Taking Control of Asthma : A Comprehensive Prevention and Treatment Plan for You and Your Family

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Here, at the start of the twenty-first century, we find ourselves witnessing two seemingly contradictory trends in the world of asthma care. We find asthma becoming more common and more severe in

our country and in many of the Westernized nations of the world. More people are developing asthma. More people are being hospitalized for treatment of severe flare-ups of asthma, and more fatal episodes of severe asthma are occurring. At the same time, our understanding of the underlying processes that make asthmatic air passageways behave the way they do has grown enormously, and better, easier-to-take treatments have made their way to our pharmacies. New, highly effective, and convenient therapies for asthma are widely available.

It wasn't very long ago -- 20 to 30 years ago -- that asthma was conceived of primarily as a disease of episodic spasm of the involuntary muscles that surround the breathing tubes, a concept understood by the Roman physician Galen nearly 2,000 years earlier. Many physicians didn't consider asthma to be a terribly serious disease. A famous physician, Sir William Osler (1849-1919), commented: "Asthmatics don't die, they just pant into old age." We sometimes still hear of the asthmatic tendency being attributed, erroneously, to emotional stresses and difficult child-parent relationships. Our treatments have focused on medications that cause the bronchial muscles to relax -- "bronchodilators." Even today, our schools and playgrounds are filled with asthmatic children who carry medication inhalers to deliver bronchodilator treatments when they are feeling short of breath or tight in the chest.

Our medical understanding of asthma has advanced dramatically over these past 20 to 30 years. We now understand asthma to be a chronic inflammatory condition of the bronchial tubes. The type of inflammation characteristic of asthma has the appearance of an allergic response. Great strides have been made in identifying what cells and chemicals in the body participate in this allergic-type reaction, and what stimuli produce it, in susceptible individuals. We now see that contraction of the muscles surrounding the breathing tubes is a manifestation of chronically inflamed asthmatic airways. The inflammation and the susceptibility to spasmodic narrowing of the breathing tubes persist even when someone with asthma feels well -- that is, totally free of symptoms.

In people with more than very mild asthma, treatment now focuses on suppressing the allergic inflammation of the breathing tubes. Safe and effective medicines, taken once or twice daily, can reduce asthmatic inflammation, inhibit contraction of the bronchial muscles, andpreventnarrowing of the air passageways. For a time, the best medicines available to treat asthma included theophylline, a not-so-distant relative of caffeine. Imagine taking -- or giving to your asthmatic child -- a caffeine-like substance just before bedtime to maintain comfortable breathing overnight! There was also a time, as we started to focus on treating inflammation of the bronchial tubes, when we asked some of our patients to inhale anti-inflammatory medicines in doses of 6 to 12 sprays at a time. Now it is a rare patient who needs more than two inhalations twice daily to keep asthma under good control.

Because of the tremendous advances in understanding and treating asthma, our book has good news to share, and also carries a message of great optimism for the future. The vast majority of people with asthma can achieve good control of their illness with currently available medications. Only a small minority cannot.

But a small part of a very large number -- say, for example, 1 percent of the estimated 15 million Americans with asthma -- is still a large number of people with persistent, difficult-to-control asthma. For this group there is also reason for optimism, because we stand on the threshold of a new age of asthma therapies with the emergence of biotherapeutic drugs specifically designed to interrupt individual steps in the allergic response. In our chapter on new and future asthma therapies, we also consider the emerging field of pharmacogenetics, which is likely to yield information that will make it possible, before a prescription is written, to predict your response to different antiasthmatic medications based on analysis of your unique genetic profile.

A parallel revolution in medicine over the last 20 to 30 years that is relevant to asthma has to do not with scientific knowledge or new medical breakthroughs but with the fundamental human interaction at the heart of the delivery of medical care: the patient-doctor relationship. Patients have become more active participants in their own care, making informed decisions under the general guidance of their physicians. Nowhere is this collaborative interaction between patient and physician more appropriate than for a chronic condition with potential, often unpredictable flare-ups, such as asthma. Again and again in studies conducted in the last two to three decades, educational programs teaching asthma comanagement skills have been shown to improve health outcomes and patient satisfaction.

The more you know about asthma and its treatments, the better the choices you make in caring for your own or your child's asthma. It is a good feeling to understand what is going on in your body, to know how to respond to signals that your body sends, and to breathe better again as a result of your actions. As you will hear in the voices of our patients throughout this book, feeling in control of your asthma -- rather than feeling overwhelmed or frightened by it -- builds confidence and a greater sense of security. This book is intended to share with you the knowledge and skills you need to gain control over your asthma, so that you can participate with your health care provider in making sound judgments about your asthma management.

This book is organized into three sections. The first section reviews what asthma is, how it is diagnosed, and how you can judge its severity. It also explores potential explanations for the rising prevalence of asthma in our communities. The second section describes in detail the medications and other forms of treatment available to treat asthma. It emphasizes practical details, including how to take your medications effectively, what short-term and long-term side effects to expect, and what relative advantages and disadvantages each medicine has. The third section guides you through strategies for managing your asthma, both on a day-to-day basis and when faced with flare-ups of your symptoms (asthmatic "attacks"). It includes information about managing asthma under special circumstances (for example, in very young children, in the elderly, and during pregnancy) and what to consider if your asthma isn't getting better. Toward the end of the book, we encourage you to develop -- with your physician -- your own asthma "action plan."

Medicine is both art and science. This book contains many opinions as well as factual information. These opinions reflect the views of the authors, who take responsibility for any errors or omissions this book may contain. At the same time, our views and practice patterns did not form in a vacuum. They have been shaped by our reading of the medical literature, by our experiences in the practice of medicine, and by our discussions with our colleagues. We are privileged to practice at an academic medical center surrounded by outstanding allergists and pulmonologists (and other related specialists) skilled in the treatment of asthma. We practice at the Partners Asthma Center, a center for excellence in asthma care that is part of the Partners Healthcare System in Massachusetts.

In 1989 allergists and pulmonary specialists at Brigham and Women's Hospital in Boston began a collaboration in asthma clinical care, to complement a long history of collaboration in asthma research. When the Brigham and Women's and Massachusetts General Hospitals formed a partnership in 1994, called Partners Healthcare, we expanded our collaboration to include allergists and pulmonologists at both hospitals. As a result, our expertise extended to children as well as adults, and we became the Partners Asthma Center. Over the years additional hospitals have joined the Partners Healthcare network. Asthma specialists at Faulkner Hospital, Newton-Wellesley Hospital, and North Shore Medical Center have joined with us in an expanded Partners Asthma Center that now comprises approximately 50 physicians, together with asthma nurses, nurse-practitioners, and respiratory therapists.

The stated mission of the Partners Asthma Center is:

To provide optimal medical care for persons with asthma and related diseases, to develop new knowledge about asthma and its management through state-of-the-art medical research, to train medical students and graduate physicians in the specialized skills of asthma care, and to promote improved understanding about asthma and related diseases through educational programs and materials for our patients, for other health care providers, and for the community.

We are grateful for the opportunity to further our mission at the Partners Asthma Center with the publication of this book. We invite you to communicate with us directly at asthma@partners.org and to visit our Web site at www.asthma.partners.org. And we wish you healthy breathing.

Christopher H. Fanta, M.D.

Lynda M. Cristiano, M.D.

Kenan E. Haver, M.D.

July 2003

Copyright © 2003 by the President and Fellows of Harvard College

Chapter 17: Testing Your Skills for Dealing with an Asthma Flare-up

Our goal, like yours, is that you never have an asthma attack -- or, at most, very rarely. At the same time, as we have emphasized in Chapter 16, we want you to be prepared and to know what to do to help yourself if an asthma attack occurs. In collaboration with your doctor, you need to develop your own Asthma Action Plan, and perhaps share some of this information with family members or close friends.

Having read this book, you should have -- and it is important that you do have -- a clear idea of what steps to take in the event of an attack of asthma. For example:

• What would you do first for a mild or moderate attack?
• What would you do if you didn't quickly get better?
• What would you do if you were suffering a severe asthma attack?
• What if the initial treatment didn't work?

Here we invite you to practice your responses to a flare-up of asthma by giving you some made-up case examples and asking what you would do. Some of these examples may mirror your own situation closely. Others may not be relevant to your asthma, or may involve treatments that you do not have available to use at home, at least today. Going through these situations will give you confidence that you can deal effectively with an asthma flare-up under various circumstances, should one occur.

Part of that decision making is knowing when to seek help. Remember that, as we emphasized in Chapter 16, managing asthma attacks does not mean having to stay at home and care for your asthma by yourself. Rather, it means two important things: first, knowing what initial steps you can take to get better, and second, knowing when, where, and how to get help quickly when you need it.

Situation #1: The Head Cold

Imagine that your asthma has been generally well controlled. You take a steroid inhaler (two puffs twice daily) to keep it under control. Most days you do not need your quick-relief bronchodilator (albuterol) inhaler at all. Other days you use it perhaps once or at most twice in a day, although you always carry it with you.

Last week you had a head cold, as did other members of your family. You had a low-grade fever for two days, with a sore throat and nasal congestion. Earlier this week your cold seemed better, but you started coughing a lot. Last night you were awakened repeatedly with coughing and slept poorly. You used the albuterol inhaler twice during the night, with some relief.

Today you are still coughing and raising clear phlegm (resembling egg white). In addition, you find yourself short of breath with even light exertion, such as walking 50 feet. You use your albuterol inhaler again, but it doesn't seem to help for more than about five minutes. You check your peak flow with your peak flow meter. You are dismayed to find that your peak flow is only 180 liters per minute, less that half your usual (400 liters per minute).

Sizing Up the Situation

This episode is more than just a bad cold. It is a severe asthma attack. It is not normal for a routine chest infection to cause shortness of breath when you walk only a short distance. In this example, a head and chest cold has caused a flare-up of underlying asthma. The low peak flow value, less than half the usual value, confirms that this is a severe attack, in the "red zone" (see Chapter 16).

Important Things to Know and Do

• If you have a compressor and nebulizer system at home (see Chapter 5), this would be a good time to use it to deliver a quick-relief bronchodilator (such as albuterol) by continuous mist.
• If you don't have a compressor and nebulizer, use your quick-relief bronchodilator inhaler with a spacer (to maximize delivery of the medication to the airways) and take four puffs, spaced one minute apart.
• If you don't have a spacer with you, use the inhaler as carefully as you can without one. You can continue to take your quick-relief bronchodilator (by nebulizer or by inhaler) every 20 minutes for one to two hours if needed. We ask parents of children with asthma flare-ups to call us if they have had to give their child two consecutive treatments.
• If you continue to have intense symptoms of asthma after using your bronchodilator two to three times, you can be certain that a major part of the problem is swelling of the bronchial tubes and filling up of the bronchial tubes with mucus. The air passageways are severely inflamed, and no amount of bronchodilator alone will treat this part of the problem. You need corticosteroids (steroids for short) to treat the swelling and inflammation of your bronchial tubes (see Chapter 6).
• When you are having a severe attack like this one, it is generally necessary to take steroids by mouth as tablets. Your doctor will probably want to prescribe prednisone, prednisolone (Prelone, Pediapred), or methylprednisolone (Medrol). You should call your doctor (or covering physician) immediately to discuss your condition and possibly get a prescription for steroid tablets or liquid. Be sure to measure your peak flow before calling. Reporting your peak flow value to your health care provider will help him or her gauge how severe the attack is and how best to respond to it.
• If you have previously had a severe attack of asthma, your doctor may have given you some steroid tablets to have at home; this would be a good time to take some, perhaps 30 to 60 milligrams. You should also plan to notify your doctor that you are ill and that you have begun a course of steroid tablets.
• Steroid tablets usually take several hours (two to six hours) to begin to exert an effect. You can continue to use your bronchodilator (for example, albuterol inhaler) as often as every hour while waiting for the tablets to take effect. You should rest and relax as much as possible. As long as your breathing (and peak flow) are steady or improving during this time, you will do fine.
• On the other hand, if your breathing is getting worse, you will need to seek emergency help. Quickly get to a nearby urgent care center or emergency room.A severe asthma attack can be dangerous, especially if you are getting worse despite frequent use of your bronchodilator.
• Here are the things that would make you or a family member want to call 911 for an emergency rescue team:

  Being unable to speak more than a word or two because of shortness of breath

  Passing out or nearly passing out

  Developing a bluish discoloration of the lips and skin due to lack of oxygen

  Having a peak flow of less than 100 liters per minute

Situation #2: The Neighbors' Cat (Part One)

Imagine that as part of your asthma you have multiple allergic sensitivities, including to cats. Nonetheless, you have been feeling well this fall, taking two inhalations twice a day of your steroid medication (except when you fall asleep without remembering your evening dose!). You are active and enjoy working out at the gym. You routinely use your bronchodilator inhaler before exercising but otherwise rarely seem to need it. Sometimes you wonder whether you still have asthma at all.

Today you are invited to your neighbors' home for dinner. They took in a stray cat last month, but because of your allergies they promise to keep the cat outside or in the basement during your visit.

The evening seems to be going fine, until you sit on a certain sofa. Soon thereafter you begin to sneeze and to develop watery, itchy eyes. You feel a tightening in your chest and itching below your chin. You use your bronchodilator inhaler once but get only minor relief. You start coughing and raise some clear mucus. Your neighbors offer you some water.

Sizing Up the Situation

Most likely, you're allergic to something in your neighbors' house, probably cat dander on the sofa and elsewhere (see Chapter 4). The best first step in treating an asthma attack caused by an allergic or irritant trigger is to remove yourself from exposure to the trigger, if possible. So step one in this situation would be to leave the neighbors' house.

Important Things to Know and Do

• In this situation, it is safe to use your bronchodilator inhaler more often than the usual limit of four to five times a day (see Chapter 5). If necessary, you can take it every 20 to 30 minutes for one to two hours or until you feel more comfortable.
• If it's available, use your peak flow meter to check your peak flow (see Chapters 2, 3, and 16). It will help you judge how severe this attack is. You may be able to estimate its severity by how you feel, especially by how breathless you are as you walk around. However, sometimes you can be fooled. The greatest concern is that you might underestimate just how sick you really are. Many people tend to minimize their symptoms, not wanting to admit that something might be seriously wrong.
• If you check your peak flow and find it to be more than half of your personal best value, you can be reassured that this is a mild-to-moderate attack (green or yellow zone). If your peak flow is less than half of your personal best value, you are having a severe attack (red zone), in which case you will need to exercise greater caution and seek more intensive treatment.

Situation #2: The Neighbors' Cat (Part Two)

When you arrive back home from your neighbors' house, you find that you can walk up to your second-story apartment without much shortness of breath. You continue to experience some coughing and wheezing. You use your quick-relief bronchodilator again, and soon thereafter you check your peak flow. It is 400 liters per minute, whereas normally your peak flow is quite steady at 500 liters per minute.

Sizing Up the Situation

A good strategy for treating a mild-to-moderate asthma attack, such as this one, is to double your usual daily dose of inhaled steroids. In this example, you would begin taking four puffs twice daily (or two puffs four times a day) of the steroid inhaler. The results are usually not as rapid and dramatic as with steroids in tablet form, but side effects are far fewer.

Important Things to Know and Do

• Sometimes the asthma response to an allergic stimulus (such as breathing in cat dander) can be delayed, reaching its maximum 6 to 12 hours after the initial exposure. Even after initial improvement, there may be subsequent worsening, referred to as a "late asthma response." Be on your guard during this time frame.
• By removing yourself from the cat dander and increasing your dose of inhaled steroids, your asthma will most likely come back under control over the next day or two. During this time, keep extraclose watch on your asthma symptoms and, if possible, your peak flow.
• If you are not getting better, contact your medical provider. If youareimproving, continue the extra puffs of the inhaled steroid for three to four more days, and if you are then all better, resume your usual dose.
• This example illustrates a good general strategy for using your inhaled steroids: increase the dose when your asthma is poorly controlled, and decrease the dose to the lowest amount sufficient to control symptoms and prevent attacks when your asthma is well controlled. Choosing the appropriate doses should be done with your doctor.

Situation #3: Home Improvements

You have exercise-induced asthma, meaning that you have asthma and that exercise is the main trigger that brings on narrowing of your airways.

Your doctor has given you a pirbuterol (Maxair) inhaler to take before you exercise in order to prevent your symptoms of coughing, wheezing, and chest tightness. If you develop any of these symptoms at any other time, you use the inhaler (usually one puff is sufficient) and obtain rapid relief.

This week the workmen have come to begin long-awaited renovations on your bedroom. There is a lot of plaster dust in the air, and you find yourself coughing at night. You don't think much about it (your spouse, who doesn't have asthma, has also had some coughing) until you develop a low-grade fever and a miserable "head cold." Your coughing now keeps you (and your spouse) up most of the night. You can't lie down in bed without becoming short of breath. Each breath is accompanied by an uncomfortable rattling in your chest. It is difficult to talk or do any light physical exertion without provoking long bouts of coughing.

You suspect that this severe coughing and chest congestion may be a sign of your asthma. You borrow your daughter's peak flow meter to measure your breathing capacity. The peak flow result, 300 liters per minute, is only two thirds of the value measured when you were in your doctor's office. You use your quick-relief pirbuterol inhaler and it helps. The coughing lessens and your peak flow increases to 330 liters per minute. However, 30 minutes later you are again coughing severely, and your peak flow is now 280 liters per minute.

Sizing Up the Situation

Get help! You are having a serious asthma attack, and the medication you have available to treat asthma, the pirbuterol inhaler, is not providing more than very temporary relief. You will need stronger therapies both to get better and to prevent getting worse, possibly dangerously ill.

Important Things to Know and Do

• Many people in these circumstances report that their quick-relief bronchodilator "stopped working." In fact, what has probably happened is that the bronchial tubes have become swollen and filled with mucus. The problem is no longer just spasm of the muscles surrounding the bronchial tubes, and the solution can no longer be just a medicine that causes those muscles to relax. You now need an anti-inflammatory medicine -- a steroid medicine -- to reduce the swelling and excess mucus production (see Chapter 6).
• The action that you take will depend on the health care resources available to you at that moment. You might call your doctor and get advice immediately, make an urgent visit to your doctor's office, or go to a nearby emergency department or other urgent care facility. Do not delay. The danger in waiting is that your asthma may worsen quickly, perhaps to the point that every breath becomes an effort and that even walking slowly seems like an impossible task.
• While you await a callback from your doctor or during your trip to a medical facility, you can continue to use your quick-relief bronchodilator inhaler. It will probably continue to help a little bit for short periods. You can take up to four puffs at a time, every 20 to 30 minutes for the next hour or two, until other medical treatments are begun (see Chapter 5).
• However, don't rely solely on the temporary improvement that your pirbuterol (or albuterol) inhaler provides. This is the most common mistake made in severe asthma attacks, the very bad attacks that end in hospitalization or even death. The brief, minor help in breathing that the quick-acting bronchodilator gives can fool you into thinking that you are getting better. Or it may convince you that you will start getting better soon. All the while your bronchial tubes continue to swell and become plugged up.
• Steroid treatment for swelling of the bronchial tubes works better and faster when started early. In this example, with the help of the peak flow meter, you can tell that you are getting worse, not better. There is no need to wait longer. Avoid the excuses, such as "I hate to bother the doctor," or "I'm sure that I will get better if I just rest for a little bit." Start now to get the medical treatments you need.

Situation #4: Blowing in the Wind

This spring has been particularly difficult for your asthma. The grass and tree pollens to which you are allergic seem to coat every surface, indoors and out. Your asthma, more troublesome over the last year or two, has become particularly severe in the last week. You have been coughing up pale yellow sputum, wheezing off and on, and feeling breathless when climbing stairs.

When you go to bed everything seems okay, but you wake up at three in the morning with the feeling that an elephant is sitting on your chest. It is difficult to pull in air. Every breath seems an effort. You sit up in bed, reach for your quick-relief bronchodilator on your bedside table, and then wait for some relief. You begin to think about what options you have if the inhaler does not help.

You take a lot of medicines on a regular basis for your asthma. You take an inhaled steroid twice daily, theophylline twice daily, a leuko-triene blocker in the evening, and prednisone, currently 10 milligrams every other day. You also have an over-the-counter antihistamine-and-decongestant combination that you use twice daily.

After 20 minutes you feel only a little bit better. You get out of bed, walk slowly to the kitchen, and make yourself some tea. Even though the doctor specifically mentioned that if you needed help you could call at any time, you are reluctant to call at this hour of the morning. You consider what else you might take for your asthma.

Sizing Up the Situation

With so many asthma medicines at your disposal, you may be tempted to take extra doses of some or all of them. Consider carefully. Some (for example, the leukotriene blocker, such as montelukast [Singulair]) won't help in a crisis; others (such as theophylline) are potentially dangerous if you take too much. In this situation you will need more of the anti-inflammatory steroids, most likely more of your prednisone.

Important Things to Know and Do

• You should never feel hesitant to call your doctor late at night in an emergency, especially if he or she has told you to do so. A severe asthma attack is a medical emergency, and your doctor, or another doctor covering for your doctor, is there to help in a crisis.
• In an asthma attack, your best options are a quick-acting bronchodilator (see Chapter 5) to open the constricted muscles surrounding the breathing tubes, and steroids to reduce the swelling (inflammation) in the walls of the tubes.
• Extra theophylline, a long-acting bronchodilator (see Chapter 7), may help somewhat, but it is risky to take without knowing how much theophylline is already in your bloodstream. Too much theophylline can cause unpleasant side effects (headache, nausea, vomiting, nervousness, and heart pounding). A very high level of theophylline in the blood can even lead to seizures and serious irregular heart rhythms. It's best not to take extra doses of theophylline without first discussing it with your doctor.
• Extra doses of a leukotriene-blocker medicine (see Chapter 7) such as zafirlukast (Accolate) or montelukast (Singulair) won't effectively treat an asthma attack. These medications are "controllers" of asthma; they are not in the category of "relievers."
• Taking more than the usual dose of your antihistamine-decongestant combination won't help your asthma. It is prescribed for allergy symptoms in your nose and eyes, not as treatment for your asthma.
• If you have one of the long-acting inhaled bronchodilators -- salmeterol (Serevent) or formoterol (Foradil) -- in your medicine cabinet, donotuse it now for quick relief. The effects of these medicines last such a long time that it is not appropriate to use them repeatedly in a crisis.
• For this attack you can take more steroids either by increasing the number of puffs of the inhaled steroid that you take each day (take twice as many as before) or by increasing the dose of prednisone. Which approach you choose will depend on how severe this attack is (time to check your peak flow with your peak flow meter!), your past experiences treating similar attacks, and your discussions with your doctor.
• Often patients who have taken steroids in tablet form for many years try to avoid increasing the dose so as to avoid more of the serious side effects they cause. However, remember that breathing is the priority! It may be necessary to increase the dose of prednisone to 10 or 20 milligramseveryday for a time, then decrease it again when you're feeling better (and when your peak flow has returned to your normal value). Be sure to notify your health care provider if you need to adjust your prednisone dose.
• It will take time (at least several hours) for the increased dose of steroids to start to reduce the inflammation of the breathing tubes. In the meantime, you can use your quick-relief bronchodilator more frequently than is usually recommended (that is, more often than the usual limit of four times a day). If necessary, you can take two to four puffs every 20 minutes for up to two hours, and then two to four puffs every hour. If you find that you do indeed need the inhaled bronchodilator that often, you are having a very severe attack. You should notify your health care provider so that you can get help and advice.
• While you wait for your breathing to return to normal, stay relaxed and breathe slowly and deeply.
• Think about how you can reduce your exposure to springtime pollen in the future (see Chapter 4). A good first step might be to keep the windows closed and to filter the indoor air with an air conditioner or window fan with attached filter. Have someone else do the dusting and vacuuming. If you must do it, clean with a damp cloth, use special filter bags on your vacuum cleaner, and, if necessary, wear a face mask while cleaning.

Situation #5: Trouble in the Nursery

Your 2-year-old son, Robert, has had a difficult night, and so have you. Yesterday he had a runny nose and a low-grade fever. His older brother, now 4 years old, has had a cold, as have many of his preschool playmates, so you weren't surprised when Robert showed signs of the same thing. His nose dripped a thick, greenish discharge, he complained that his throat was hurting him, and he had a rattling-sounding cough. As usual, he was superactive throughout the day; not even the beginnings of a head and chest cold slowed down this ball of energy.

However, around midnight he crawled into your bedroom and into your bed. The poor guy couldn't stop coughing. Sometimes he would cough so hard that he gagged and had dry heaves. He would fall off to sleep for five or ten minutes, then wake again, coughing and fussing. He couldn't get comfortable. You could hear his breathing even while he slept. He breathed through his mouth, and at times he seemed to breathe very fast. While he slept, you counted his breaths, using the bedside clock with its second hand to time exactly one full minute. His breathing rate was 30 breaths in a minute. You recall that a breathing rate of 40 or more breaths a minute while sleeping was meant to trigger an alarm for you. He -- and you -- sleep fitfully.

Dealing with Robert's asthma is a new experience for you. None of his older siblings has had asthma, and his father's asthma went away before you met him, so it has not been part of your married life. It was just six months ago that the pediatrician diagnosed Robert's asthma. She said that his lingering cough with each cold was an indication of asthma, and on several occasions she heard wheezing when listening to Robert's lungs with her stethoscope. She gave you some medicines and instructions, but until now you have not needed them. She even talked to you about possible flare-ups of asthma. You search your memory to recall what she advised for just such an event as this.

Sizing Up the Situation

Having awrittenAsthma Action Plan can help you remember exactly your doctor's advice for how best to handle an asthma attack, even when you are feeling agitated or sleep-deprived. Despite having a written Asthma Action Plan and following its recommendations, if at any time you are uncomfortable about whether what you are doing to treat your child's asthma is the best thing, consult with your doctor or other health care provider.

Important Things to Know and Do

• Robert's severe coughing, chest rattling, and rapid breathing suggest that with this chest cold, which is probably a viral infection like his brother's, he is suffering a flare-up of his asthma. Viral respiratory infections are the most common cause of asthma attacks in young children. Unlike his older siblings, he needs antiasthmatic medications to be included in the treatment of his colds. He should receive his quick-acting bronchodilator and possibly other asthma medicines for his chest symptoms.
• The pediatrician probably gave you albuterol (Ventolin, Proventil) or levalbuterol (Xopenex) as his quick reliever. She may have given you an albuterol metered-dose inhaler with a spacer and face mask, or an albuterol or levalbuterol solution to be administered by a compressor-driven nebulizer. Now is the time to give your child a dose of this quick-relief medication. Even if it may make him a little bit jittery, don't hesitate to give it to him, even in the middle of the night. If his coughing and distress get better, it is likely that he, and you, will sleep better, despite the stimulating side effects of these adrenaline-derived bronchodilators.
• As their descriptive name implies, these quick-acting bronchodilators (see Chapter 5) bring relief quickly. If they are going to help, they will probably do so within five to ten minutes. However, their effect also wears off relatively quickly, usually within three to four hours. If your child continues to have troublesome coughing and seems listless or just not himself, it may be necessary to repeat the dose in three to four hours, and again three to four hours thereafter, continuing throughout the day.
• Your Asthma Action Plan may indicate that when more than one or two doses of the quick-acting bronchodilator are needed, you should begin a controller medicine. You may have a leukotriene-blocker tablet that you can give him (for example, montelukast [Singulair Chewtab]), a steroid spray with spacer and face mask (for example, fluticasone [Flovent] with an Optichamber spacer and face mask), or a steroid solution for your nebulizer (budesonide [Pulmicort Respules]). Continue to give your child the inhaled bronchodilatorin additionto this controller medicine.
• It is possible that your child will not get better, even when you and he follow your Asthma Action Plan to the letter. No asthma plan, no matter how well thought out, is 100 percent successful every time. If your child's condition seems to be deteriorating despite your taking all the appropriate measures, seek help. There are more powerful treatments available for his asthma, such as a steroid liquid to be swallowed (for example, prednisolone [Prelone]). It may be that he needs to be more closely monitored in a hospital setting, where the oxygen in his blood can be measured and where experienced nurses and doctors can attend to his breathing difficulties, day and night if necessary. Part of your Asthma Action Plan should be getting your child quickly and safely to a medical facility when treatments at home are not working.

Copyright © 2003 by the President and Fellows of Harvard College

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Excerpted from The Harvard Medical School Guide to Taking Control of Asthma: A Comprehensive Prevention and Treatment Plan for You and Your Family by Harvard Medical School Staff, Lynda Cristiano, Christopher H. Fanta, Kenan Haver
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.