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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
- 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.
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.
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
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.
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.
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.
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
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.
use the diary to:
clearly and succinctly on the telephone.
recall events since the last visit.
triggers that provoke an attack.
them in starting and reducing medicines, following
a written home treatment plan.
to give medicines regularly.
how asthma and its various treatments effect
the child's daily life.
the effect of changing a dosage or medicine.
the effect of eliminating a trigger.
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.
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.
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.”
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.
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.
Mitchell, R.N. and Carlene Gibbons, R.N. provided
receive a free copy of the Asthma Signs Diary,
send a self-addressed No. 10 (long) envelope with
Asthma Signs Diary
125 Red Gate Lane
Amherst, MA 01002