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The Asthma Signs Diary

Asthma Signs Diary - English

Asthma Signs Diary
for children under age 5
by Thomas F. Plaut, M.D.

An interactive tool for learning about and managing asthma, this diary helps parents of young children understand asthma triggers, signs, symptoms and medicines. It gives the doctor a wealth of clinical information to use in assessing progress and guiding therapy.

Click here to view a larger image

Click here to view instruction for use

Asthma patients who are younger than five are hospitalized at more than double the rate of children ages five to fourteen. There are several reasons for this:

  • Their airways are smaller, so they become blocked more easily.
  • They experience upper respiratory tract infections, a major trigger, more frequently.
  • Most children under five cannot use a peak flow meter to monitor an episode.
  • Their parents have not learned an effective method of tracking the course of an asthma episode.

Only the last factor is within the control of parents and health care providers. After parents learn to track the progress of an episode, they can learn to intervene effectively.

Nineteen years ago, my partners and I described a comprehensive asthma management program that reduced asthma hospitalization in our practice to 31% of the national average. [Pediatrics, 1986; 78:542.] Parent education was a key part of the program. We taught the parents four signs of asthma that they could use to monitor the course of an episode. A sign is something that an observer can see or hear. It does not rely on patient report or parental interpretation.

We chose signs that we could see and teach to parents during a visit. We focused on signs that appear early in an episode, change as an episode becomes worse, and improve when the episode gets better. We taught these signs to the parents of our asthma patients, discussing them at well child visits as well as asthma visits.

At the same time, we established a treatment program based on the presence and severity of these asthma signs. We wanted parents to check the child’s signs, give medicine as directed in a written plan, and observe the child for change. If the episode did not improve, they were to modify the treatment. If that didn’t help, they were to contact one of us.

After we established this program, the parents had a more solid basis for assessing their child’s status. They came in for treatment at the right time, rather than too early or too late. Based on these results, we knew we had worked out a plan that was appropriate for the management of asthma attacks in young children.

In 1993, I constructed a diary that displays the asthma signs clearly. I wanted parents to relate changes in their child’s asthma to the triggers that occurred and to medicines their child was taking.

I score wheezing and retractions on a scale of 0-5, and cough and respiratory rate on a scale of 0-3. Parents who total these scores an plot them are able to manage mild and moderate episodes at home. Also, they understand when to seek emergency care. This total score is used to guide treatment. The green zone, or okay zone, is limited to a score of zero. A patient in the green zone has no cough, no wheeze, no retractions and no increase in respiratory rate. Scores in the High Yellow Zone (1 to 4 points) indicate a mild episode calling for a change in treatment. Scores in the Low Yellow Zone (5 to 8 points) indicate a moderate episode requiring more intensive treatment. A score in the Red Zone (9 points or more) demands immediate treatment in the emergency room or a well equipped office.

Parents use the diary to:

  • Communicate clearly and succinctly on the telephone.
  • Accurately recall events since the last visit.
  • Identify triggers that provoke an attack.
  • Guide them in starting and reducing medicines, following a written home treatment plan.
  • Remember to give medicines regularly.
  • Understand how asthma and its various treatments effect the child's daily life.
  • Note the effect of changing a dosage or medicine.
  • Note the effect of eliminating a trigger.

Occasionally, scoring has to be modified. If a slim child sucks in the chest skin during normal breathing, his retraction score should be modified. If a child exhibits only a cough during an episode, but it is so severe that he cannot sleep, the usual scoring system will not lead to adequate treatment. To remedy this, increase the score for severe cough to 5. This will put him in the low yellow zone, where treatment is more aggressive. This graphic three-color diary enables parents to see the course of events and the way triggers, signs and medicines are related to each other.

Some asthma specialists have found the diary sheet “too complicated and too cumbersome to fill out.” Let me assure you that a mother does not have to be a high school graduate to use this diary. It takes interest, it takes thought, and it takes some work to learn. It certainly helps if the health care provider is interested and knowledgeable enough to help the parent learn.

An asthma nurse saw a 12-month-old boy who had already made 22 visits to the clinic and emergency room for bronchospasm. She spent five minutes explaining the Asthma Signs Diary to his teenage mother. At a follow-up visit the next day, she told the doctor, “Before I used this diary, I did not know what to look for.”

Parents often analyze their diaries at home. They observe the changes that take place when they change the dose of medicine or their child is exposed to a trigger. I am usually able to confirm their analysis at the next visit.

Recently I gave a presentation to a group of allergists, a number of whom know more about asthma than I. After I had described the usefulness of the asthma diary, one of them asked me how many of my patients keep a diary. “All of them,” I said. His next question was, “How do you make your patients use this diary?” The question surprised me. I don’t have the power to make my patients do anything. They start to keep a diary because I say I think it will help them learn about asthma and help them control it. They usually keep a diary until their child has been in the green zone for two months and they understand the interactions between triggers, signs and medicines. After that, they resume recording when their child is exposed to a trigger, changes medicine, and for the week before a follow-up appointment.

Berri Mitchell, R.N. and Carlene Gibbons, R.N. provided helpful comments.

To receive a free copy of the Asthma Signs Diary, send a self-addressed No. 10 (long) envelope with postage to:

Sample Asthma Signs Diary
Pedipress, Inc.
125 Red Gate Lane
Amherst, MA 01002

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