke was coughing at an abnormal rate but that he did not know why. When the doctor listened to Luke's chest, everything sounded fine. However, when he timed Luke's breaths on his watch he felt that Luke was breathing slightly quicker than normal. The doctor recommended we contact an allergist and a lung specialist, and in the meantime gave him an antihistaminic to see if it would calm the cough. At this point, Luke was waking up on and off all night.

Two days later, I called the doctor's office and requested to see another pediatrician. Tuesday morning we went to see a new doctor. The doctor listened to our concerns. During the examination, she detected a slight wheeze and agreed that Luke was breathing slightly quicker than normal. The doctor explained to us that she wanted to try giving albuterol by nebulizer. We administered this to Luke and after 20 minutes, she came back to recheck him. The wheeze was gone and Luke's breathing had returned to normal. The doctor gave us referrals to see a lung specialist and an allergist. She prescribed cromolyn to be administered by compressor driven nebulizer. This was approximately three weeks ago. The lung specialist advised us to continue on this treatment and to return in two months for a follow-up appointment.

The allergist ran some allergy and lab tests and told us that if the test results proved positive, she would contact us for further consultation. Neither specialist would commit themselves that Luke may have asthma. At this point, my sister recommended that I read Children With Asthma: A Manual for Parents because she went through a similar experience with her daughter who has asthma.

After reading the book, I became even more frustrated, because I realized that Luke had very similar situations to some of the children in the book. Plus, I discovered that the nurse told us a very different way of using the compressor driven nebulizer than how the book explained to use it. We feel very frustrated over this whole situation. All we would like for our son is to determine what is wrong...and what we can do to help him. My husband and I feel so helpless. Presently, Luke is still coughing and sneezing throughout the day and night.

Luke has spent numerous hours with many different doctors, all of whom did not significantly help him. We were told nothing was wrong with our son, even though he coughed all day and night. Before our first appointment with you, we read Children With Asthma, which talks about asthma children like Luke, and we started filling out an Asthma Signs Diary, which helped us monitor Luke's condition."

When Wendy brought Luke in for his first visit in March 1993, she came with these written goals:

I would like to learn how to prevent my son from coughing and sneezing, without being a nervous mother. I would like to know if my son has asthma and if so learn everything I need to know to help him. I would like to see my son not coughing and not so stressed when I give him his medicine.

Wendy later wrote an account of that first visit, and the changes that she and her husband made in Luke's care after our discussion.

At the time of our first consultation, when Luke was 8 months old, my husband and I were unclear about asthma in general, and we were very frustrated over the chain of events we were experiencing with our other doctors.

At the first visit, we reviewed Luke's Asthma Signs Diary for the previous two weeks. He had had a cough every day. His total signs score usually ranged between two and five. You asked my husband and me to show how we administered Luke's cromolyn using the nebulizer. As we watched Luke we realized immediately that he was not getting much of the medicine. It was escaping from the top and sides of the mask. At that point we decided to use a mouthpiece with the nebulizer instead of a mask. We doubled his dose of cromolyn, added albuterol to the solution, and gave him prednisolone (an oral steroid) for seven days.

You recommended that we purchase several items to reduce dust within the household. We encased Luke's crib mattress in an allergy-type encasing, we bought a HEPA air filter for the bedroom, and we began keeping the dog out of the bedroom. All of these changes have improved our son's well being. We now have the knowledge, confidence and skills to keep our son from having major asthma problems. When Luke gets very excited, or if the weather is nasty, he still coughs. However, my husband and I have learned not to panic. If Luke continues to cough, we increase his dose of albuterol and try to eliminate the triggers. Luke is a very happy child. When he becomes cranky, his asthma usually needs attention.

Two weeks later, Luke came in for a second visit. He was doing extremely well taking daily cromolyn and albuterol. His parents had kept an Asthma Signs Diary each day, which showed that his sign scores had greatly improved (decreased). His parents had purchased a HEPA filter which seemed to be soaking up the cigarette smoke from the downstairs neighbors. They started using the Pari-Jet nebulizer and found that it has cut the total amount of time it takes to give four ampules of cromolyn each day from sixty to thirty minutes.

At Luke's appointment three months later, Wendy wrote, "We have gained vast amounts of knowledge on asthma. Our son is one hundred percent better than he was in February." At age 2, Luke stopped taking cromolyn by compressor driven nebulizer and started taking an inhaled steroid by holding chamber with mask.

At age 5, Luke takes an inhaled steroid daily and albuterol as needed for symptoms. His dad reports that Luke's asthma control has been good for the preceding year. He made two urgent visits to the doctor and needed two short treatments with an oral steroid. He has not had any major problems since the summer and has been able to play outside in the winter for long periods of time.

Nathan, age 1
Marilyn Sansouci
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Our fourth son, Nathan, was born in April 1981. He weighed 8 pounds, 10 ounces and was a very handsome little fellow. We were very pleased with him. He was healthy and fine until one day in November when he caught a cold. We treated it with aspirin and a decongestant. This didn't seem to help him at all.

By the third day he became worse. He began to cough quite frequently and he was breathing rapidly. By the time evening came, our baby was struggling to breathe. We immediately called an ambulance which took us to the hospital. He was put in an oxygen tent for several days. After taking chest X rays, the doctor said that our son had pneumonia. He gave him an antibiotic and after a week's stay in the hospital, Nathan was sent home. He did fine for three weeks but when he caught another cold, it turned into a nightmare.

Late one night I awoke from a sound sleep with a feeling that I should look in on the baby. I check on all the boys every night (a mother's routine) before I go to bed, but this time it was different. When I went into Nathan's room I heard him wheezing and coughing and gasping for air. I ran and woke my husband. We rushed our baby to the hospital and on the way total fear gripped me. I feared that this time we were going to lose our son. By the time we got to the hospital, Nathan's lips began to turn blue from lack of oxygen. He was put into an oxygen tent again, and all we could do was pray to God that our baby would be all right. I believe it was a miracle, an answer to prayer, that Nathan did survive. They took more chest X rays and did a test for cystic fibrosis, which was negative, and we were very thankful for that.

I remember feeling distressed and wondering how long this would continue before we would find out what was causing our little boy to get so sick so often. Approximately one week later, when I was to bring Nathan home from the hospital, I called his doctor to ask if he had made a diagnosis yet. He told me there was still no diagnosis and encouraged me just to be happy he was better. Well, by this time I had had my fill of finding out nothing concerning my baby. Certainly we were happy that he was better, but for how long? We knew something was terribly wrong but we just didn't know what. We decided it was time to change doctors. At this time we were referred to another pediatrician by a friend. The first time we visited this new doctor and I told him of Nathan's trauma, he diagnosed him as having asthma and began treatment with
theophylline three times a day. Despite this treatment, Nathan was still hospitalized for asthma twice more before his first birthday.

In March of 1982 we joined a health maintenance organization. The next time Nathan had an asthma episode, he was examined by our new family doctor, who then phoned for a pediatric consultation. After he got off the phone he ordered three shots for Nathan. I believe the shots were epinephrine twice, followed by a long-acting epinephrine preparation. Nathan responded and was able to go home within an hour. He continued treatment with theophylline capsules and prednisone three times a day for a short period of time. This was the first time that he had an asthma episode and was not admitted to the hospital. We were so thrilled to be able to take our baby home the same night. It was beautiful not to have to go home to an empty crib. This was the beginning of learning about our son's asthma.

Nathan was fine for about a month and then he had another episode. This time our family doctor increased the theophylline dose but Nathan couldn't tolerate the full amount. He got hyperactive and wouldn't sleep at night. He did calm down after it was reduced. The consulting pediatrician prescribed metaproterenol followed by cromolyn, both delivered by a compressor driven nebulizer three times a day. This amounts to a regular program of treatment and prevention at the same time.

Not long ago, my family doctor recommended that my husband and I attend the Parents' Asthma Group that was held in Amherst. We attended two two-hour sessions and are we glad we did. We learned a lot about asthma and how to detect episodes early and how to monitor these episodes. We also learned about various medicines used to treat asthma, their good effects and also their undesirable effects. It was good to share experiences with other parents: to hear what they were going through and how it affected them. It helps to know that we are not the only parents going through these problems.

In the beginning of Nathan's sickness, we feared for his life. At the Parents' Asthma Group we learned that it was rare for a child to die of asthma. Only one of every twenty-five thousand children with asthma die of it each year. If parents have adequate knowledge and see that their children get proper treatment, this tiny number will become smaller still.

Nathan is now 3 years old and doing much better. In the two years he has been on this new treatment plan, he hasn't needed to be admitted to the hospital once. He takes theophylline capsules twice a day except when he begins a cold, then I add another capsule at night. He takes metaproterenol and cromolyn by nebulizer three times a day. Since we've learned more about how to deal with Nathan's condition and he's been on this medication, he has gone as long as three months without an episode. Before he was having them at least once a month. What an improvement!

Nathan's mom wrote this update in 1987, when Nathan was six years old:

In the past two years Nathan has had a tremendous improvement in his health. I am grateful for the knowledge I gained on how to deal with asthma and for the parents who shared their experiences on how to cope with asthma. It is nice to know that others have dealt with this problem. My husband David gives me a lot of support and help.

Nathan now has asthma episodes twice a year. He has one in the spring and one in the late fall. That is a real improvement from having an episode every other month. Nathan still takes a long-acting theophylline preparation three times a day. Recently he had an attack and we started giving metaproterenol by nebulizer four to six times a day. He also took prednisone twice a day for a week. After a couple days of treatment Nathan was fine and as playful and active as ever.

Nathan loves to ride his bike and play baseball with his three older brothers. He is excited about starting kindergarten this fall. I'm so happy with Nathan's progress. It is a relief not to be frantic and upset with worry if he does have an asthma episode. I believe the key to overcoming the problem of asthma is to detect it early and to give the child proper treatment.

Each child has different symptoms. In Nathan's case he will get itchy, usually behind his ears and on his chest, and he might be cranky for a couple of days. Then he will start symptoms of a cold and he'll start wheezing. Now that Nathan is getting older he knows when he starts to have trouble and he will come to me and ask for a nebulizer treatment.

Asthma is a problem, but as long as we know enough to treat it properly, we can go on and live normal happy lives. I am going to have my fifth baby this September. People have asked me, "Well, aren't you worried about your new baby having asthma?" Of course I hope and pray that this new baby will not have asthma. But I am not too worried, because my husband and I know how to deal with it.

I spoke with Nathan's mom in 1998, more than ten years after I last saw Nathan. He is now 17 and has excellent control over his asthma. During the past decade, he has not needed oral steroids or any urgent visits to a doctor or to be hospitalized for asthma. For the last five years, Nathan has taken no controller medicines. He plays on the high school basketball team and treats asthma symptoms with albuterol one or two games per year.

Shoshana, age 3
Tamara Barbasch
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Shoshana has had troubles resulting from “allergies” since her birth in October 1992. Although these problems always fell within the “mild” range, they were troublesome to us because they were chronic: no matter what we did, they always returned. I began to notice her eczema when she was approximately one month old, and her skin was dry, rough, and prone to patches of redness or small, reddish bumps. Although she was completely breast-fed until she was 5 months old, she would “break out,” especially on her cheeks, shortly after nursing—so I realized that she was reacting to the foods that I had eaten prior to her nursing.
In February of 1994, when Shoshana was 16 months old, she developed a cold with typical symptoms of nasal congestion and postnasal drip. On the fourth or fifth day, she became unusually irritable, demanding, clingy, and inconsolable. She cried repeatedly throughout the day in response to tiny problems which would otherwise never bother her (something dropped on the floor). This constellation of behaviors remains, to this day, as the most significant clue that an asthma episode is developing. At the time, however, I was unaware of its significance.
Later that day, Shoshana began to breathe rapidly and laboriously. I thought that she was simply congested and having difficulty breathing because of her stuffed-up nose. Shortly, the labored breathing developed into an audible wheeze. By this time, Shoshana was crying continuously, had developed a fever, and had vomited her dinner. At the pediatrician’s office, we were told that Shoshana was probably having an asthma attack (she responded with some improvement to an updraft treatment of albuterol) and that she would have to be hospitalized that night. We spent two days at the hospital, learning about asthma (reading Children With Asthma over and over), and learning how to use a compressor driven nebulizer machine. Shoshana was given albuterol and prednisolone and was kept inside an oxygen tent. Her condition had improved within twenty-four hours. We continued the medicines, tapering as directed, for one week.
After this episode, we watched very carefully. I fantasized that the incident requiring hospitalization (which was extremely difficult for all of us) was a “fluke” and that Shoshana did not really have asthma at all. In fact, in mid-March Shoshana developed cold symptoms again without any asthma symptoms, so I was almost convinced that it would not happen again.
On April 25, 1994, during Shoshana’s 18-month well visit to the pediatrician, her doctor detected mild bronchospasm and prescribed albuterol updraft treatments two to three times per day for several days. Although she had been exhibiting cold symptoms, Shoshana had given no indication that she was experiencing any difficulty breathing. I was still not convinced.
In early May, however, Shoshana began to exhibit a “cold” that lasted for five weeks or so. We now believe that this was allergic rhinitis in response to the pollination of trees in our area at that time. On May 13, the nasal congestion and nasal drip symptoms led to mild wheezing and coughing, which we treated with albuterol by compressor driven nebulizer. She then developed an upper respiratory infection, with a fever of 104 degrees, and more asthma symptoms. On May 25, Shoshana had moderate asthma symptoms and was prescribed prednisolone in addition to albuterol. Her pediatrician recommended and prescribed cromolyn to be taken daily, but I was hesitant because I was still not quite convinced that she needed daily medicine. She was having asthma symptoms less than once a week. If she developed asthma only when she had nasal congestion and a nasal drip, I reasoned, then we should treat the symptoms as they appeared.
Shoshana’s most recent experience with asthma, developing on June 20, has somehow led me to alter my thoughts regarding her treatment. Again, during this most recent episode, she had developed cold symptoms, otitis media in both ears (requiring antibiotic treatment), and asthma symptoms. The wheezing was particularly “stubborn” this time. We gave her albuterol by nebulizer thirteen times in twenty-four hours, yet she showed little improvement. The next day, we began administering prednisolone again.
I have finally realized that Shoshana’s asthma is not going to simply “disappear,” although, of course, I wish that it would! It is painful to see her suffer each time, and watch our child become “a different person” as she regresses to a crying, clinging, inconsolable “mess.” The frequent albuterol treatments and prednisolone administrations have become much more difficult as Shoshana enters into a developmental period typical of toddlers, wherein she refuses to comply with absolutely anything we wish to have her do.
You made an excellent point during our telephone conversation when you said that parents must believe that their child needs to take a medicine that tastes terrible or causes discomfort. If they are not convinced, the child will sense their ambivalence and often refuse to take it. With Shoshana, I believe that part of the problem does have to do with exactly this fact: I have never felt entirely comfortable with what we have been doing.
The second part of the problem, however, is a result of her extreme mood and behavior changes during an acute asthma episode, which contribute further to her “negativism” in complying with any treatments. I find this part of the entire situation the most frustrating. When I am trying to help my child and she is spitting prednisolone all over me or vigorously struggling against me as I am trying to force the nebulizer mouthpiece to her lips, I feel hopeless, dejected, angry, frustrated, and depressed.
I have had enough of “reactive” treatment methods: I wish to treat my daughter’s asthma “proactively” and prevent any further episodes, if possible. If cromolyn, the asthma “wonder drug,” will work to do that, then I am ready to use it! My husband and I are both highly educated, highly motivated individuals who are interested in learning the details of how to make a treatment plan work properly. So I am appealing to you for some assistance in helping us to learn exactly what to do, how to do it, and why we are doing it—in order to make it work!
At our first consultation, I told Shoshana’s parents that if they need to give more than six treatments of albuterol by compressor driven nebulizer in twenty-four hours during Shoshana’s episode, that is a sign that the asthma is worsening or that their technique for giving medicine is ineffective. I showed them how to use a compressor driven nebulizer and watched Shoshana take a treatment. With the mouthpiece properly placed, mist came out of the top of the nebulizer cup both during inspiration and expiration.
Usually, mist comes out only during expiration. When a child is breathing in you should not see mist escape. Clearly, Shoshana was not inhaling the medicine. What was wrong? We realized that Shoshana was breathing through her nose and no medicine was entering her mouth. So, I recommended using a mouthpiece so the medicine could enter through her nose.
After recording Shoshana’s asthma signs in a diary each day, her parents realized that she needed to take a controller medicine and started to give cromolyn by compressor driven nebulizer. Three months later her mother wrote:
After a four-week trial of giving cromolyn by compressor driven nebulizer, we switched over to an inhaled steroid, at her pediatrician’s suggestion. Since then we have not had to use any prednisolone syrup and have not had any sleepless nights filled with Shoshana’s crying and misery. She truly does seem to have asthma that falls into the mild range, and we are so glad to have determined that only a minimal amount of medicine is necessary.
I spoke with Shoshana’s mother on the phone in 1998. She said that Shoshana’s asthma control has been excellent for the past year. Now 6 years old, she has taken no oral steroids, has had no urgent visits to the doctor, emergency room, or the hospital, nor has she missed school. She continues to take a very low daily dose of an inhaled steroid by holding chamber with mask.

Karen Warren, age 22
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The earliest memory that I have of asthma is the deafening sound of my own wheezing on the way to the doctor's office when I was ten years old. My chest ached and I wasn't getting any satisfaction from my attempts to gulp for air - it just wasn't there. Instead I took short, shallow breaths, which were equally unsatisfying. The next memory is the "green room" (my pediatrician had a "green room," a "yellow room"...etc.) where I cried as I received my first shot of adrenaline, and minutes later violently puked.

Following this first attack, I started taking theophylline (with applesauce). I still won't eat applesauce to this day. I took theophylline as directed for two weeks, and I was in the emergency room using a nebulizer four days after I stopped. The machine was terrifying and no one explained anything about what was going on. I think my parents aged more than I did that night.

Upon returning home from the emergency room I had a host of medicines to choose from: albuterol, cromolyn, theophylline.......only we were never taught what each of the medications did, how much to take, when to take them. The cromolyn Spinhaler was not only a complete nuisance, but in addition, I hadn't been taught how to use it properly; half of the powder remained stuck in the tube, while the rest was choked out as I coughed upon inhaling.

Finally my parents thought it would be wise for me to see an allergist. One of my brothers had severe allergies, so perhaps, we thought, this was the missing link. After dozens of scratch tests and little blue-and-yellow bruises up and down my arms, they found that I was allergic to pollen, dust and mold spores. There went the carpet and my plants.

I was in junior high, and the albuterol seemed to be doing the job, with an occasional dosage of theophylline (although this left me nauseous and shaky). This regimen continued through high school, as I participated in soccer and had a rigorous, outdoor practice every afternoon. I recall taking the theophylline pills in the locker room; as long as I took them, I was all right, except when we did sprints. They sent me hacking and choking off the field.

During high school, I was in the emergency room again twice. Although the nebulizer was more familiar, I still didn't know how it was working to make me feel better.

My first semester at college was a nightmare. I visited the health services over half a dozen times that winter (in the middle of the night, of course) and became friends with the nebulizer. As far as the physicians were concerned, I was doing the right thing by coming in, but they had no advice for me on a long-term basis.

Consequently, I taught myself how to slow down an episode as I felt it coming on by taking small breaths and ceasing all activity. In addition, I learned to avoid situations, namely, any strenuous exercise, that would trigger my asthma. I felt frustrated and cheated by having to restrict my activity, and I often exceeded my limits. This stubborn behavior always resulted in moderate to severe attacks.

Now as I prepare to graduate, it seems I am back where I started. Since the flu last semester I have wheezed upon waking every morning. If I take an afternoon nap - I wheeze. And more recently, I have been unable to sleep through the night.

I drive to classes that are far away instead of having to deal with wheezing on the walk home. I have an inhaler at home, in my dorm, in my car...and I miss soccer and bike riding and the little things, like being able to take a really deep breath and feel satisfaction.

Karen came in for her first consultation in April 1993. She expressed these goals for her visit: "I would like to learn how to use the various pieces of asthma equipment properly - so I can best benefit from their use. In addition, I would like to feel that there can be an end to this restless-night, achy-chest, twelve-year pain in the butt."

I told Karen I expected her to achieve excellent control of her asthma, to have symptoms only rarely, and to be able to play any sport she wanted. We reviewed asthma in general and discussed asthma devices (holding chamber, peak flow meter, and peak flow diary), medicines, and environmental measures. I prescribed a seven-day burst of an oral steroid to be taken simultaneously with cromolyn and albuterol.

One week later, Karen reported she was sleeping through the night for the first time in three weeks. She woke without wheezing or coughing for the first time in six months and could laugh without coughing for the first time in a year. Karen stopped driving to her distant classes because she could now walk
there without trouble.

In May 1993, one month after her initial visit, Karen came in for a follow-up visit. It had taken her seven days to recover from welding fumes in metal art class. She had a cold at the same time. I substituted an inhaled steroid for cromolyn as her controller medicine, and she improved steadily. She felt fine six
days later.

In 1998, Karen told me that her asthma control is excellent. She has not taken oral steroids, nor has she visited an emergency room or an asthma doctor. She has missed no work due to asthma in the four years since her last visit. She stopped taking an inhaled steroid in 1996, and her only symptom at present is a slight wheeze when she has a cold. She is in excellent health, works out five days a week, and pretreats with albuterol prior to strenuous exercise.

Jeffrey Wolfman, age 38
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I was born in Oakland, California. At approximately 18 months, I was diagnosed with asthma. Both of my parents smoked and continued smoking until the mid 1960s. To the best of my recollection, I did not take any medications until elementary school. I was taken to the local hospital emergency room on numerous occasions for treatment whenever an asthma attack occurred.

I was an active, athletic child, always able to keep up with others in school sports. I played varsity basketball, soccer, and was on the ski team in high school. I attended college in Colorado, where I was involved in intramural sports. I placed 15th out of 70 in a bicycle race from Colorado Springs to Aspen in 1973. I took a combination medicine containing theophylline, ephedrine, and an antihistamine for my asthma from the time I was in elementary school until age 30.

I have always had difficulties with allergies and eczema. I was treated for my allergies through injection therapy during elementary school in California and then most recently for five years (1988-1992) in Boston.

At age 30 (1984), my doctor changed my medicine to theophylline. Seven years later, my doctor changed my brands of theophylline and quick relief medicine and added an antihistamine. This year I started taking a different antihistamine and started using an inhaled steroid.

In November of 1992, I was asked to participate in an experiment at Beth Israel Hospital, testing the effect of cold air on asthmatic lungs and the relative recovery time to restore normal breathing after using various inhaled medicines. The study required that the subjects take no medicine of any type for twenty-four hours prior to the test. After fifteen hours without medicine, my bronchial passages became severely constricted, and my lung capacity did not even register on the peak flow meter. Normal breathing was restored after administering albuterol.

I have a number of allergies to certain foods, trees and grasses, and dust and animal dander. To deal with drastic emergencies, I carry an EpiPen with me at all times. Over the last two years, I have begun to have noticeable difficulty breathing and have felt that my respiratory capacity has diminished significantly. I have become very sensitive to smoke, perfume, soaps, and a variety of environmental substances, pollen and dust in particular. Any minor physical activity, even climbing a flight of stairs, leaves me winded and feeling the need for asthma medicine.

During my consultation, I hope that I may be able to better understand the problems I have been experiencing and the changes in my asthma, and to develop a treatment plan using appropriate medicines that will allow me to resume some of my normal activities. I would like to have greater endurance with the least amount of medicine possible.

At Jeffrey's first asthma consultation, we discussed additional details of his asthma history. He had taken prednisone only once, in 1989, for nine days, and had no emergency room visits or hospitalizations for respiratory problems in the past twelve months. His family had a history of eczema, asthma, and hay fever. Jeffrey did not use a holding chamber to take his medicines. During the month prior to his first appointment, his peak flow score never exceeded 375 before taking a quick relief medicine, a low score for a man his age and height.

After some coaching during the physical examination, Jeffrey was able to blow a peak flow score of 550 before inhaling albuterol. His chest was clear. I asked him to demonstrate his inhaler use. He held the MDI at his mouth, began to breathe in, and simultaneously released one puff of medicine. He took two seconds to breathe in, then held his breath for six seconds. Both his inhalation and breath hold were too short for him to get the full benefit from his medicine. He took his inhaled steroid before his beta2-agonist (quick relief medicine), another error.

I assessed Jeffrey to have moderate persistent asthma that had required daily medicine since elementary school. Over the past two years he had found that his tolerance to exercise and pollutants had decreased. He was taking an inhaled steroid, theophylline, pirbuterol (a quick relief medicine), and an antihistamine daily. He had not been properly instructed in use of the metered dose inhaler, holding chamber, asthma diary, or a peak flow meter, nor did he know which inhaler to use first. He did not know how long it took for his medicines to work or how long their effects lasted.

At the first visit, I recommended that Jeffrey add an oral steroid to his current medicines for the next seven days. This additional treatment would help clear his airways, reduce symptoms, and let him establish his personal best peak flow. I showed him how to use the inhaler and demonstrated use of the holding chamber with MDI.

Nine days later, Jeffrey came in for a second visit. He reported that he had taken his medicine as directed and started feeling better in two days. He felt more physically able than at any time in the past four years. Prior to his visit, he could not push his 10-month-old uphill in a carriage, nor he could roughhouse with his 3-year-old son. Most of his activities with his 3-year-old were "housebound" like reading and coloring. But at the time of his second visit, he was running with his family and was able to climb three flights of stairs at work or walk a mile and a half across a college campus without tiring. He had not used a quick relief medicine at night since starting the oral steroid burst. His 10-month-old, not his asthma, was waking him three times a night.

At a four-month follow-up visit, Jeffrey said he had no symptoms and that his asthma control was excellent. His personal best peak flow score was 650. Four years later, in 1998, his asthma control continued to be excellent. He was taking a low dose of an inhaled steroid and using albuterol daily. He was walking a mile a day and swimming regularly with his kids.

Cynthia Miller, age 65
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I lived in New York City until I was 5 years old. The summer I turned 4, I spent my birthday in bed with a cough. During the winters of '37, '38, and '39, I was often bedridden with bronchitis. My health must have been "fragile" as I had to rest a lot.

Ages 11, 12, and 13, I spent summers in Long Island, with lots of bike riding, swimming and tennis. Riding horseback, I always liked to ride up front to avoid the dust. On damp, muggy, still days, I always had trouble breathing. I had all sorts of tests, including allergy tests, which were positive for dust and mold. I was given no specific medicine or shots for allergies and was advised to sleep on a foam pillow.

I remember always needing my nap in the afternoon in May and early June. Muggy nights in May and June found me kneeling by the window with my nose pressed against the screen trying to get "more air." I was always very athletic, playing hockey, soccer, tennis, basketball, swimming competitively, and riding a horse and a bike. Only muggy air slowed me down. I have had sinusitis two or more times a year since childhood and rhinitis which I have treated with inhaled steroids for the past six years.

Between the ages of 20 and 60, I was married to a man who smoked four packs of cigarettes a day. The smell of cigarette smoke brings on sneezing and choking along with coughing. I don't wheeze very often.

At present, I have great trouble sleeping in an airless room, or exercising in humidity or heat. I keep the heat low in winter, since air blowing on me bothers me. When we changed from oil/hot air heat to gas/baseboard heat, I started sleeping better and choked less.

My coughing spasms can often come on unexpectedly. In one case I had just visited a huge indoor flower market. The next day I was in the hospital because of breathing trouble.

For the past six months, I have been aware of every breath. Last summer, I noticed I could not ride my bike in the heat. I could not breathe properly. The day I came down with this "bronchitis," I noticed a restriction in my lungs at the end of a deep breath in while I was biking uphill. The next day I was out of breath and could not walk uphill without gasping for air. This lasted for a week.

I want to learn whatever is necessary, including changes in my lifestyle, to ward off attacks. I want to familiarize myself with "clues" indicating an approaching problem, and if an attack starts, know how to immediately start remedying the situation. As a result of new knowledge and skills, I hope to gain confidence in dealing with my asthma problems.

Cynthia had a history of breathing problems for sixty years. She had been diagnosed with bronchitis three or four times a year and was hospitalized once for pneumonia in 1986. She was first diagnosed with asthma two weeks before her first visit with me and was treated with inhaled albuterol, an antibiotic, and a cough medicine.

A physical examination showed that Cynthia had signs of both asthma and sinusitis. I assessed her to have mild to moderate persistent asthma since childhood. I suggested that she read further about asthma, reduce triggers in her environment, and monitor peak flow. I instructed her in the use of a peak flow meter, holding chamber, and the technique of nasal irrigation (for her sinusitis). I also prescribed an oral steroid, an inhaled steroid, and albuterol, and I treated her for rhinitis and sinusitis.

Three weeks after her initial appointment, she said the improvement in her condition was "fantastic." She had kicked the dog and the cat out of the bedroom and had gotten rid of the carpeting to reduce allergens. She started using a mask for allergenic or dusty environments, purchased a HEPA air filter and vacuum cleaner, bought a filter for the furnace, and watched the asthma video I loaned her. Her cough had disappeared in four days, her mild wheeze had disappeared in five days, and her activity had returned to normal in about seven days. During the first week of treatment, she had occasional difficulty with sleep (probably due to the oral steroid). She found the nasal washes helpful. She felt like her old energetic self for the first time in many years.

Three months after her initial consultation, Cynthia wrote this update:

Having had pneumonia twice and severe "bronchitis" many times, I believe I had an unconscious fear of doing "top performance" – whether riding my bike as fast as I could go or hiking hills at a faster pace. Now the unconscious fear in my breathing is put at rest. My last asthma attack awoke me in a rage of coughing and choking. It was scary but I knew what to do. I finally have a handle on my own management, something I never had before.

My mind and body have been freed from a fear that I have had since I was a young child. Knowledge of asthma has given me the confidence to exercise more fully. Now that I know what to expect, my inner self no longer constantly asks me "what could happen if...?" All this frees up a lot more energy and as I enjoy doing so many things, I find I have been able to move "smoothly" and joyously from one to another. There are no more daily interruptions by breathing problems.

The knowledge and skills I have gained in the past four months enable me to feel free and secure in any place I go. I can now hike three miles without getting out of breath. I feel like the "little engine that could." I went up to the barn yesterday and did not bring my mask, as I did not realize how horribly dusty everything was. My breathing worsened immediately. My problem is I feel so good that I forget I have asthma and forget to carry my mask always with me. I must remind myself!

When we spoke in 1998, Cynthia reported that her asthma control continues to be excellent with the treatment plan we had worked out.

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