David Tinkelman, M.D.
Editor, Journal of Asthma
January 2001

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.

Kirkus Reviews
November 15, 1999

Pediatrician Plaut, 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 asthma.

Thomas J. Kallstrom, RRT, FAARC
Advance for Managers of Respiratory Care
March 2000

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.

UNDERSTANDING ASTHMA
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 of Asthma.

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.

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.

Vignettes, written 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 concepts.

Asthma pathophysiology 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.

Physicians specializing in the treatment of asthma will undoubtedly agree with the tenets of this thorough work. Specific practices may
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 intention here.

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 well.

Table of Contents
Introduction
Working with your Doctors
How to Choose a Doctor
Seeking a Consultation
Asthma Stories
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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Asthma Stories

The Basics of Asthma

What is Asthma?
Expectations
Excellent Asthma Control
Basic Facts
Naming and Diagnosing Asthma
Natural Course of Asthma
Monitoring Peak Flow Scores and Asthma Signs
Asthma Severity
Asthma Triggers
Allergies and Asthma
Special Considerations for Diagnosis and Treatment of Asthma

Asthma Medicines

Understanding Your Medicines
Controller Medicines
Quick Relief Medicines
Quiz on Asthma Medicines

Devices for Inhaling Asthma Medicines

Inhaling Asthma Medicine Deep into Your Airways
The Right Medicine the Wrong Way
Metered Dose Inhalers (MDIs)
Holding Chambers
Dry Powder Inhalers (DPIs)
Compressor Driven and Ultrasonic Nebulizers

Peak Flow

Using Peak Flow at Home
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 Tool?
Peak Flow Meters

Asthma Treatment

Effective Asthma Treatment
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 Doctors

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

Health Planning
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 Affair
Two Mothers' Stories about Living with Asthma
Role of Family Members
Divorce
Asthma Education Groups and Asthma Support Groups
Feelings
Travel

Introduction: You 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 inhaled medicines
• 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 asthma reaction.

Careful monitoring 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.

Asthma 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 use.

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.

Treatment plans. 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 Asthma Guide

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 are dramatic.

THOMAS F. PLAUT, MD
Amherst, Massachusetts

Working With Your Doctors
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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 Guidelines.

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 questions.

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 work with.

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 issues:

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.

CURRENT APPROACH 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 doctor:

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.

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 MANAGEMENT

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 PATIENT'S CONTRIBUTION

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.

COMMUNICATION

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 to you.

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.

Seeking a Consultation
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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 a year.
• you have recently been hospitalized for asthma.
• 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.

Asthma Stories
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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.