Patients and parents should understand that the presence of
symptoms or the need for emergency care is usually
due to an inadequate treatment program or an incomplete
understanding of asthma.
F. PLAUT, M.D.
American Journal of Asthma and Allergy for Pediatricians
Vol.4, No. 4, Summer 1991, Edited 2005
professionals, librarians, and teachers are showing
an increasing interest in asthma. To choose helpful
educational materials, they must become more familiar
with this complex illness. This article outlines 10
elements that should be included in any comprehensive
asthma book or program.
elements discussed in this article were presented
to 20 experts in the field. I asked them to displace
any of the nine elements with an item that they considered
more important. All but one accepted the nine elements
without change. Three urged me to add decision-making
to the list, because knowledge alone will not lead
to appropriate management. Ten of the experts responded
in writing. They included three allergists, four pulmonologists,
two psychologists, and one asthma research nurse.
Elements of Education
Establish the expectation that the child will lead
a fully active life, play any sport, attend school
regularly, and sleep through the night. A major flaw
in many educational materials is the idea that children
should adjust to asthma symptoms. In 2005, the vast
majority of children with asthma should have symptoms
no more than two days a week, on average. Patients
and parents should understand that if symptoms occur
more often, their treatment program is inadequate
or their understanding of asthma is incomplete.
The Four Signs of Asthma Trouble
Cough, wheeze, sucking in the chest skin (retractions),
and breathing faster are the major common signs of
an asthma attack in children. Understanding these
signs can improve the communication between patient
and physician. Parents can judge whether their child's
asthma is improving or worsening and then can take
four signs mentioned here suffice for almost every
patient. Parents will benefit more from learning these
four signs fully than learning a larger number incompletely.
Late signs, such as blue skin and lips, incessant
vomiting, or breathing hunched over, deserve little
mention because parents should be taught to prevent
them by interveaning early.
An accurate diary is essential for managing childhood
asthma. Parents can learn about asthma triggers, symptoms,
and the duration and adverse effects of asthma medications
by analyzing such a diary. The diary also serves as
an account that can be reviewed during office visits.
Overreactivity and the Two Phases of the Asthma
The airways of asthmatic patients are very sensitive
and may over-react to allergens, pollutants and other
triggers. The early phase of an asthma episode is
characterized by bronchoconstriction, which responds
to bronchodilators. The late phase is distinguished
by inflammation, which responds to high doses of inhaled
steroids or to oral steroids.
Two Medicine Types
Controller medicines are used to prevent or lessen
the frequency and severity of attacks. They should
be taken daily by people who have symptoms more than
two days a week. They include inhaled steroids, long
acting beta2-agonists, leukotriene modifiers, nedocromil
and cromolyn. The quick relief medicines are bronchodilators
(short acting beta2-agonists, anticholinergics and
theophylline). They relax the muscles that constrict
the airways. Oral steroids are in a class of their
own. They are used to treat severe episodes and also
used every other day to treat very severe asthma.
The desired and adverse effects of these medicines
should be described.
Devices for the Delivery of Medication
This includes their proper use and a description of
the relative merits of metered dose inhalers, holding
chambers, and compressor-driven nebulizers. The four
elements of proper inhaler use - proper positioning,
hand-breath coordination, slow inhalation, and a 5
to 10-second breath-hold - should be highlighted.
Indications and instructions should also be given
for the use of holding chambers, compressor-driven
nebulizers and peak flow meters.
Peak Flow Monitoring
Monitoring peak flow is the key to successful management
of asthma at home. Peak flow monitoring provides objective
information that can be used to make treatment decisions
based on a preset plan. It provides an accurate means
of communication with the physician and can improve
asthma care for almost all patients five years of
age and older.
An understanding and avoidance of the triggers of
asthma (e.g., exercise, viral respiratory infections,
irritants, allergens, some drugs and chemicals, and
cold air) may allow the patient to live a normal life
while reducing medicine intake. Therefore, a comprehensive
book should describe possible triggers and how to
avoid or prevent them.
Criteria for Choosing a Competent Asthma Doctor
The physician should give written instructions, teach
and monitor the use of treatment devices such as holding
chambers and a compressor-driven nebulizer, measure
air flow with a peak flow meter or a spirometer at
each visit, and be accessible. Competence in these
areas is more important than certification in any
Treatment decision should be based on peak flow scores
or the four signs of asthma and a knowledge of asthma
triggers and medications. Markers can indicate when
treatment should be changed. A four zone Asthma Action
Plan can guide parents in home treatment and tell
them when to consult their physician.
Efficacy of Education
education is a continuing process. Parents need tools
to continue their learning and to improve their ability
to analyze and manage their child's illness. To reach
the maximum number of children with asthma, educational
materials must be designed for home use. The text
should be clear and concise so parents and patients
can readily understand and use the material.
presentation and discussion with a knowledgeable leader,
such as a nurse, respiratory therapist, health educator,
parent of a child with asthma, or a physician, often
will enhance the effectiveness of a good book or program.
Most parents find a single 2-hour or 4-hour session
most convenient. Multiple session programs have a
high dropout rate and have reached only a small fraction
of children with asthma in the United States.
matter where asthma education takes place, the 10
basic elements outlined above should be covered. Anything
less will leave many parents lacking the information
they need to control their child’s asthma. A
parent who understands these elements, and who works
with an up-to-date and supportive physician, can achieve
optimal control over asthma.
The author would like to acknowledge the comments
of: Kathleen Conboy, RN, MS; Thomas L. Creer, PhD;
Gerd J.A. Cropp, MD, PhD; Elliot F. Ellis, MD; Gilbert
A. Friday, MD; Shirley Murphy, MD; Sydney R. Parker,
PhD; Thomas L. Petty, MD; Marianna Martin Sockrider,
MD; and John A. Winder, MD. Beth Gradone provided