Patients and parents should understand that the presence of symptoms or the need for emergency care is usually due to an inadequate treatment program or an incomplete understanding of asthma.

THOMAS F. PLAUT, M.D.
American Journal of Asthma and Allergy for Pediatricians
Vol.4, No. 4, Summer 1991, Edited 2005

Health professionals, librarians, and teachers are showing an increasing interest in asthma. To choose helpful educational materials, they must become more familiar with this complex illness. This article outlines 10 elements that should be included in any comprehensive asthma book or program.

Nine elements discussed in this article were presented to 20 experts in the field. I asked them to displace any of the nine elements with an item that they considered more important. All but one accepted the nine elements without change. Three urged me to add decision-making to the list, because knowledge alone will not lead to appropriate management. Ten of the experts responded in writing. They included three allergists, four pulmonologists, two psychologists, and one asthma research nurse.

Basic Elements of Education

Proper Expectations
Establish the expectation that the child will lead a fully active life, play any sport, attend school regularly, and sleep through the night. A major flaw in many educational materials is the idea that children should adjust to asthma symptoms. In 2005, the vast majority of children with asthma should have symptoms no more than two days a week, on average. Patients and parents should understand that if symptoms occur more often, their treatment program is inadequate or their understanding of asthma is incomplete.

The Four Signs of Asthma Trouble
Cough, wheeze, sucking in the chest skin (retractions), and breathing faster are the major common signs of an asthma attack in children. Understanding these signs can improve the communication between patient and physician. Parents can judge whether their child's asthma is improving or worsening and then can take necessary action.

The four signs mentioned here suffice for almost every patient. Parents will benefit more from learning these four signs fully than learning a larger number incompletely. Late signs, such as blue skin and lips, incessant vomiting, or breathing hunched over, deserve little mention because parents should be taught to prevent them by interveaning early.

Record Keeping
An accurate diary is essential for managing childhood asthma. Parents can learn about asthma triggers, symptoms, and the duration and adverse effects of asthma medications by analyzing such a diary. The diary also serves as an account that can be reviewed during office visits.

Overreactivity and the Two Phases of the Asthma Reaction
The airways of asthmatic patients are very sensitive and may over-react to allergens, pollutants and other triggers. The early phase of an asthma episode is characterized by bronchoconstriction, which responds to bronchodilators. The late phase is distinguished by inflammation, which responds to high doses of inhaled steroids or to oral steroids.

Two Medicine Types
Controller medicines are used to prevent or lessen the frequency and severity of attacks. They should be taken daily by people who have symptoms more than two days a week. They include inhaled steroids, long acting beta2-agonists, leukotriene modifiers, nedocromil and cromolyn. The quick relief medicines are bronchodilators (short acting beta2-agonists, anticholinergics and theophylline). They relax the muscles that constrict the airways. Oral steroids are in a class of their own. They are used to treat severe episodes and also used every other day to treat very severe asthma. The desired and adverse effects of these medicines should be described.

Devices for the Delivery of Medication
This includes their proper use and a description of the relative merits of metered dose inhalers, holding chambers, and compressor-driven nebulizers. The four elements of proper inhaler use - proper positioning, hand-breath coordination, slow inhalation, and a 5 to 10-second breath-hold - should be highlighted. Indications and instructions should also be given for the use of holding chambers, compressor-driven nebulizers and peak flow meters.

Peak Flow Monitoring
Monitoring peak flow is the key to successful management of asthma at home. Peak flow monitoring provides objective information that can be used to make treatment decisions based on a preset plan. It provides an accurate means of communication with the physician and can improve asthma care for almost all patients five years of age and older.

Triggers
An understanding and avoidance of the triggers of asthma (e.g., exercise, viral respiratory infections, irritants, allergens, some drugs and chemicals, and cold air) may allow the patient to live a normal life while reducing medicine intake. Therefore, a comprehensive book should describe possible triggers and how to avoid or prevent them.

Criteria for Choosing a Competent Asthma Doctor
The physician should give written instructions, teach and monitor the use of treatment devices such as holding chambers and a compressor-driven nebulizer, measure air flow with a peak flow meter or a spirometer at each visit, and be accessible. Competence in these areas is more important than certification in any particular specialty.

Decision Making
Treatment decision should be based on peak flow scores or the four signs of asthma and a knowledge of asthma triggers and medications. Markers can indicate when treatment should be changed. A four zone Asthma Action Plan can guide parents in home treatment and tell them when to consult their physician.

Efficacy of Education
Asthma education is a continuing process. Parents need tools to continue their learning and to improve their ability to analyze and manage their child's illness. To reach the maximum number of children with asthma, educational materials must be designed for home use. The text should be clear and concise so parents and patients can readily understand and use the material.

Group presentation and discussion with a knowledgeable leader, such as a nurse, respiratory therapist, health educator, parent of a child with asthma, or a physician, often will enhance the effectiveness of a good book or program. Most parents find a single 2-hour or 4-hour session most convenient. Multiple session programs have a high dropout rate and have reached only a small fraction of children with asthma in the United States.

No matter where asthma education takes place, the 10 basic elements outlined above should be covered. Anything less will leave many parents lacking the information they need to control their child’s asthma. A parent who understands these elements, and who works with an up-to-date and supportive physician, can achieve optimal control over asthma.

Acknowledgments
The author would like to acknowledge the comments of: Kathleen Conboy, RN, MS; Thomas L. Creer, PhD; Gerd J.A. Cropp, MD, PhD; Elliot F. Ellis, MD; Gilbert A. Friday, MD; Shirley Murphy, MD; Sydney R. Parker, PhD; Thomas L. Petty, MD; Marianna Martin Sockrider, MD; and John A. Winder, MD. Beth Gradone provided valuable assistance.