Implementing preventive measures that focus on the patient’s role in daily monitoring and managing asthma at home can prevent adverse outcomes.

The old adage “an ounce of prevention is worth a pound of cure” was never more appropriate than when considering the need for self-monitoring and management of asthma at home. 

The statistics can be startling: 

• More than 17 million Americans suffer from some form of asthma.1 
• Asthma attacks account for more than 2 million emergency department (ED) visits and 500,000 hospital admissions each year.1 
• More than 5,000 people die each year from asthma, and the number of deaths caused by asthma has nearly doubled since 1978.1,2 
• Direct health care expenses alone amount to more than $17 billion per year, including $1.6 billion for inpatient care and $1 billion for medications.2 

Managing asthma at home is not merely a convenience, it is an absolute necessity. Many hospital admissions and virtually all fatalities from asthma can be prevented with assessment and intervention at home.3 Although there has been an explosion of information available to both clinicians and patients, comprehensive education programs are not always readily available. 

The goal of monitoring asthma at home is to allow patients to manage their condition, so their condition does not manage them. Asthmatics who learn about their condition, follow a daily monitoring routine, and take charge of their condition can expect to be rewarded with fewer exacerbations. They can reasonably expect to experience improvements in lung function, activities of daily living, and quality of life. 

What Patients Need to Know 

Daily peak flow monitoring is the cornerstone of an asthma home treatment program. The daily readings are essential for monitoring the severity of symptoms and the effectiveness of treatment.1,3 Peak flow monitoring provides asthmatics with an important early warning sign that an asthma episode is approaching. When used with a daily log and a clear action plan, peak flow monitoring provides asthmatics with a powerful ally in managing their condition. The patient has a written record of his checks, and the clinician can reinforce the importance of daily monitoring by checking the patient’s peak flow log at regular intervals. 

Although they generally require more coaching, even preschoolers can be trained to use a peak flow meter daily. Regardless of age or behavior modification, creating the habit of performing peak flow checks every day is the greater challenge. 

Ideally, peak flows should be checked twice daily at approximately the same time each day. 

Using a peak flow meter correctly involves: 

• moving the sliding indicator to the “0” position; 
• standing up and filling the lungs with a deep breath; 
• placing the mouthpiece into the mouth, making a good seal around it with the lips; 
• blowing out as hard and as fast as possible (like blowing out birthday candles). DO NOT block the opening or make a “tah” maneuver with the tongue, as this will result in an inaccurate “high” reading; 
• noting the number next to where the sliding indicator has stopped; 
• resetting the peak flow meter to zero and repeating the above maneuver twice; 
• writing the best reading of three attempts in the log. 

Predicted versus Personal Best 

Clinicians can provide patients with a predicted peak flow, based on charts that denote averages based on age, sex, and height.3 “Personal best” is often higher than predicted best and is a reflection of the individual’s best effort on a “good” week, when symptoms are minimal.1 Action plans should be based on personal best, not predicted results.1,3 

Keep a Daily Peak Flow Log 

The Daily Peak Flow Log should include the date, time of day, peak flow (in liters per minute), and any symptoms noted at the time of the test. 

Know Your Zones 

Red, yellow, and green “zones” put the patient’s daily checks into an easy-to-remember context, with 100% representing his personal best. 

Green: >80% of personal best; indicates the condition is under control. The patient should continue the normal management routine. 

Yellow: 50% to 80% of personal best; indicates a worsening condition. This is the patient’s early warning of more serious problems. The patient should institute the action plan developed with his physician. This may include a phone call to the physician and increasing treatments. Patients should be advised not to ignore worsening conditions even if they “feel fine.” 

Red: < 50% of personal best; indicates a medical alert. The patient is having serious problems and should immediately implement the elements of his action plan that correspond to the red zone. 

Know Your Action Plan 

Every patient should have a clear plan of action that corresponds to each zone and was developed in conjunction with the physician. Many peak flow meters include a red, yellow, and green tape that sticks directly on the peak flow meter. Always ascertain that the beginning of the red zone corresponds to 50% of personal best. In other words, if personal best is 600 lpm, the red zone should begin at 300 lpm. The patient’s action plan, complete with appropriate phone numbers, should be kept with or taped on the peak flow meter. 

Keep a Journal 

In addition to a peak flow log, asthmatics should consider keeping a journal for 2 weeks or more. An asthma journal will help the patient and clinician work together to manage the condition at home and avoid exacerbations.2 

A journal should include the following information: 

• how the patient subjectively feels each day; 
• the date, time, and any symptoms; 
• what was eaten; 
• weather; 
• activities; 
• emotional state; and 
• especially note when an asthma symptom was experienced in relation to a potential trigger. 

Know Your Triggers 

Patients should identify and eliminate aggravating environmental triggers. Asthmatics and their families need to clean up the environment at home and at work or school with the greatest emphasis placed on the individual’s most aggravating triggers.3 This means first identifying triggers including: 

Tobacco smoke. Quit smoking and ban it from the home and car. Tobacco smoke is an irritant and decreases mucociliary action. Environmental tobacco smoke exposes passive smokers to carbon monoxide and other toxins, including benzene and formaldehyde. 

Children who live in homes where parents smoke are hospitalized more frequently and have longer hospital stays than do children who live in homes where no one smokes.4 

Carpeting. Remove synthetic carpets (especially in the bedroom) and switch to hardwood or other washable surface. Use removable rugs as needed. 

Pets. Avoid keeping furry pets, especially dogs, cats, and guinea pigs, and birds. 

Cockroaches. Eliminate cockroach infestations—their fecal matter and saliva are allergens.4 

Feather pillows or comforters. Use hypoallergenic pillows and bedding. Wash bedding weekly at >130 degrees to eliminate dust mites. 

Damp basements and indoor molds. Clean and disinfect kitchen counters and shower tile. Eliminate mildew or moldy places. Decrease humidity to < 50%. Make sure air conditioners, furnaces, dehumidifiers, and refrigerators are kept clean and are properly vented. If a humidifier is used in the winter, KEEP IT CLEAN using a white vinegar solution. 

Vacuuming. Equip the vacuum with a high efficiency particulate air (HEPA) filter bag, and, if possible, the asthmatic should avoid being in the room when it is vacuumed. 

Formaldehyde (synthetic carpets, paints, plastics, furniture). Avoid particleboard and especially medium-density fiberboard in furniture. 

Perfumes, deodorants, cosmetics. Avoid using scented sprays, incense, and candles. 

Other potential triggers to consider. Nitrogen dioxide and carbon monoxide (from gas stoves and furnaces); pesticides; volatile chemicals (found in cleaners, shampoos, aerosol sprays, and paint thinner); and wood smoke. 

Patients should consider obtaining an air purifier with a HEPA filter. When selecting a specific unit, remember that the more air it moves, the better. Avoid cheap desktop units. It is most realistic to focus on a single room (the bedroom) where an air filter can impact a finite space. 

Enlist the Help of an Allergy and Asthma Specialist 

If the patient has moderate to severe asthma, or if the physician treats only asthma symptoms and does not work with the patient and family to develop a comprehensive, long-term management plan, a referral to an allergy and asthma specialist should be seriously considered. Multiple hospital admissions, failure to meet the goals of asthma therapy, or a life-threatening asthma attack are strong indicators that the patient’s asthma is out of control and the help of a specialist should be enlisted.1,2 

Learn to be Assertive 

A soccer mom said that when her child began to have an asthma attack during a soccer game, the coach admonished him to “play through it.” The mother offered a second opinion and overruled that call. 

Adults in leadership positions—especially teachers and athletic coaches—need to become knowledgeable about asthma management.3 It will always be difficult for a 10-year-old asthmatic to challenge bad advice from an unwitting adult, but assertiveness training can make a difference. And failure to contradict a teacher or coach could have potentially disastrous consequences. 

The Challenge 

Asthmatics and their families have much to learn about managing the disease, including pathophysiology, medications, environmental factors, and dietary considerations. Most important, they need to understand the importance of managing asthma on a daily basis and anticipating, rather than merely reacting to, exacerbations. The depth and breadth of information available are impressive and the volume of information grows daily. 

Communicating so much essential information, reteaching and reinforcing important techniques such as proper inhaler use and peak flow technique, and providing regular follow-up are often problematic. The acute care setting is often the worst place to address asthma education—patients may be distracted or under stress and clinicians are often under tight time constraints. But when asthma is managed from crisis to crisis, it is often the only education opportunity available for some patients. In the physician’s office, asthma management training may often be limited to a single session, with weekly follow-up consultations impractical or unaffordable. 

Home care clinicians have perhaps the best opportunity to educate patients and families, in the comfort of their own home. However, there is no reimbursement structure to cover the cost of a comprehensive, ongoing education program at home. 

An overriding challenge in each of these settings is that comprehensive asthma training takes time, and time costs money. For all the talk of preventative health care, few insurance carriers seem ready to pick up the tab for providing asthma training to the patients and families that need it. 

However, the need for comprehensive education services for asthmatics is obvious. The benefits of a well-educated and prepared asthmatic population include a reduction in ED and hospital admissions, reduced mortality, and improved quality of life.3 While the value of providing asthma education is easy to understand, hospital systems and insurance carriers are often reluctant to fund asthma education programs in today’s cost-conscious environment. 

Hospital-Based Model 

Northern Colorado Medical Center, Greeley, Colo, has addressed these challenges by developing a comprehensive classroom-based asthma education program. 

The hospital system absorbs the cost of the program, and justifies the expense based on well-documented decreases in hospital and ED visits. Perhaps the enlightened approach of this fledgling program will serve as a model for health care systems nationwide. 

Patients are referred to the program by physicians or when they are admitted into the system with an asthma diagnosis. The program provides patients and families with individual counseling and 3-hour classes each week for 4 weeks. Follow-up is provided at 6 months and 1 year, or more often if needed. 

The classroom setting is more efficient than sending a clinician into each home. It is more relaxed and has less distractions than the acute care setting, and patients and families can enjoy the camaraderie and support that comes from a group setting. 

Paula Schneider, RRT, resource respiratory therapist for the program, said its mission is to “empower patients to manage the disease so that the disease doesn’t manage them.” 

Key points emphasized in the program include: 

• increasing patient knowledge and sense of control over the disease; 
• behavior modification and family counseling; 
• pace breathing and use of relaxation and visualization techniques; 
• learning about medications; 
• understanding the importance of performing daily peak flow checks and knowing when and how to implement action plans. Schneider emphasizes that patients learn that “peak flow checks are the key to the management of your day.” She added that 90% of patients who came into the program did not have an action plan when they started. 

Conclusion 

The good news is that more information, treatments, and tools are available than ever before for self-monitoring and management of asthma at home. 

Thomas L. Petty, MD, often suggests that “modern medicine should focus on prevention,” and that this opportunity should not be missed with the treatment of asthma. Presently, we may not be able to prevent asthma from occurring, but we can definitely prevent the most adverse outcomes by implementing preventative measures that focus on the patient’s role in daily self-monitoring and managing asthma at home. Truly, an ounce of prevention at home is worth a pound of cure at the hospital. 

It is now time for the health care system, including hospitals, insurance providers, clinicians, and asthma patients, to work together toward the goal of making these tools and the latest information available to patients and families in the form of coherent, cohesive, and comprehensive asthma education programs. N 

John Wolfe, RRT, is an account manager for Lincare, Fort Collins, Colo, and serves as the chairman of the Northern Council for the American Lung Association of Colorado.

References 

1. Berger WE. Allergies and Asthma for Dummies. Foster City, Calif: IDG Books Worldwide Inc; 2000:53,141-144, 157, 213-226. 

2. Wray BB. Taking Charge of Asthma. New York City: John Wiley and Sons Inc; 1998:42-56, 90-120, 156. 

3. American Lung Association Asthma Advisory Group. Edelman, NH, ed. Family Guide to Asthma and Allergies. New York: Life Time Media Inc; 1998:18-32, 53-57, 75-89, 169, 206. 

4. Vavra J. Environmental pollution and asthma. RT Magazine. 2000;13(3):106-107.