Today is my final guest blog in this series on asthma. I am deeply grateful to DrGreene.com for inviting me and to all the readers for viewing my posts. I hope you have found them helpful.

Do you have an “asthma action plan” in place for your child? Due to the chronic nature of asthma, it is imperative to pay attention to the progression of symptoms, and one of the best ways to do so is by building an asthma action plan around your “peak flow,” preparing you to successfully deal with asthma when things go awry. “Peak flow” is a measurement of your lung function and can be taken with a “peak flow meter,” a small hand-held device that you can use pretty much anywhere. Taking in a deep breath and then blowing out into the device as hard as you can gives a number – your peak flow. Usually children as young as 5 years can do this maneuver. Measuring peak flow a number of times when you are well gives you your child’s personal best number.

Most current action plans are developed around the traffic signal structure of green, yellow and red zones, each based upon the asthma symptoms present and the current peak flow measurement.  The green zone corresponds to 80-100% of this number, yellow 50-80% and red, less than 50%. For example, if 200 is your child’s personal best, green corresponds to 160-200, yellow to 100-160 and red, less than 100. Since the peak flow is effort-dependent, it may be falsely low if your child is tired and unable to give a good effort, so you’ll want to consider the level of other symptoms, as well.

So, what should you watch out for in each zone, and how should you react?

• In the green zone, your child is experiencing no acute asthma symptoms, peak flow is 80-100% of his or her best, and no action – other than continuing current medications – is necessary.
• In the yellow zone, peak flow is at 50-80%, and you may see coughing and wheezing, nighttime symptoms, or tightness in the chest. Your action steps in the yellow zone need to be discussed ahead of time with your physician. Usually you will need to provide your child with rescue medication several times a day. Additionally, I recommend parents contact me at this stage, because complementary treatment and medications such as prednisone may be needed. (I have some parents keep a small supply of prednisone at home to begin if their child continues in the yellow zone for longer than a day. The goal is always to nip problems in the bud, before symptoms worsen.
• In the red zone, serious symptoms are present such as breathing hard and fast, being unable to talk easily, blue color or duskiness of the lips, skin or fingernails among other things. During this stage, rescue medicines providing no relief. Peak flow is less than 50% of best. This is a medical emergency. It is time to get to a doctor or hospital. Calling 911 to get help is probably the best action.

While this is the basic structure of an asthma action plan, Beating Asthma: Seven Simple Principles offers a more detailed discussion. I also recommend discussing an asthma action plan directly with your family physician.

Thanks again for joining me this week! I truly hope that the topics covered will help you take ownership of your child’s asthma and plan ahead to prepare for (and avoid!) tough times. Be empowered to beat asthma. You can do this. The quality of life will improve for your child and yourself!

I wish you and your family easy breathing!

Treating asthma is a dynamic process, the goal being controlled asthma, which interferes with your life to the smallest extent possible. In the quest to control asthma, medications are also important. The best approach is referred to as “step therapy,” which means searching for the correct level and combination of medications to keep your child’s asthma in control. Remember, when control is achieved you will need rescue medicine twice a week or less; nighttime asthma symptoms occur fewer than two times a month, and you will use fewer than two canisters of rescue inhaler in a given year.

Let’s look at how step therapy works.

Quick relief. The medication common to all treatment plans is the rescue or quick relief medication: short acting bronchodilators, used when acute symptoms such as cough, wheezing or chest tightness occur. A metered dose inhaler or nebulizer can deliver them. Albuterol and levalbuterol are the short acting rescue medications most commonly used today.

Anti-inflammatory. Medications are stepped up to the next level when treatment with short acting bronchodilators doesn’t suffice. Most commonly these are some type of inhaler steroid or anti-inflammatory inhaled drugs. Pulmicort, Flovent, and Asmanex are common brand names. Often times the medication known as Singulair (montelukast) is used instead of the inhaled steroids. Asthma in children can often controlled using just the first and second steps of therapy.

Combos. For those whose asthma still isn’t controlled, the next step is known as combination medications, which are the pairing of an inhaled steroid with a long acting bronchodilator. Common brand names include Symbicort, Dulera and Advair. This is the final step for most children, and no further steps up need to be taken.

Once control is achieved, your child should be maintained at this step for a period of time (my personal preference is 6-12 months) and then an attempt should be made to step down to the next lowest level of therapy. If successful, this level should again be continued for a period of time before attempting further reductions. The idea is always to use the least amount of medications while maintaining your child’s asthma in “controlled” mode. Again, this whole process is dynamic – after all, your little one is growing and changing every day – and must be individualized for each child treated.

Do you have questions about your child’s medication regimen? Share your concerns here, or, for further reference, check out the in-depth information on asthma medications in my book, Beating Asthma: Seven Simple Principles.

Thanks for reading. As always, I am interested in hearing your thoughts!

Thinking back to childhood, I still have great affection for my physician, Dr. Judge. Visits to him never seemed rushed. He always carefully listened to my mother (and me), performed an unhurried physical examination, and patiently explained the diagnosis and treatment to us in his quiet office, which was attached to his family home. He was always kind and respectful. His only employee was a registered nurse, Janet, who always wore a clean, white, crisply starched uniform and cap. She greeted us when we entered the office, brought us back to the examination room, administered injections as well as assisted with procedures, and collected our payment before we left the office.

Fifty years later, these strong memories remain. Who cares? You might ask. That was then; this is now. What does this have to do with me? I understand. No one wants to live in the past.

My point is this: The qualities that Dr. Judge embodied which made him a good physician back then, make for a good physician today – and probably have from time immemorial.

Many things change over time and physicians today are busier than ever, for a myriad of reasons. In addition to an explosion in medical knowledge, insurance company and governmental regulations have expanded the demands on private practices, adding to the stress on the relationship between physicians and those they want to help. Still, you should expect your physician to exhibit some essential relationship skills (in addition to having good current medical knowledge and technical know-how). These include active listening skills, an unrushed demeanor, an ability to explain things free of medical jargon, and an ability to be nonjudgmental.

But there are also things that you, the patient or parent, can do to improve your communication with your health care provider.

Be prepared for your office visit. Write down the questions you would like answered. Then remember to use your list. Sometimes, when you are confronted with a difficult diagnosis or your child has just experienced a scary asthma attack, you may not be as together, calm or receptive as you normally would be. That’s why preparation is essential. A written list of questions can guide you during those moments when overwhelm is at a maximum. (Of course, try to keep it under two single-spaced, typewritten pages, so you don’t scare your doctor off!)

Questions attract, statements repel. Many of us, myself included, might be prone to point out behavior that we do not find helpful by bluntly making a statement about it. On the other hand, we are all inclined to give a thoughtful response to a question posed to us. For example, your physician explains something using medical jargon and it blows right by you. You could respond by making a statement such as, “That was complete gibberish, and I didn’t understand a thing” – sounding just a tad confrontational. Alternatively, you could say, “Gee, doc, I didn’t quite understand the last statement you made. Would you repeat that again to help me understand better?” You are likely to get (1) a more friendly response from your physician by asking the question and (2) meet your goal of understanding the diagnosis, treatment, etc.

In my lifetime, I’ve been on both sides of that conversation, and I’ve had my own favorable experiences (Dr. Judge) and not-so-favorable ones. How have you handled the rough patches in your relationship with your physician? Please share your tips!

Historically, asthma has been looked upon as a disease of weakness. Sadly, this misunderstanding persists today among some people. This belief is a myth. Asthma is a chronic illness of the lungs. One need not look very far to find examples of strong leaders, athletes and others vigorous individuals who have been afflicted with asthma and yet excelled in their lives.

What exactly happens in the lungs with asthma? We know that genetic as well as external factors play a role in causing asthma, but research has not yet explained why asthma affects one person and not another. We do know that several key reactions occur in the lungs. First, the airways are twitchy and respond in an exaggerated manner to various triggers such as allergens, smoke, air pollution, and strong odors. The smooth muscle in the airway wall contracts and narrows at the presence of a trigger. Next, asthmatic lungs become inflamed and produce an overabundance of mucus. This chain of reactions make it difficult to breathe and produce coughing and wheezing.

Knowing all this, the cornerstone of bringing your or your child’s asthma under control lies in preventing exposure to your asthma triggers in the first place. Although there are general asthma triggers, each individual is unique, and the first step is to identify the triggers associated with your child. By reviewing your past experiences with asthma, you should be able to identify key triggers. If you are the parent of a child with asthma, my experience has shown that you are already quite savvy when it comes to this. As experts in your children, you may have already associated critical triggers with worsening asthma. If you need additional help evaluating triggers, speak with your pediatrician or an asthma and allergy specialist.

Here are some strategies you might pursue to avoid asthma triggers:

• Pets: If you know that cats or dogs trigger your child’s asthma, having one in your home can be a major problem; visiting family or friends with animals that are known triggers for you can also be problematic. Know that simply keeping the pets out of sight is not enough since these allergens may remain present and active six to 12 months after an animal is out of the home.
• Air pollution: Ozone is a common pollution component, and when levels are elevated, such as on hot, windless days in urban areas, restricting outdoor activities becomes a must. The EPA’s websitehas helpful information on ozone. Respiratory infections can act as triggers, especially the influenza virus. This is why the influenza vaccine is recommended yearly for everyone with asthma.
• Smoke: Cigarette smoke is an obvious trigger to avoid, but even smoke from campfires and barbecue grills can spark an attack and must be avoided. That does not mean you can’t camp out or enjoy an afternoon barbecue – just be aware of the smoke and stay upwind!

One final thought. Others may judge you as being too uptight or overprotective of your child when you are diligent about avoiding triggers. Ignore it. By avoiding triggers you can avoid an asthma attack. Your actions in the moment can make the difference between a peaceful night at home and a crazy rush to the ER. Stick to your guns!

Come with me on a journey into the life of a young child with asthma: Feel what they feel when their asthma strikes.

It is nighttime and you are comfortably sleeping. Suddenly you begin to cough, and you awaken feeling as if you can’t breathe. As if your lungs are being painfully squeezed or something heavy is sitting on your chest. You try to take a deep breath but cannot. You are frightened and struggling for air. Still in the fog between sleep and being fully awake, coughing and wheezing, panic grips you, making breathing even more difficult. At a deep level you feel as if you might die. You slide out of bed and hurry to your parents’ room, seeking help and comfort. Gasping for air, and it… is… hard… to… speak. You want these terrible feelings to stop, to be able to breathe easily again. Mom and dad wake up and move into action. They prepare your asthma nebulizer, meaning help is on the way. Slowly, ever so slowly, you feel the tightness begin to subside as you breathe in the soothing medication mist. You relax, and the weight is lifted from your chest. The attack has subsided, but the fear that it could happen again at any time stays in your memory.

A frightening experience, this not-uncommon scenario is one of the faces of uncontrolled asthma. In addition to sleep disturbance, asthma results in thousands of unexpected doctor visits and ER visits; missed days of school and work; hospitalizations; an inability to engage in daily activities; and, at its worst, death for 4,000 Americans each year.

But people with asthma shouldn’t feel resigned to living with uncontrolled asthma. Asthma can, and should be, controlled.

Well-controlled asthma allows full participation in life. It rarely if ever disturbs your sleep, sends you to the ER, hospitalizes you, disrupts your daily routine, or frightens you. When asthma does begin to tilt out of control, there are often warning signs that develop early on that, when recognized and acted upon, greatly reduce the chance that an asthma attack will surprise you.

Dr. Mark Millard, a pulmonary specialist at Baylor Health System in Dallas Texas, developed a set of questions known as the “Rules of Two,” an easy-to-use tool to help you recognize when asthma is not well-controlled and action is necessary. Each question involves the number two, hence the “Rules of Two.” I use these every day in my asthma practice.

When asthma is controlled,

• You use your rescue medication (bronchodilator inhaler) fewer than twicea week
• Nighttime asthma symptoms occur fewer than twotimes a month
• You refill your rescue inhaler prescription fewer than two times a year

If one or more of these guidelines are not being met, that should serve as an alert that asthma is no longer well-controlled, and it’s time to take action to head off future problems. You may want to visit your physician for further evaluation, treatment, and a possible an adjustment to your medication regimen.

Please keep the Rules of Two in mind for your child with asthma. They are a first, critical step in shifting away from the frightening surprises of uncontrolled asthma and moving toward the relative calm and peace of mind that comes with controlled asthma.

I would love to hear your thoughts on how the “Rules of Two” work for you!

What happens when women with asthma get pregnant? Does their asthma get better or worse? Should they use more asthma medicines when pregnant? Or less? How does the asthma itself affect their babies? The current state of evidence appears in the January 2005 Journal of Allergy and Clinical Immunology. Asthma is more common in pregnant women than previously thought, affecting up to 1 in 12 pregnant women – and the number is rising.

Careful study suggests that during pregnancy asthma improves significantly in about 23 percent of women, stays the same in about 47 percent and gets worse in about 30 percent. Most pregnant women appear to be under treated for their asthma, partly because of legitimate concerns about medication use during pregnancy. But untreated asthma is associated with a higher rate of problems for the baby than is asthma that is treated with the right medications. A number of studies have shown that, used correctly, the short-acting inhaler albuterol and inhaled steroids, especially budesonide (Pulmicort), can be safe and effective during pregnancy. There is not enough data yet to be sure about other inhaled steroids and other long-acting inhalers. Oral steroids are better to avoid, if possible. These findings have all been taken into account in the new evidence-based guidelines for managing asthma during pregnancy published in this issue of the journal. If you have asthma during pregnancy you may want to review the latest guidelines with your doctor.

Changes in the home environment can be as powerful as medications in treating asthma, according to an exciting study in the September 9, 2004 New England Journal of Medicine. Researchers in the Inner-City Asthma Study Group followed almost 1,000 elementary school children with allergic asthma severe enough to require at least one hospitalization or two emergency visits. The study lasted for two years.

Half of the children received routine asthma treatment. The other half had 5 to 7 home visits by environmental counselors during the first year of the study in order to identify and reduce allergens in the home. The visitors looked for dust mites, passive smoking, cockroaches, pets, rodents, and mold, and helped with home changes depending on the child.s allergy skin testing. Part of the plan included creating an environmentally safe sleep zone for the child. Allergy covers were placed on the mattress, box spring, and pillows of the child’s bed. The environmental counselors gave the families a vacuum cleaner equipped with a high-efficiency particulate air (HEPA) filter and either a power brush if the child’s bedroom or family room was carpeted or a bare-floor brush and instructed in its use. A HEPA air purifier was set up in the child’s bedroom if the child was exposed to tobacco smoke, allergic to cats or dogs, or sensitized to mold. For children sensitized and exposed to cockroach allergen, professional pest control came. The results were outstanding, both during the year of the visits, and the following year.

The benefit of the changes translates into 34 fewer days with reported wheeze during the 2 years of the study, compared with similar children who did not have the home changes. They also averaged missing almost 2 weeks less school during the two years, and four fewer urgent or emergency visits for their asthma. This effect is similar to what we see from inhaled steroid medicines for asthma.

Aren’t all these changes expensive? If you add together the all the equipment and professional services costs, the environmental changes cost about $1,500 to $2,000 per child. This is about the same as the cost of two years of an inhaled corticosteroid and albuterol for a child with moderately severe asthma. The benefit of the environmental changes lasted for at least a year after the visits. If the benefits continue longer, the cost per year of benefit would be even lower. And these same changes could be implemented by many families at much less expense. Keep in mind, though, that the effort to address multiple possible triggers in this study was much more effective than previous studies where only a single change was made.

For my own child, I would want to do all I could to create an environment that reduced the triggers of his asthma. I expect this would decrease the medicines needed to keep his asthma under optimal control. When possible, I prefer addressing causes to treating symptoms.

Although childhood asthma has been increasing in recent years, children with higher blood levels of important antioxidant nutrients are less likely to develop asthma, according to a large study in the February 1, 2004 American Journal of Respiratory and Critical Care Medicine. The study looked at over 6,000 children aged 4 to 16 years.

Separate analyses showed that those in the top 16 percent of vitamin C, beta carotene, and selenium in the blood tests were all 10 to 20 percent less likely to develop asthma than their peers. Even more dramatically, high selenium levels cut the risk of asthma in half among children exposed to tobacco smoke. Selenium is found in many foods, including meat, seafood, eggs, bran, whole wheat, oats, walnuts, garlic, and brown rice – it is often destroyed in food processing. Beta carotene gives yellow and orange fruits and vegetables their vibrant colors. It’s also in green leafy vegetables. Getting it in the diet is far more effective than any vitamin or supplement. Vitamin C is abundant in many foods, including citrus fruits, greens, broccoli, sweet potatoes, bell peppers, tomatoes, cantaloupe, and strawberries. This study is another good reason to help our children to enjoy eating delicious whole foods – fruits, vegetables, grains, nuts, and lean sources of protein.

If children take standard amounts of inhaled steroids to prevent asthma flare-ups, do they end up shorter than their peers?

We know that conventional doses of inhaled steroids can slow the rate of growth in children, but it turns out that there is little if any effect on their eventual adult height, according to a comprehensive analysis of the available long-term evidence published in the January 2004 Archives of Diseases in Childhood.

A conventional dose would be up to 400 micrograms per day of beclomethasone, or the equivalent. Untreated moderate asthma delays puberty by about 1 year 4 months. Treatment with inhaled steroids results in children.s achieving their predicted heights . no different from non-asthmatics. The study leaves open the possibility that severe asthma might decrease adult height, but by no more than ½ inch. The long-term benefits of using inhaled steroids to control asthma appear to significantly outweigh the long-term side effects. Children with asthma deserve a proactive treatment plan to reduce their flare-ups and to minimize the effect of their asthma on their lives.

If your child has asthma, or might have asthma, you may want to learn all you can about it rather than relying on the bits and pieces you learn at office visits or in the ER. Besides giving your child better care, this may result in happier, better behaved kids, according to a study in the September 2003 Journal of Allergy and Clinical Immunology.

The less that parents are familiar with asthma (especially from having asthma themselves or having it in the family), the more likely that the children will develop behavioral difficulties. Parents may expect too much from their kids. On the other hand, they may back off from expectations because the child has asthma or because they don’t want to provoke a wheezing episode.

Learning to understand asthma and to approach it with calm, capable confidence is a great gift to yourself as well as to your child.