Parents of children with asthma and adult patients
will learn what to do in every asthma situation,
how to get the best effect from their asthma medicines,
how to track asthma with a diary and when to call
for help. Includes special tips on managing asthma
at school and while traveling, real-life asthma
stories and detailed information on the use of
inhalers, peak flow monitoring and home treatment
plans. Also contains a resource section, medical
bibliography, glossary and index.
Plaut wrote the Asthma Guide for People of All
Ages at the request of physicians across the United
States who wanted a practical book for parents
and adult patients. The Asthma Guide contains
30 first person stories that describe the asthma
experiences of patients from seven months to 65
years. It covers the basics of asthma and the
medicines and devices used to treat it. The sections
on monitoring asthma by peak flow, and by the
four signs of asthma in young children, are more
complete than in any book written for parents,
patients or professionals. Use of diaries and
action plans is described in detail. Templates
in the book can be copied for personal use. There
is a special section devoted to asthma in the
Editor, Journal of Asthma
Physicians are constantly
searching their offices for literature to give
to patients about asthma. We find these from professional
associations, lay associations, pharmaceutical
companies, and others. In Tom Plaut’s Asthma
Guide for People of Ages, physicians can reduce
their searching time and find a single superb
resource for their patients. This book is far
more than a "guide." It has an excellent
chapter about asthma pathophysiology, which is
the basis for many of the other chapters dealing
with the management of asthma. To help the family
deal emotionally with this chronic problem, Dr.
Plaut has included short vignettes from parents
and patients regarding their own experiences with
asthma that add to the basic what-to-do aspects
found throughout the text. I am particularly pleased
with the strong position that Dr. Plaut takes
regarding the need for the patient to work closely
with the physician. This book is not held out
at all to be a physician substitute, but rather
provides “the basic information you need
to communicate clearly with your doctor."
The Journal of Asthma salutes Dr. Plaut for his
continued devotion to providing patients with
the most up-to-date scientific information and
guidelines in an affordable, understandable format.
November 15, 1999
a specialist in asthma treatment (Children with
Asthma: A Guide for Parents, etc.), makes no bones
about it: A well-informed patient, working with
a knowledgeable health-care practitioner, can
control his or her disease so completely that
"you will have symptoms no more than two
days per week, will rarely miss school or work
because of asthma, will rarely require an urgent
visit to the doctor or emergency room, and will
be able to exercise as long and as hard as anyone
else." Plaut goes on to provide readers--even
those suffering frequent severe attacks of the
disease--with the tools and an action plan for
reaching these goals. He explains the anatomy
and physiology of the disease; what asthma medications
are available and how to use them (the proper
technique when inhaling a medication is vital);
and how to monitor and interpret peak flow (a
measure of lung function and the most important
early indicator of trouble). Plaut then discusses
treatment plans in depth and includes clear, well-designed
forms for tracking the disease and its treatment,
plus a short "asthma diary" for patients
and their physicians.
First-rate help, indispensable for those with
Thomas J. Kallstrom, RRT, FAARC
Advance for Managers of Respiratory Care
If patients are
to gain control of their asthma, they must be
better educated so that they can care for themselves
as their physician intends. Asthma Guide for People
of all Ages, written by Tom Plaut, MD, with Teresa
Jones, MA, gives readers tools to accomplish this.
Dr. Plaut is a pediatrician by education and practice,
but he has gone outside his specialty to write
a most useful text that addresses key components
of asthma care for all ages. His many years of
experience in the field have made him a solid
authority on this topic.
The book is presented in a straight-talk type
of style. As Dr. Plaut notes in the opening segment
of the book, his audience is the diagnosed asthmatic.
Accordingly, his language is easy to read and
comprehend. If he uses words not commonly uttered
by the nonprofessional or are potentially confusing,
a definition is provided.
The opening chapter, a compilation of true narratives
written by patients, grabbed my attention. This
is a great idea and a most unique approach. Unfortunately,
I'm not sure what the authors' intention was by
dividing the stories into the 1980's and 1990's.
This format was not especially useful.
The following section presented pathophysiology
of the disease, keeping in mind the audience's
probably level of understanding. While this isn't
an easy task, the underlying causes of asthma
are presented clearly. In this section, Dr. Plaut
discusses diagnosis, trigger and treatment of
the disease. Clear and definitive figures help
to reference the written word. The book is consistent
with the recommendations of the Expert Panel Report
II: Guidelines for the Diagnosis and Management
I noted an excellent analysis of how and why physicians
may use terms like RAD (reactive airways disease)
vs. asthma when they talk to patients. While well-meaning
physicians may try not to worry their patient
by using unfamiliar terms like RAD, such words
can interfere with good physician/patient communication.
I see this in my practice all the time. Dr. Plaut
recommends that we call it what it is, if indeed
it is asthma. I agree. His ability to get at the
core of issues that concern most patients and
parents of asthmatics is commendable.
The pharmacology section is well-written and covers
the potential medications that patients are likely
to be prescribed. It's up-to-date and offers useful
information, such as common drug administration
problems that patients may encounter. For example,
Dr. Plaut lists remedial steps the patient can
take if he or she misses a dose of medication.
The devices section logically follows pharmacology.
Dr. Plaut presents details of all available delivery
devices, including their efficacy, most analysis
and ease of use. He rightfully states that while
many home care companies can provide nebulizers
without a prescription, the patient must be instructed
by the physician, respiratory therapist or the
nurse. This observation often is overlooked. Missing
from this chapter was discussion of the two most
common methods of nebulizer disinfection: white
vinegar vs. quaternary ammonium compounds.
The peak flow and asthma diary chapters offer
clear and concise information on these two important
components of asthma monitoring. The author presents
this information with the understanding that patients
must be an active part of their care. If these
techniques are done incorrectly, the patient is
possibly basing care on erroneous information.
A chapter on school asthma confronts common problems
that are seen within the pediatric patient population.
Most of this information also is pertinent to
the adult patient as occupational exposure issues.
Dr. Plaut suggests well-reasoned approaches that
the patient can use to intervene in areas that
we sometimes think are out of our control.
A related chapter on family and travel addresses
a wide variety of problems liked to asthma that
rarely are discussed. These include divorce, babysitter
care and support groups.
The Asthma Guide for People of All Ages can be
likened to an asthma version of Dr. Spock's care
of the baby and child books that have been a staple
for decades. The cost is reasonable, and at 310
pages it's not too lengthy.
This book should be in the possession of all asthmatics,
especially the newly diagnosed. It also should
adorn the bookshelves of those health care professionals
who wish to share accurate and timely information
with their patients.
Kathleen R. May, M.D.
Annals of Allergy, Asthma & Immunology
This latest asthma
educational tool, for patients of all ages, by
Dr. Thomas Plaut, incorporates current medical
information while maintaining a personal tone
that speaks directly to those suffering from this
chronic disease. The guide is overwhelmingly positive
in perspective and should motivate patients to
take charge of their asthma. The importance of
both personal knowledge and communication with
all members of the health care team is underscored.
by patients and parents, comprise the first chapter,
"Asthma Stories." Selected patients
and their stories are referenced in subsequent
chapters to highlight important details. Use of
specific, personal narratives heightens the reader's
interest and promotes the logical unfolding of
is thoroughly reviewed in a straightforward manner
for the lay person, including discussion in several
places about the rote of allergy in asthma. Asthma
details introduced in this chapter segue conceptually
to the successive section about asthma medications.
Various medication aspects are noted, including
purpose, onset of action, timing of administration,
potential adverse effects, and dosage. The dangers
associated with using inhaled epinephrine, outlined
briefly, could have been further emphasized.
Devices for inhaling
asthma medications are given thorough coverage,
including an essential overview of proper inhaler
technique. Repeatedly and daily in our care of
asthma patients, improper inhaler technique is
detected. Arguably, the situation would improve
greatly if all health care personnel, in addition
to patients, were required to review this section!
National Heart, Lung, and Blood Institute updated
guidelines are heavily referenced in multiple
chapters, especially with regard to use of home
treatment plans. That all patients may benefit
from written asthma plans is reiterated, with
accompanying examples from selected patients.
Additional contemporary clinical research is referenced
appropriately throughout the book.
Sections on asthma
in specific circumstances include school-based
treatment and travel preparedness. A cornerstone
of school asthma management is undeniably the
school nurse, who is increasingly burdened with
responsibilities in many school districts. Potential
environmental issues within school buildings themselves
are considered, with an illustrative patient vignette.
Workplace environmental issues, perhaps beyond
the scope of this text, are not specifically addressed.
Emphasis is placed on children with asthma in
discussing family issues and interaction with
caregivers. Careful and organized travel planning
for those with asthma is reviewed.
in the treatment of asthma will undoubtedly agree
with the tenets of this thorough work. Specific
differ in the application of these tenets, but
the author does recognize these differences and
cautions readers to review management details
with their physicians. One minor area of contention
is the influenza vaccine recommendation: immunizing
those who have had several severe asthma episodes
yearly or receive daily medication- The implication
is that patients with milder asthma or less severe
exacerbations would not benefit from influenza
immunization, which is perhaps not the author's
Resources for patients
and parents are found at the end of the guide.
An abbreviated list of contents includes sample
asthma peak expiratory flow rate diaries, asthma
treatment plans, educational books, pamphlets,
and organizations devoted to asthma care. The
medical glossary included here is a tremendous
resource for patients and their families.
This guide is aptly
dedicated “to patients, parents, and professionals
who are willing to learn." In its entirety,
this book gives the patient essential tools for
understanding and managing asthma: at the same
time it never presumes to obviate physician input.
Long-term asthma control must be achieved through
effective communication among all involved. Reading
this guide is required of Dr. Plaut's patients.
For our patients, primary care colleagues, and
other health care professionals with an interest
in asthma, the guide is recommended reading as
excerpts from the book, click below:
Working with your Doctors
How to Choose a Doctor
Seeking a Consultation
Luke, age 7 months
Nathan, age 1
Shoshana, age 3
Karen Warren, age 22
Jeffrey Wolfman, age 38
Cynthia Miller, age 65
Table of Contents
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The Basics of Asthma
What is Asthma?
Excellent Asthma Control
Naming and Diagnosing Asthma
Natural Course of Asthma
Monitoring Peak Flow Scores and Asthma Signs
Allergies and Asthma
Special Considerations for Diagnosis and Treatment
Quick Relief Medicines
Quiz on Asthma Medicines
Devices for Inhaling
Inhaling Asthma Medicine
Deep into Your Airways
The Right Medicine the Wrong Way
Metered Dose Inhalers (MDIs)
Dry Powder Inhalers (DPIs)
Compressor Driven and Ultrasonic Nebulizers
Using Peak Flow at
Measuring Peak Flow
The Personal Best Peak Flow Score
Using Peak Flow to Guide Asthma Treatment
Interpreting Your Peak Flow Scores
Usefulness of Peak Flow
Learning from Peak Flow
Do Peak Flow Scores Always Tell You What Is Going
On in Your Lungs?
Does Everyone Agree That Peak Flow Is a Helpful
Peak Flow Meters
The Home Treatment Plan Based on Peak Flow
Treatment for Children Under 5 Years of Age
The Home Treatment Plan Based on Asthma Signs
Signs Based Treatment Plan for Young Children
Taking Inhaled Steroids
Working With Your
How to Choose a Doctor
How Often Should You See Your Doctor for Asthma?
Achieving Excellent Asthma Control
Seeking a Consultation
Asthma Visits for Young Children
In the Emergency Room and Hospital
Asthma at School
Legal Aspects of Asthma at School
Indoor Air Quality
The Environment Plays a Key Role in Asthma
Health Problems Related to Indoor Air Quality
Understanding Indoor Air Quality in Schools
Family and Travel
Asthma is a Family
Two Mothers' Stories about Living with Asthma
Role of Family Members
Asthma Education Groups and Asthma Support Groups
Can Control Asthma
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You are probably
aware of reports that asthma emergencies and hospitalizations
are increasing. My patients and my readers rarely
have these problems. They have learned to control
their asthma and you can, too. By "controlling
your asthma" I mean that you will have symptoms
no more than two days per week, will rarely miss
school or work because of asthma, will rarely
require an urgent visit to the doctor or emergency
room, will not be hospitalized, and will be able
to exercise as long and as hard as everyone else.
To achieve this control, you will need to learn:
• how to deliver
• how to check your condition using peak
flow or asthma signs
• how to follow a written plan based on
your asthma treatment zones
You could get the
information in this book from your doctor, but
it would take at least ten hours. It would be
difficult for you to remember, and you would probably
not want to pay for it. It makes more sense to
use this book as a foundation that you and your
doctor can build on. By doing so, you can become
a skilled manager of your asthma care and continue
your learning process.
My first book, Children
With Asthma: A Manual for Parents, has helped
hundreds of thousands of families since it was
first published in 1983. Many patients and health
professionals asked me to expand my writing to
include adults. This book outlines the blueprint
for achieving excellent asthma control for people
of all ages. It is consistent with the recommendations
of the Expert Panel Report 2: Guidelines for the
Diagnosis and Management of Asthma, a comprehensive
report on asthma care published by the National
Heart, Lung and Blood Institute in 1997.
Dr. Tom Plaut's Asthma
Guide provides you with the basic information
you need to communicate clearly with your doctor.
It will help you understand asthma and its treatment
so you can follow a plan designed by your doctor
to control asthma. As you read, you will meet
people who have overcome many of the problems
you face. I am convinced that you, too, can improve
your asthma control.
Most asthma books
discuss the basics of asthma and the medicines
used to treat it. You will find that important
information here, but I believe that you need
to learn more than that before you can fully control
your asthma. I give serious attention to the following
areas of asthma care:
The basics of asthma.
Understanding asthma starts with learning how
the lungs work and how they change during the
will tell you that an asthma episode is beginning
and how severe it is. Allergens and other substances
in your environment can trigger an asthma episode.
It makes more sense to reduce triggers such as
tobacco smoke, animal dander, or dust in your
home than to increase your dose of medicines.
We now understand how important it is to control
and prevent long-term inflammation in the airways.
We also know a lot more about asthma medicines,
who is most likely to benefit from them, and what
adverse effects to watch for. You will read about
the medicines currently available to treat asthma,
how they work, what they are supposed to do, how
long they take to act, what adverse effects may
occur, and the usual doses prescribed for home
Devices for inhaling
asthma medicine. Taking the right medicines, especially
the ones needed daily to control persistent asthma,
is an important part of your asthma treatment.
Yet, many people who see me for an asthma consultation
are taking the right medicines the wrong way.
Their techniques for using a metered dose inhaler
(alone or with a holding chamber), a dry powder
inhaler, or a nebulizer are flawed. This prevents
them from getting the full benefit from their
medicines and may increase the adverse effects.
You need specific instructions and demonstrations
from a health professional to learn the proper
use of each device. The descriptions and illustrations
in this chapter will help.
Peak flow. For patients
five years of age and older, tracking airflow
is the key to successful asthma treatment. The
peak flow meter, a portable and inexpensive device,
has revolutionized asthma care because you can
use it at home to monitor your airflow. Once you
know how to blow peak flow scores, you can learn
to judge your asthma status and adjust treatment
at home. You can also discuss specific numbers
with your doctor, instead of using vague terms.
As a result, you will receive better advice
Using an asthma diary.
A well-designed asthma diary helps you collect
information in an organized and useful fashion.
It aids you in learning about your individual
asthma situation, keeping track of medicines,
and figuring out when to change your treatment.
A diary that displays the asthma treatment zones
also helps you communicate with health professionals
and family members.
A one-page written treatment plan guides you in
your daily routine and in care of an asthma episode.
Based on peak flow scores or the four signs of
asthma, it is easy to follow since the zones are
identical to those in the asthma diaries. Once
you have worked out an effective plan with your
doctor, you will be able to manage most asthma
problems at home.
An effective collaboration
between you and your doctor requires that you
do the day-to-day work of asthma management. It
requires that your doctor guide you in learning
how to use devices, diaries, and a treatment plan.
He or she needs to prescribe the medicines and
environmental changes that are essential for you
to gain control over your asthma.
Using Dr. Tom Plaut's
This is not a do-it-yourself
book. It gives you the information you need to
understand asthma and work with your health care
provider. It does not give specific advice for
your individual situation. If you were to read
this book ten times, you would know more about
asthma than most people. But you would still need
the help of a health professional to manage your
asthma effectively and safely. Your doctor will
work out an asthma treatment plan based on all
the individual information you collect, and will
provide emergency care if you need it. The more
knowledgeable and experienced you become, the
more responsibility you can take on and the better
care you will receive.
You will find clear
explanations of the many areas of asthma management.
Illustrations and first-person stories clarify
the more complex aspects of asthma care. Step-by-step
examples demonstrate how to use asthma management
tools such as an asthma diary and a home treatment
plan. Forms for your personal use are available
at the back of the book. An extensive resource
section and a medical bibliography can lead you
to additional information…
Almost all of my patients gain excellent control
over their asthma. There are no secrets or shortcuts.
The day-to-day work is not exciting, but the results
THOMAS F. PLAUT,
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You must work closely
with a competent doctor to control your asthma
safely and effectively. That doctor will give
you written instructions, teach you to use your
devices, measure air flow at each visit, and treat
you in a manner consistent with the 1997 NHLBI
I believe you can
achieve excellent asthma control only when you
and your doctor actively share with each other
complementary knowledge, skills, attitudes, and
behaviors. A good doctor brings a breadth of experience
and medical knowledge to the collaboration. You
bring the daily observations, insights, and growing
understanding of your own asthma situation. It
takes both of you to build and carry out a successful
asthma management plan.
Your doctor needs
to have comprehensive knowledge of asthma and
the medicines used to treat it. He must recognize
that you want to be the primary manager of asthma
once you acquire the skills and knowledge you
need. He must support you as you learn, and he
must also be readily accessible toanswer your
If you want to be
a major manager of your asthma, you have to work,
too. By reading this book, you have begun the
process of building your knowledge and exploring
your attitudes about asthma care. With the support
and guidance of your doctor, you can become skilled
in measuring and monitoring peak flow, observing
the signs and symptoms of asthma, and using devices
to deliver medicines.
Once you and your
doctor have worked out an asthma management plan,
you can make that plan effective by following
its guidelines and continuing to observe how well
it is working. Most asthma problems will be temporary,
and you will be able to manage them at home. However,
even after you have acquired extensive knowledge
about your asthma, treating it still requires
collaboration with your doctor. There may be some
situations that you cannot or should not handle
at home. Don't guess. Stay within the boundaries
of your written plan.
Taking care of asthma
is a shared responsibility. In the early stages
of your learning, it is only safe to take on a
small portion of that responsibility. As you grow
in knowledge, skills, confidence, and experience,
you will be able to take on more. A good doctor
will help you judge your ability to manage asthma
and transfer responsibility to you in an appropriate
and timely way.
The approach I describe
in this chapter is based on my experience and
is followed by many asthma specialists. It works
well for patients who want to take control of
their asthma and to prevent or manage most of
their episodes. Once you have high expectations
for asthma control, you can make sure that you
get the care you want. The following stories illustrate
how two mothers found doctors that they could
How to Choose a Doctor
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A doctor's particular
specialty is not as important as his interest
in asthma. It takes time and effort for a doctor
to stay up-to-date in diagnosis and treatment,
although the 1997 NHLBI Guidelines have made that
job easier. If you have mild intermittent or mild
persistent asthma, you may be able to achieve
excellent control working with a good primary
care physician (pediatrician, family practitioner,
or internist). If you do not achieve excellent
control, or if you have moderate persistent asthma,
periodic consultation with an asthma specialist
will be helpful in almost all cases (see "Seeking
a Consultation," this chapter). Once you
have worked out a good plan with a specialist,
you can follow this plan with your primary care
physician and see the consultant occasionally
for review. If you have severe persistent asthma,
you should be treated by an asthma specialist.
To judge whether
your regular doctor will be able to help you achieve
excellent control, you need to consider several
Does the doctor employ
currently recommended treatment?
Can the doctor communicate to you what you need
to know to manage asthma?
Does the doctor listen well enough to learn about
your specific asthma situation?
Does the doctor want to help you to learn to manage
your asthma at home?
I will discuss each
of these points to help you make an informed decision
about whether your current physician has the qualities
that will help you to
gain control of your asthma.
TO ASTHMA CARE
Use the following
criteria to assess whether your doctor is up-to-date
in his approach to asthma care. A competent asthma
Gives you written
instructions. This means that your doctor provides
you with a written home treatment plan (often
called an asthma action plan) that you can understand.
The plan should clearly list all of your asthma
medicines and doses, when and how to take them,
and when to add or stop taking additional doses.
The plan should be based on peak flow or signs
scores and the zone system.
Teaches and monitors
your use of devices. The office staff or the doctor
should teach you how to use each prescribed device
(inhaler, holding chamber, nebulizer, peak flow
meter) and observe you as you use each one. Even
after your technique is perfect it will need to
be checked at visits.
your peak flow or FEV1 at each visit. At an office
visit, your doctor can get important information
about your airways by checking your peak flow
score with a peak flow meter or your forced expiratory
volume (FEV1) with a spirometer. This airflow
information is essential to monitor your progress
and adjust your treatment.
Approaches asthma treatment in a manner consistent
with the Expert Panel Report 2: Guidelines for
the Diagnosis and Management of Asthma, in 1997.
The Guidelines are the most comprehensive guide
to effective asthma care currently available.
Your doctor and the office staff should be familiar
with this document, or with the more readable
version, Practical Guide for the Diagnosis and
Management of Asthma. Treatment consistent with
its recommendations will almost always lead to
Not all experts agree
on every part of the Guidelines. A good doctor
may suggest treatment that differs from the Guidelines
and will be able to explain clearly why he recommends
that approach for you. I suggest that you purchase
the Practical Guide and become familiar with its
key points (see Resource Section).
If your doctor meets
the four criteria discussed here, he is up-to-date
on asthma treatment and can help you take control
of your asthma and live a fully active life. However,
consider these additional factors before making
your final decision.
ATTITUDE TOWARD HOME
Now you need to decide
how well the doctor's attitude toward home management
fits with yours. Please remember, no matter how
good the doctor, you have the primary responsibility
for your care. A good doctor will teach you how
to provide this care within certain well-defined
limits. He will help you learn the skills you
need to manage asthma at home and help you judge
how much you can handle as you become more skilled.
Home management of
asthma depends on your ability to observe, score,
record, and assign a zone to peak flow scores
and the signs of asthma. Your observations guide
the actions that you take based on your written
plan. Effective home management also depends on
your ability to take the medicines you need properly
and promptly. It is your doctor's job, and yours,
to make sure that you understand your asthma medicines
and how to take them.
ATTITUDE TOWARD THE
A doctor needs detailed
information from you to develop the most effective
treatment plan. Both his medical knowledge and
your individual knowledge are necessary to reach
the goal of asthma control. You need to write
an account of your life experience with asthma
similar to the stories (from the 1990s) in Chapter
1. Your doctor needs to read it. Does he supplement
this information by careful questioning? Does
he analyze the information you have collected
in your asthma diary? Does he want to know about
the environment you live and work in? As your
doctor conducts an asthma visit, it will become
clear how much he values your input.
A doctor may know
everything there is to know about asthma. However,
that knowledge won't do you any good unless the
doctor can communicate the important information
Doctors vary widely
in their ability to communicate, just as patients
do. If you feel that you are getting the information
you need from your doctor, his communication style
is probably compatible with yours. Patients often
find that communication with their doctor improves
greatly after they read this book. If you leave
the office confused or frustrated, you might benefit
from working with a doctor who can communicate
more clearly with you.
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Even when patients
and parents have had a good experience and work
well with their doctor, they may want a second
opinion from an asthma specialist on some prescribed
course of action or to get a fuller understanding
of their situation.
This is accepted
medical practice, and you should not feel at all
uncomfortable in asking for it. Involve your regular
doctor in the process by asking that he provide
a clinical summary and suggest a consultant. A
competent physician will not be insulted by this
request. In fact, he will want to be involved
in recommending a consultant who would be particularly
skilled to help with your care. Some patients
prefer to make all the consultation arrangements
on their own.
I recommend that
you seek a consultation if:
• you limit
your activity or miss school or work more than
one day per year because of asthma, in spite of
reviewing the situation with your regular doctor.
• your doctor suggests that you limit activities
because of asthma.
• you have to go to the doctor's office
or emergency room for urgent care more than once
• you have recently been hospitalized for
• you have nighttime symptoms (cough or
wheeze) that wake you up one night a week or daytime
symptoms more than twice per week, despite reviewing
the situation with your regular doctor.
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The asthma stories
which follow are true stories which give real
details of asthma care. They were written by my
patients or by the parents of my young patients.
They demonstrate that asthma, even when it caused
severe problems in the past, can be controlled.
age 7 months
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son Luke is seven months old. Since his birth
in August 1992, my husband and I have been telling
the doctors that Luke coughs, sneezes and sounds
very raspy, and occasionally spits up mucus. We
were told this was normal for newborn infants.
age 2 months, Luke developed a virus with a slight
fever. After Luke was sick for three weeks, the
doctor decided to run some X rays and lab work;
all results were negative. At this time his coughing
and spitting up mucus became much more pronounced.
One afternoon my mother was watching Luke. He
was lying in his crib in another room when my
mom heard a violent cry. When she reached Luke,
he was spitting up mucus and gasping for air.
I called the doctor, who once again told me there
was nothing wrong with Luke and that this was
very normal for infants.
early November 1992, we went back to the doctor,
for a routine checkup. We discussed our concerns
that Luke was still very raspy and coughing every
few minutes throughout the day and night. I also
voiced my concern that his eyes were awfully tearful.
We were basically told that everything sounded
clear and we should try not to worry about either
of these concerns, because Luke was growing and
appeared healthy. The doctor said, "If the
coughing and sneezing continue when Luke is about
a year old, we will run some tests on him."
At this point I became so frustrated that I asked,
"Could this be asthma or allergies?"
I received no response other than, again, "I
do not hear a wheeze. He really is too young to
detect allergies." I decided to call the
Second Opinion Clinic at Boston Children's Hospital.
The doctor there agreed that the symptoms might
be either asthma or allergies, but at Luke's age
it was really difficult to determine. The doctor
gave us some soybean formula to try.
this point, we did not know where to continue
in this battle, but we kept searching for the
answers. During Thanksgiving, we discussed that
we needed to find another pediatrician, one who
would listen to our concerns and not make us feel
like paranoid parents. Right after Christmas,
my parents left for three weeks on vacation. When
they returned in January 1993, my mother commented,
"I can't believe Luke is still coughing and
he sounds worse!" I agreed. I knew at this
point that I had to find some answers to this
woke up the next Saturday much more congested.
He was coughing non-stop (he could not catch his
breath between coughs) and he was sneezing every
few minutes. So we decided to take him to Boston
Children's emergency room.
visit became an eye opener. The doctor told us
that Luke was coughing at an abnormal rate but
that he did not know why. When the doctor listened
to Luke's chest, everything sounded fine. However,
when he timed Luke's breaths on his watch he felt
that Luke was breathing slightly quicker than
normal. The doctor recommended we contact an allergist
and a lung specialist, and in the meantime gave
him an antihistaminic to see if it would calm
the cough. At this point, Luke was waking up on
and off all night.
days later, I called the doctor's office and requested
to see another pediatrician. Tuesday morning we
went to see a new doctor. The doctor listened
to our concerns. During the examination, she detected
a slight wheeze and agreed that Luke was breathing
slightly quicker than normal. The doctor explained
to us that she wanted to try giving albuterol
by nebulizer. We administered this to Luke and
after 20 minutes, she came back to recheck him.
The wheeze was gone and Luke's breathing had returned
to normal. The doctor gave us referrals to see
a lung specialist and an allergist. She prescribed
cromolyn to be administered by compressor driven
nebulizer. This was approximately three weeks
ago. The lung specialist advised us to continue
on this treatment and to return in two months
for a follow-up appointment.
allergist ran some allergy and lab tests and told
us that if the test results proved positive, she
would contact us for further consultation. Neither
specialist would commit themselves that Luke may
have asthma. At this point, my sister recommended
that I read Children With Asthma: A Manual for
Parents because she went through a similar experience
with her daughter who has asthma.
reading the book, I became even more frustrated,
because I realized that Luke had very similar
situations to some of the children in the book.
Plus, I discovered that the nurse told us a very
different way of using the compressor driven nebulizer
than how the book explained to use it. We feel
very frustrated over this whole situation. All
we would like for our son is to determine what
is wrong...and what we can do to help him. My
husband and I feel so helpless. Presently, Luke
is still coughing and sneezing throughout the
day and night.
has spent numerous hours with many different doctors,
all of whom did not significantly help him. We
were told nothing was wrong with our son, even
though he coughed all day and night. Before our
first appointment with you, we read Children With
Asthma, which talks about asthma children like
Luke, and we started filling out an Asthma Signs
Diary, which helped us monitor Luke's condition."
Wendy brought Luke in for his first visit in March
1993, she came with these written goals:
would like to learn how to prevent my son from
coughing and sneezing, without being a nervous
mother. I would like to know if my son has asthma
and if so learn everything I need to know to help
him. I would like to see my son not coughing and
not so stressed when I give him his medicine.
later wrote an account of that first visit, and
the changes that she and her husband made in Luke's
care after our discussion.
the time of our first consultation, when Luke
was 8 months old, my husband and I were unclear
about asthma in general, and we were very frustrated
over the chain of events we were experiencing
with our other doctors.
the first visit, we reviewed Luke's Asthma Signs
Diary for the previous two weeks. He had had a
cough every day. His total signs score usually
ranged between two and five. You asked my husband
and me to show how we administered Luke's cromolyn
using the nebulizer. As we watched Luke we realized
immediately that he was not getting much of the
medicine. It was escaping from the top and sides
of the mask. At that point we decided to use a
mouthpiece with the nebulizer instead of a mask.
We doubled his dose of cromolyn, added albuterol
to the solution, and gave him prednisolone (an
oral steroid) for seven days.
recommended that we purchase several items to
reduce dust within the household. We encased Luke's
crib mattress in an allergy-type encasing, we
bought a HEPA air filter for the bedroom, and
we began keeping the dog out of the bedroom. All
of these changes have improved our son's well
being. We now have the knowledge, confidence and
skills to keep our son from having major asthma
problems. When Luke gets very excited, or if the
weather is nasty, he still coughs. However, my
husband and I have learned not to panic. If Luke
continues to cough, we increase his dose of albuterol
and try to eliminate the triggers. Luke is a very
happy child. When he becomes cranky, his asthma
usually needs attention.
weeks later, Luke came in for a second visit.
He was doing extremely well taking daily cromolyn
and albuterol. His parents had kept an Asthma
Signs Diary each day, which showed that his sign
scores had greatly improved (decreased). His parents
had purchased a HEPA filter which seemed to be
soaking up the cigarette smoke from the downstairs
neighbors. They started using the Pari-Jet nebulizer
and found that it has cut the total amount of
time it takes to give four ampules of cromolyn
each day from sixty to thirty minutes.
Luke's appointment three months later, Wendy wrote,
"We have gained vast amounts of knowledge
on asthma. Our son is one hundred percent better
than he was in February." At age 2, Luke
stopped taking cromolyn by compressor driven nebulizer
and started taking an inhaled steroid by holding
chamber with mask.
age 5, Luke takes an inhaled steroid daily and
albuterol as needed for symptoms. His dad reports
that Luke's asthma control has been good for the
preceding year. He made two urgent visits to the
doctor and needed two short treatments with an
oral steroid. He has not had any major problems
since the summer and has been able to play outside
in the winter for long periods of time.
Nathan, age 1
back to links
fourth son, Nathan, was born in April 1981. He
weighed 8 pounds, 10 ounces and was a very handsome
little fellow. We were very pleased with him.
He was healthy and fine until one day in November
when he caught a cold. We treated it with aspirin
and a decongestant. This didn't seem to help him
the third day he became worse. He began to cough
quite frequently and he was breathing rapidly.
By the time evening came, our baby was struggling
to breathe. We immediately called an ambulance
which took us to the hospital. He was put in an
oxygen tent for several days. After taking chest
X rays, the doctor said that our son had pneumonia.
He gave him an antibiotic and after a week's stay
in the hospital, Nathan was sent home. He did
fine for three weeks but when he caught another
cold, it turned into a nightmare.
one night I awoke from a sound sleep with a feeling
that I should look in on the baby. I check on
all the boys every night (a mother's routine)
before I go to bed, but this time it was different.
When I went into Nathan's room I heard him wheezing
and coughing and gasping for air. I ran and woke
my husband. We rushed our baby to the hospital
and on the way total fear gripped me. I feared
that this time we were going to lose our son.
By the time we got to the hospital, Nathan's lips
began to turn blue from lack of oxygen. He was
put into an oxygen tent again, and all we could
do was pray to God that our baby would be all
right. I believe it was a miracle, an answer to
prayer, that Nathan did survive. They took more
chest X rays and did a test for cystic fibrosis,
which was negative, and we were very thankful
remember feeling distressed and wondering how
long this would continue before we would find
out what was causing our little boy to get so
sick so often. Approximately one week later, when
I was to bring Nathan home from the hospital,
I called his doctor to ask if he had made a diagnosis
yet. He told me there was still no diagnosis and
encouraged me just to be happy he was better.
Well, by this time I had had my fill of finding
out nothing concerning my baby. Certainly we were
happy that he was better, but for how long? We
knew something was terribly wrong but we just
didn't know what. We decided it was time to change
doctors. At this time we were referred to another
pediatrician by a friend. The first time we visited
this new doctor and I told him of Nathan's trauma,
he diagnosed him as having asthma and began treatment
theophylline three times a day. Despite this treatment,
Nathan was still hospitalized for asthma twice
more before his first birthday.
March of 1982 we joined a health maintenance organization.
The next time Nathan had an asthma episode, he
was examined by our new family doctor, who then
phoned for a pediatric consultation. After he
got off the phone he ordered three shots for Nathan.
I believe the shots were epinephrine twice, followed
by a long-acting epinephrine preparation. Nathan
responded and was able to go home within an hour.
He continued treatment with theophylline capsules
and prednisone three times a day for a short period
of time. This was the first time that he had an
asthma episode and was not admitted to the hospital.
We were so thrilled to be able to take our baby
home the same night. It was beautiful not to have
to go home to an empty crib. This was the beginning
of learning about our son's asthma.
was fine for about a month and then he had another
episode. This time our family doctor increased
the theophylline dose but Nathan couldn't tolerate
the full amount. He got hyperactive and wouldn't
sleep at night. He did calm down after it was
reduced. The consulting pediatrician prescribed
metaproterenol followed by cromolyn, both delivered
by a compressor driven nebulizer three times a
day. This amounts to a regular program of treatment
and prevention at the same time.
long ago, my family doctor recommended that my
husband and I attend the Parents' Asthma Group
that was held in Amherst. We attended two two-hour
sessions and are we glad we did. We learned a
lot about asthma and how to detect episodes early
and how to monitor these episodes. We also learned
about various medicines used to treat asthma,
their good effects and also their undesirable
effects. It was good to share experiences with
other parents: to hear what they were going through
and how it affected them. It helps to know that
we are not the only parents going through these
the beginning of Nathan's sickness, we feared
for his life. At the Parents' Asthma Group we
learned that it was rare for a child to die of
asthma. Only one of every twenty-five thousand
children with asthma die of it each year. If parents
have adequate knowledge and see that their children
get proper treatment, this tiny number will become
is now 3 years old and doing much better. In the
two years he has been on this new treatment plan,
he hasn't needed to be admitted to the hospital
once. He takes theophylline capsules twice a day
except when he begins a cold, then I add another
capsule at night. He takes metaproterenol and
cromolyn by nebulizer three times a day. Since
we've learned more about how to deal with Nathan's
condition and he's been on this medication, he
has gone as long as three months without an episode.
Before he was having them at least once a month.
What an improvement!
mom wrote this update in 1987, when Nathan was
six years old:
the past two years Nathan has had a tremendous
improvement in his health. I am grateful for the
knowledge I gained on how to deal with asthma
and for the parents who shared their experiences
on how to cope with asthma. It is nice to know
that others have dealt with this problem. My husband
David gives me a lot of support and help.
now has asthma episodes twice a year. He has one
in the spring and one in the late fall. That is
a real improvement from having an episode every
other month. Nathan still takes a long-acting
theophylline preparation three times a day. Recently
he had an attack and we started giving metaproterenol
by nebulizer four to six times a day. He also
took prednisone twice a day for a week. After
a couple days of treatment Nathan was fine and
as playful and active as ever.
loves to ride his bike and play baseball with
his three older brothers. He is excited about
starting kindergarten this fall. I'm so happy
with Nathan's progress. It is a relief not to
be frantic and upset with worry if he does have
an asthma episode. I believe the key to overcoming
the problem of asthma is to detect it early and
to give the child proper treatment.
child has different symptoms. In Nathan's case
he will get itchy, usually behind his ears and
on his chest, and he might be cranky for a couple
of days. Then he will start symptoms of a cold
and he'll start wheezing. Now that Nathan is getting
older he knows when he starts to have trouble
and he will come to me and ask for a nebulizer
is a problem, but as long as we know enough to
treat it properly, we can go on and live normal
happy lives. I am going to have my fifth baby
this September. People have asked me, "Well,
aren't you worried about your new baby having
asthma?" Of course I hope and pray that this
new baby will not have asthma. But I am not too
worried, because my husband and I know how to
deal with it.
spoke with Nathan's mom in 1998, more than ten
years after I last saw Nathan. He is now 17 and
has excellent control over his asthma. During
the past decade, he has not needed oral steroids
or any urgent visits to a doctor or to be hospitalized
for asthma. For the last five years, Nathan has
taken no controller medicines. He plays on the
high school basketball team and treats asthma
symptoms with albuterol one or two games per year.
back to links
has had troubles resulting from “allergies”
since her birth in October 1992. Although these
problems always fell within the “mild”
range, they were troublesome to us because they
were chronic: no matter what we did, they always
returned. I began to notice her eczema when she
was approximately one month old, and her skin
was dry, rough, and prone to patches of redness
or small, reddish bumps. Although she was completely
breast-fed until she was 5 months old, she would
“break out,” especially on her cheeks,
shortly after nursing—so I realized that
she was reacting to the foods that I had eaten
prior to her nursing.
In February of 1994, when Shoshana was 16 months
old, she developed a cold with typical symptoms
of nasal congestion and postnasal drip. On the
fourth or fifth day, she became unusually irritable,
demanding, clingy, and inconsolable. She cried
repeatedly throughout the day in response to tiny
problems which would otherwise never bother her
(something dropped on the floor). This constellation
of behaviors remains, to this day, as the most
significant clue that an asthma episode is developing.
At the time, however, I was unaware of its significance.
Later that day, Shoshana began to breathe rapidly
and laboriously. I thought that she was simply
congested and having difficulty breathing because
of her stuffed-up nose. Shortly, the labored breathing
developed into an audible wheeze. By this time,
Shoshana was crying continuously, had developed
a fever, and had vomited her dinner. At the pediatrician’s
office, we were told that Shoshana was probably
having an asthma attack (she responded with some
improvement to an updraft treatment of albuterol)
and that she would have to be hospitalized that
night. We spent two days at the hospital, learning
about asthma (reading Children With Asthma over
and over), and learning how to use a compressor
driven nebulizer machine. Shoshana was given albuterol
and prednisolone and was kept inside an oxygen
tent. Her condition had improved within twenty-four
hours. We continued the medicines, tapering as
directed, for one week.
After this episode, we watched very carefully.
I fantasized that the incident requiring hospitalization
(which was extremely difficult for all of us)
was a “fluke” and that Shoshana did
not really have asthma at all. In fact, in mid-March
Shoshana developed cold symptoms again without
any asthma symptoms, so I was almost convinced
that it would not happen again.
On April 25, 1994, during Shoshana’s 18-month
well visit to the pediatrician, her doctor detected
mild bronchospasm and prescribed albuterol updraft
treatments two to three times per day for several
days. Although she had been exhibiting cold symptoms,
Shoshana had given no indication that she was
experiencing any difficulty breathing. I was still
In early May, however, Shoshana began to exhibit
a “cold” that lasted for five weeks
or so. We now believe that this was allergic rhinitis
in response to the pollination of trees in our
area at that time. On May 13, the nasal congestion
and nasal drip symptoms led to mild wheezing and
coughing, which we treated with albuterol by compressor
driven nebulizer. She then developed an upper
respiratory infection, with a fever of 104 degrees,
and more asthma symptoms. On May 25, Shoshana
had moderate asthma symptoms and was prescribed
prednisolone in addition to albuterol. Her pediatrician
recommended and prescribed cromolyn to be taken
daily, but I was hesitant because I was still
not quite convinced that she needed daily medicine.
She was having asthma symptoms less than once
a week. If she developed asthma only when she
had nasal congestion and a nasal drip, I reasoned,
then we should treat the symptoms as they appeared.
Shoshana’s most recent experience with asthma,
developing on June 20, has somehow led me to alter
my thoughts regarding her treatment. Again, during
this most recent episode, she had developed cold
symptoms, otitis media in both ears (requiring
antibiotic treatment), and asthma symptoms. The
wheezing was particularly “stubborn”
this time. We gave her albuterol by nebulizer
thirteen times in twenty-four hours, yet she showed
little improvement. The next day, we began administering
I have finally realized that Shoshana’s
asthma is not going to simply “disappear,”
although, of course, I wish that it would! It
is painful to see her suffer each time, and watch
our child become “a different person”
as she regresses to a crying, clinging, inconsolable
“mess.” The frequent albuterol treatments
and prednisolone administrations have become much
more difficult as Shoshana enters into a developmental
period typical of toddlers, wherein she refuses
to comply with absolutely anything we wish to
have her do.
You made an excellent point during our telephone
conversation when you said that parents must believe
that their child needs to take a medicine that
tastes terrible or causes discomfort. If they
are not convinced, the child will sense their
ambivalence and often refuse to take it. With
Shoshana, I believe that part of the problem does
have to do with exactly this fact: I have never
felt entirely comfortable with what we have been
The second part of the problem, however, is a
result of her extreme mood and behavior changes
during an acute asthma episode, which contribute
further to her “negativism” in complying
with any treatments. I find this part of the entire
situation the most frustrating. When I am trying
to help my child and she is spitting prednisolone
all over me or vigorously struggling against me
as I am trying to force the nebulizer mouthpiece
to her lips, I feel hopeless, dejected, angry,
frustrated, and depressed.
I have had enough of “reactive” treatment
methods: I wish to treat my daughter’s asthma
“proactively” and prevent any further
episodes, if possible. If cromolyn, the asthma
“wonder drug,” will work to do that,
then I am ready to use it! My husband and I are
both highly educated, highly motivated individuals
who are interested in learning the details of
how to make a treatment plan work properly. So
I am appealing to you for some assistance in helping
us to learn exactly what to do, how to do it,
and why we are doing it—in order to make
At our first consultation, I told Shoshana’s
parents that if they need to give more than six
treatments of albuterol by compressor driven nebulizer
in twenty-four hours during Shoshana’s episode,
that is a sign that the asthma is worsening or
that their technique for giving medicine is ineffective.
I showed them how to use a compressor driven nebulizer
and watched Shoshana take a treatment. With the
mouthpiece properly placed, mist came out of the
top of the nebulizer cup both during inspiration
Usually, mist comes out only during expiration.
When a child is breathing in you should not see
mist escape. Clearly, Shoshana was not inhaling
the medicine. What was wrong? We realized that
Shoshana was breathing through her nose and no
medicine was entering her mouth. So, I recommended
using a mouthpiece so the medicine could enter
through her nose.
After recording Shoshana’s asthma signs
in a diary each day, her parents realized that
she needed to take a controller medicine and started
to give cromolyn by compressor driven nebulizer.
Three months later her mother wrote:
After a four-week trial of giving cromolyn by
compressor driven nebulizer, we switched over
to an inhaled steroid, at her pediatrician’s
suggestion. Since then we have not had to use
any prednisolone syrup and have not had any sleepless
nights filled with Shoshana’s crying and
misery. She truly does seem to have asthma that
falls into the mild range, and we are so glad
to have determined that only a minimal amount
of medicine is necessary.
I spoke with Shoshana’s mother on the phone
in 1998. She said that Shoshana’s asthma
control has been excellent for the past year.
Now 6 years old, she has taken no oral steroids,
has had no urgent visits to the doctor, emergency
room, or the hospital, nor has she missed school.
She continues to take a very low daily dose of
an inhaled steroid by holding chamber with mask.
Warren, age 22
back to links
earliest memory that I have of asthma is the deafening
sound of my own wheezing on the way to the doctor's
office when I was ten years old. My chest ached
and I wasn't getting any satisfaction from my
attempts to gulp for air - it just wasn't there.
Instead I took short, shallow breaths, which were
equally unsatisfying. The next memory is the "green
room" (my pediatrician had a "green
room," a "yellow room"...etc.)
where I cried as I received my first shot of adrenaline,
and minutes later violently puked.
this first attack, I started taking theophylline
(with applesauce). I still won't eat applesauce
to this day. I took theophylline as directed for
two weeks, and I was in the emergency room using
a nebulizer four days after I stopped. The machine
was terrifying and no one explained anything about
what was going on. I think my parents aged more
than I did that night.
returning home from the emergency room I had a
host of medicines to choose from: albuterol, cromolyn,
theophylline.......only we were never taught what
each of the medications did, how much to take,
when to take them. The cromolyn Spinhaler was
not only a complete nuisance, but in addition,
I hadn't been taught how to use it properly; half
of the powder remained stuck in the tube, while
the rest was choked out as I coughed upon inhaling.
my parents thought it would be wise for me to
see an allergist. One of my brothers had severe
allergies, so perhaps, we thought, this was the
missing link. After dozens of scratch tests and
little blue-and-yellow bruises up and down my
arms, they found that I was allergic to pollen,
dust and mold spores. There went the carpet and
was in junior high, and the albuterol seemed to
be doing the job, with an occasional dosage of
theophylline (although this left me nauseous and
shaky). This regimen continued through high school,
as I participated in soccer and had a rigorous,
outdoor practice every afternoon. I recall taking
the theophylline pills in the locker room; as
long as I took them, I was all right, except when
we did sprints. They sent me hacking and choking
off the field.
high school, I was in the emergency room again
twice. Although the nebulizer was more familiar,
I still didn't know how it was working to make
me feel better.
first semester at college was a nightmare. I visited
the health services over half a dozen times that
winter (in the middle of the night, of course)
and became friends with the nebulizer. As far
as the physicians were concerned, I was doing
the right thing by coming in, but they had no
advice for me on a long-term basis.
I taught myself how to slow down an episode as
I felt it coming on by taking small breaths and
ceasing all activity. In addition, I learned to
avoid situations, namely, any strenuous exercise,
that would trigger my asthma. I felt frustrated
and cheated by having to restrict my activity,
and I often exceeded my limits. This stubborn
behavior always resulted in moderate to severe
as I prepare to graduate, it seems I am back where
I started. Since the flu last semester I have
wheezed upon waking every morning. If I take an
afternoon nap - I wheeze. And more recently, I
have been unable to sleep through the night.
drive to classes that are far away instead of
having to deal with wheezing on the walk home.
I have an inhaler at home, in my dorm, in my car...and
I miss soccer and bike riding and the little things,
like being able to take a really deep breath and
came in for her first consultation in April 1993.
She expressed these goals for her visit: "I
would like to learn how to use the various pieces
of asthma equipment properly - so I can best benefit
from their use. In addition, I would like to feel
that there can be an end to this restless-night,
achy-chest, twelve-year pain in the butt."
told Karen I expected her to achieve excellent
control of her asthma, to have symptoms only rarely,
and to be able to play any sport she wanted. We
reviewed asthma in general and discussed asthma
devices (holding chamber, peak flow meter, and
peak flow diary), medicines, and environmental
measures. I prescribed a seven-day burst of an
oral steroid to be taken simultaneously with cromolyn
week later, Karen reported she was sleeping through
the night for the first time in three weeks. She
woke without wheezing or coughing for the first
time in six months and could laugh without coughing
for the first time in a year. Karen stopped driving
to her distant classes because she could now walk
there without trouble.
May 1993, one month after her initial visit, Karen
came in for a follow-up visit. It had taken her
seven days to recover from welding fumes in metal
art class. She had a cold at the same time. I
substituted an inhaled steroid for cromolyn as
her controller medicine, and she improved steadily.
She felt fine six
1998, Karen told me that her asthma control is
excellent. She has not taken oral steroids, nor
has she visited an emergency room or an asthma
doctor. She has missed no work due to asthma in
the four years since her last visit. She stopped
taking an inhaled steroid in 1996, and her only
symptom at present is a slight wheeze when she
has a cold. She is in excellent health, works
out five days a week, and pretreats with albuterol
prior to strenuous exercise.
Wolfman, age 38
back to links
was born in Oakland, California. At approximately
18 months, I was diagnosed with asthma. Both of
my parents smoked and continued smoking until
the mid 1960s. To the best of my recollection,
I did not take any medications until elementary
school. I was taken to the local hospital emergency
room on numerous occasions for treatment whenever
an asthma attack occurred.
was an active, athletic child, always able to
keep up with others in school sports. I played
varsity basketball, soccer, and was on the ski
team in high school. I attended college in Colorado,
where I was involved in intramural sports. I placed
15th out of 70 in a bicycle race from Colorado
Springs to Aspen in 1973. I took a combination
medicine containing theophylline, ephedrine, and
an antihistamine for my asthma from the time I
was in elementary school until age 30.
have always had difficulties with allergies and
eczema. I was treated for my allergies through
injection therapy during elementary school in
California and then most recently for five years
(1988-1992) in Boston.
age 30 (1984), my doctor changed my medicine to
theophylline. Seven years later, my doctor changed
my brands of theophylline and quick relief medicine
and added an antihistamine. This year I started
taking a different antihistamine and started using
an inhaled steroid.
November of 1992, I was asked to participate in
an experiment at Beth Israel Hospital, testing
the effect of cold air on asthmatic lungs and
the relative recovery time to restore normal breathing
after using various inhaled medicines. The study
required that the subjects take no medicine of
any type for twenty-four hours prior to the test.
After fifteen hours without medicine, my bronchial
passages became severely constricted, and my lung
capacity did not even register on the peak flow
meter. Normal breathing was restored after administering
have a number of allergies to certain foods, trees
and grasses, and dust and animal dander. To deal
with drastic emergencies, I carry an EpiPen with
me at all times. Over the last two years, I have
begun to have noticeable difficulty breathing
and have felt that my respiratory capacity has
diminished significantly. I have become very sensitive
to smoke, perfume, soaps, and a variety of environmental
substances, pollen and dust in particular. Any
minor physical activity, even climbing a flight
of stairs, leaves me winded and feeling the need
for asthma medicine.
my consultation, I hope that I may be able to
better understand the problems I have been experiencing
and the changes in my asthma, and to develop a
treatment plan using appropriate medicines that
will allow me to resume some of my normal activities.
I would like to have greater endurance with the
least amount of medicine possible.
Jeffrey's first asthma consultation, we discussed
additional details of his asthma history. He had
taken prednisone only once, in 1989, for nine
days, and had no emergency room visits or hospitalizations
for respiratory problems in the past twelve months.
His family had a history of eczema, asthma, and
hay fever. Jeffrey did not use a holding chamber
to take his medicines. During the month prior
to his first appointment, his peak flow score
never exceeded 375 before taking a quick relief
medicine, a low score for a man his age and height.
some coaching during the physical examination,
Jeffrey was able to blow a peak flow score of
550 before inhaling albuterol. His chest was clear.
I asked him to demonstrate his inhaler use. He
held the MDI at his mouth, began to breathe in,
and simultaneously released one puff of medicine.
He took two seconds to breathe in, then held his
breath for six seconds. Both his inhalation and
breath hold were too short for him to get the
full benefit from his medicine. He took his inhaled
steroid before his beta2-agonist (quick relief
medicine), another error.
assessed Jeffrey to have moderate persistent asthma
that had required daily medicine since elementary
school. Over the past two years he had found that
his tolerance to exercise and pollutants had decreased.
He was taking an inhaled steroid, theophylline,
pirbuterol (a quick relief medicine), and an antihistamine
daily. He had not been properly instructed in
use of the metered dose inhaler, holding chamber,
asthma diary, or a peak flow meter, nor did he
know which inhaler to use first. He did not know
how long it took for his medicines to work or
how long their effects lasted.
the first visit, I recommended that Jeffrey add
an oral steroid to his current medicines for the
next seven days. This additional treatment would
help clear his airways, reduce symptoms, and let
him establish his personal best peak flow. I showed
him how to use the inhaler and demonstrated use
of the holding chamber with MDI.
days later, Jeffrey came in for a second visit.
He reported that he had taken his medicine as
directed and started feeling better in two days.
He felt more physically able than at any time
in the past four years. Prior to his visit, he
could not push his 10-month-old uphill in a carriage,
nor he could roughhouse with his 3-year-old son.
Most of his activities with his 3-year-old were
"housebound" like reading and coloring.
But at the time of his second visit, he was running
with his family and was able to climb three flights
of stairs at work or walk a mile and a half across
a college campus without tiring. He had not used
a quick relief medicine at night since starting
the oral steroid burst. His 10-month-old, not
his asthma, was waking him three times a night.
a four-month follow-up visit, Jeffrey said he
had no symptoms and that his asthma control was
excellent. His personal best peak flow score was
650. Four years later, in 1998, his asthma control
continued to be excellent. He was taking a low
dose of an inhaled steroid and using albuterol
daily. He was walking a mile a day and swimming
regularly with his kids.
Miller, age 65
back to links
lived in New York City until I was 5 years old.
The summer I turned 4, I spent my birthday in
bed with a cough. During the winters of '37, '38,
and '39, I was often bedridden with bronchitis.
My health must have been "fragile" as
I had to rest a lot.
11, 12, and 13, I spent summers in Long Island,
with lots of bike riding, swimming and tennis.
Riding horseback, I always liked to ride up front
to avoid the dust. On damp, muggy, still days,
I always had trouble breathing. I had all sorts
of tests, including allergy tests, which were
positive for dust and mold. I was given no specific
medicine or shots for allergies and was advised
to sleep on a foam pillow.
remember always needing my nap in the afternoon
in May and early June. Muggy nights in May and
June found me kneeling by the window with my nose
pressed against the screen trying to get "more
air." I was always very athletic, playing
hockey, soccer, tennis, basketball, swimming competitively,
and riding a horse and a bike. Only muggy air
slowed me down. I have had sinusitis two or more
times a year since childhood and rhinitis which
I have treated with inhaled steroids for the past
the ages of 20 and 60, I was married to a man
who smoked four packs of cigarettes a day. The
smell of cigarette smoke brings on sneezing and
choking along with coughing. I don't wheeze very
present, I have great trouble sleeping in an airless
room, or exercising in humidity or heat. I keep
the heat low in winter, since air blowing on me
bothers me. When we changed from oil/hot air heat
to gas/baseboard heat, I started sleeping better
and choked less.
coughing spasms can often come on unexpectedly.
In one case I had just visited a huge indoor flower
market. The next day I was in the hospital because
of breathing trouble.
the past six months, I have been aware of every
breath. Last summer, I noticed I could not ride
my bike in the heat. I could not breathe properly.
The day I came down with this "bronchitis,"
I noticed a restriction in my lungs at the end
of a deep breath in while I was biking uphill.
The next day I was out of breath and could not
walk uphill without gasping for air. This lasted
for a week.
want to learn whatever is necessary, including
changes in my lifestyle, to ward off attacks.
I want to familiarize myself with "clues"
indicating an approaching problem, and if an attack
starts, know how to immediately start remedying
the situation. As a result of new knowledge and
skills, I hope to gain confidence in dealing with
my asthma problems.
had a history of breathing problems for sixty
years. She had been diagnosed with bronchitis
three or four times a year and was hospitalized
once for pneumonia in 1986. She was first diagnosed
with asthma two weeks before her first visit with
me and was treated with inhaled albuterol, an
antibiotic, and a cough medicine.
physical examination showed that Cynthia had signs
of both asthma and sinusitis. I assessed her to
have mild to moderate persistent asthma since
childhood. I suggested that she read further about
asthma, reduce triggers in her environment, and
monitor peak flow. I instructed her in the use
of a peak flow meter, holding chamber, and the
technique of nasal irrigation (for her sinusitis).
I also prescribed an oral steroid, an inhaled
steroid, and albuterol, and I treated her for
rhinitis and sinusitis.
weeks after her initial appointment, she said
the improvement in her condition was "fantastic."
She had kicked the dog and the cat out of the
bedroom and had gotten rid of the carpeting to
reduce allergens. She started using a mask for
allergenic or dusty environments, purchased a
HEPA air filter and vacuum cleaner, bought a filter
for the furnace, and watched the asthma video
I loaned her. Her cough had disappeared in four
days, her mild wheeze had disappeared in five
days, and her activity had returned to normal
in about seven days. During the first week of
treatment, she had occasional difficulty with
sleep (probably due to the oral steroid). She
found the nasal washes helpful. She felt like
her old energetic self for the first time in many
months after her initial consultation, Cynthia
wrote this update:
had pneumonia twice and severe "bronchitis"
many times, I believe I had an unconscious fear
of doing "top performance" – whether
riding my bike as fast as I could go or hiking
hills at a faster pace. Now the unconscious fear
in my breathing is put at rest. My last asthma
attack awoke me in a rage of coughing and choking.
It was scary but I knew what to do. I finally
have a handle on my own management, something
I never had before.
mind and body have been freed from a fear that
I have had since I was a young child. Knowledge
of asthma has given me the confidence to exercise
more fully. Now that I know what to expect, my
inner self no longer constantly asks me "what
could happen if...?" All this frees up a
lot more energy and as I enjoy doing so many things,
I find I have been able to move "smoothly"
and joyously from one to another. There are no
more daily interruptions by breathing problems.
knowledge and skills I have gained in the past
four months enable me to feel free and secure
in any place I go. I can now hike three miles
without getting out of breath. I feel like the
"little engine that could." I went up
to the barn yesterday and did not bring my mask,
as I did not realize how horribly dusty everything
was. My breathing worsened immediately. My problem
is I feel so good that I forget I have asthma
and forget to carry my mask always with me. I
must remind myself!
we spoke in 1998, Cynthia reported that her asthma
control continues to be excellent with the treatment
plan we had worked out.