Implementing preventive measures that focus on the
patient’s role in daily monitoring and managing asthma at home
can prevent adverse outcomes.
The old adage “an ounce of
prevention is worth a pound of cure” was never more
appropriate than when considering the need for self-monitoring
and management of asthma at home.
The statistics can be startling:
- More than 17 million Americans suffer from some form of
- Asthma attacks account for more than 2 million emergency
department (ED) visits and 500,000 hospital admissions each
- More than 5,000 people die each year from asthma, and
the number of deaths caused by asthma has nearly doubled
- Direct health care expenses alone amount to more than
$17 billion per year, including $1.6 billion for inpatient
care and $1 billion for medications.2
Managing asthma at home is not merely a convenience, it is
an absolute necessity. Many hospital admissions and virtually
all fatalities from asthma can be prevented with assessment
and intervention at home.3 Although there has been an
explosion of information available to both clinicians and
patients, comprehensive education programs are not always
The goal of monitoring asthma at home is to allow patients
to manage their condition, so their condition does not manage
them. Asthmatics who learn about their condition, follow a
daily monitoring routine, and take charge of their condition
can expect to be rewarded with fewer exacerbations. They can
reasonably expect to experience improvements in lung function,
activities of daily living, and quality of life.
What Patients Need to Know
Daily peak flow monitoring is the cornerstone of an asthma
home treatment program. The daily readings are essential for
monitoring the severity of symptoms and the effectiveness of
treatment.1,3 Peak flow monitoring provides asthmatics with an
important early warning sign that an asthma episode is
approaching. When used with a daily log and a clear action
plan, peak flow monitoring provides asthmatics with a powerful
ally in managing their condition. The patient has a written
record of his checks, and the clinician can reinforce the
importance of daily monitoring by checking the patient’s peak
flow log at regular intervals.
Although they generally require more coaching, even
preschoolers can be trained to use a peak flow meter daily.
Regardless of age or behavior modification, creating the habit
of performing peak flow checks every day is the greater
Ideally, peak flows should be checked twice daily at
approximately the same time each day.
Using a peak flow meter correctly involves:
- moving the sliding indicator to the “0” position;
- standing up and filling the lungs with a deep
- placing the mouthpiece into the mouth, making a good
seal around it with the lips;
- blowing out as hard and as fast as possible (like
blowing out birthday candles). DO NOT block the opening or
make a “tah” maneuver with the tongue, as this will result
in an inaccurate “high” reading;
- noting the number next to where the sliding indicator
- resetting the peak flow meter to zero and repeating the
above maneuver twice;
- writing the best reading of three attempts in the
Clinicians can provide patients with a predicted peak flow,
based on charts that denote averages based on age, sex, and
height.3 “Personal best” is often higher than predicted best
and is a reflection of the individual’s best effort on a
“good” week, when symptoms are minimal.1 Action plans should
be based on personal best, not predicted results.1,3
Keep a Daily
Peak Flow Log
The Daily Peak Flow Log should include the date, time of
day, peak flow (in liters per minute), and any symptoms noted
at the time of the test.
Red, yellow, and green “zones” put the patient’s daily
checks into an easy-to-remember context, with 100%
representing his personal best.
Green: >80% of personal best; indicates the condition is
under control. The patient should continue the normal
Yellow: 50% to 80% of personal best; indicates a worsening
condition. This is the patient’s early warning of more serious
problems. The patient should institute the action plan
developed with his physician. This may include a phone call to
the physician and increasing treatments. Patients should be
advised not to ignore worsening conditions even if they “feel
Red: < 50% of personal best; indicates a medical alert.
The patient is having serious problems and should immediately
implement the elements of his action plan that correspond to
the red zone.
Know Your Action
Every patient should have a clear plan of action that
corresponds to each zone and was developed in conjunction with
the physician. Many peak flow meters include a red, yellow,
and green tape that sticks directly on the peak flow meter.
Always ascertain that the beginning of the red zone
corresponds to 50% of personal best. In other words, if
personal best is 600 lpm, the red zone should begin at 300
lpm. The patient’s action plan, complete with appropriate
phone numbers, should be kept with or taped on the peak flow
In addition to a peak flow log, asthmatics should consider
keeping a journal for 2 weeks or more. An asthma journal will
help the patient and clinician work together to manage the
condition at home and avoid exacerbations.2
A journal should include the following information:
- how the patient subjectively feels each day;
- the date, time, and any symptoms;
- what was eaten;
- emotional state; and
- especially note when an asthma symptom was experienced
in relation to a potential trigger.
Patients should identify and eliminate aggravating
environmental triggers. Asthmatics and their families need to
clean up the environment at home and at work or school with
the greatest emphasis placed on the individual’s most
aggravating triggers.3 This means first identifying triggers
Tobacco smoke. Quit smoking and ban it from the home and
car. Tobacco smoke is an irritant and decreases mucociliary
action. Environmental tobacco smoke exposes passive smokers
to carbon monoxide and other toxins, including benzene and
Children who live in homes where parents smoke are
hospitalized more frequently and have longer hospital stays
than do children who live in homes where no one
Carpeting. Remove synthetic carpets (especially in the
bedroom) and switch to hardwood or other washable surface.
Use removable rugs as needed.
Pets. Avoid keeping furry pets, especially dogs, cats,
and guinea pigs, and birds.
Cockroaches. Eliminate cockroach infestations—their fecal
matter and saliva are allergens.4
Feather pillows or comforters. Use hypoallergenic pillows
and bedding. Wash bedding weekly at >130 degrees to
eliminate dust mites.
Damp basements and indoor molds. Clean and disinfect
kitchen counters and shower tile. Eliminate mildew or moldy
places. Decrease humidity to < 50%. Make sure air
conditioners, furnaces, dehumidifiers, and refrigerators are
kept clean and are properly vented. If a humidifier is used
in the winter, KEEP IT CLEAN using a white vinegar
Vacuuming. Equip the vacuum with a high efficiency
particulate air (HEPA) filter bag, and, if possible, the
asthmatic should avoid being in the room when it is
Formaldehyde (synthetic carpets, paints, plastics,
furniture). Avoid particleboard and especially
medium-density fiberboard in furniture.
Perfumes, deodorants, cosmetics. Avoid using scented
sprays, incense, and candles.
Other potential triggers to consider. Nitrogen dioxide
and carbon monoxide (from gas stoves and furnaces);
pesticides; volatile chemicals (found in cleaners, shampoos,
aerosol sprays, and paint thinner); and wood smoke.
Patients should consider obtaining an air purifier with a
HEPA filter. When selecting a specific unit, remember that the
more air it moves, the better. Avoid cheap desktop units. It
is most realistic to focus on a single room (the bedroom)
where an air filter can impact a finite space.
Enlist the Help
of an Allergy and Asthma Specialist
If the patient has moderate to severe asthma, or if the
physician treats only asthma symptoms and does not work with
the patient and family to develop a comprehensive, long-term
management plan, a referral to an allergy and asthma
specialist should be seriously considered. Multiple hospital
admissions, failure to meet the goals of asthma therapy, or a
life-threatening asthma attack are strong indicators that the
patient’s asthma is out of control and the help of a
specialist should be enlisted.1,2
Learn to be
A soccer mom said that when her child began to have an
asthma attack during a soccer game, the coach admonished him
to “play through it.” The mother offered a second opinion and
overruled that call.
Adults in leadership positions—especially teachers and
athletic coaches—need to become knowledgeable about asthma
management.3 It will always be difficult for a 10-year-old
asthmatic to challenge bad advice from an unwitting adult, but
assertiveness training can make a difference. And failure to
contradict a teacher or coach could have potentially
Asthmatics and their families have much to learn about
managing the disease, including pathophysiology, medications,
environmental factors, and dietary considerations. Most
important, they need to understand the importance of managing
asthma on a daily basis and anticipating, rather than merely
reacting to, exacerbations. The depth and breadth of
information available are impressive and the volume of
information grows daily.
Communicating so much essential information, reteaching and
reinforcing important techniques such as proper inhaler use
and peak flow technique, and providing regular follow-up are
often problematic. The acute care setting is often the worst
place to address asthma education—patients may be distracted
or under stress and clinicians are often under tight time
constraints. But when asthma is managed from crisis to crisis,
it is often the only education opportunity available for some
patients. In the physician’s office, asthma management
training may often be limited to a single session, with weekly
follow-up consultations impractical or unaffordable.
Home care clinicians have perhaps the best opportunity to
educate patients and families, in the comfort of their own
home. However, there is no reimbursement structure to cover
the cost of a comprehensive, ongoing education program at
An overriding challenge in each of these settings is that
comprehensive asthma training takes time, and time costs
money. For all the talk of preventative health care, few
insurance carriers seem ready to pick up the tab for providing
asthma training to the patients and families that need
However, the need for comprehensive education services for
asthmatics is obvious. The benefits of a well-educated and
prepared asthmatic population include a reduction in ED and
hospital admissions, reduced mortality, and improved quality
of life.3 While the value of providing asthma education is
easy to understand, hospital systems and insurance carriers
are often reluctant to fund asthma education programs in
today’s cost-conscious environment.
Northern Colorado Medical Center, Greeley, Colo, has
addressed these challenges by developing a comprehensive
classroom-based asthma education program.
The hospital system absorbs the cost of the program, and
justifies the expense based on well-documented decreases in
hospital and ED visits. Perhaps the enlightened approach of
this fledgling program will serve as a model for health care
Patients are referred to the program by physicians or when
they are admitted into the system with an asthma diagnosis.
The program provides patients and families with individual
counseling and 3-hour classes each week for 4 weeks. Follow-up
is provided at 6 months and 1 year, or more often if
The classroom setting is more efficient than sending a
clinician into each home. It is more relaxed and has less
distractions than the acute care setting, and patients and
families can enjoy the camaraderie and support that comes from
a group setting.
Paula Schneider, RRT, resource respiratory therapist for
the program, said its mission is to “empower patients to
manage the disease so that the disease doesn’t manage
Key points emphasized in the program include:
- increasing patient knowledge and sense of control over
- behavior modification and family counseling;
- pace breathing and use of relaxation and visualization
- learning about medications;
- understanding the importance of performing daily peak
flow checks and knowing when and how to implement action
plans. Schneider emphasizes that patients learn that “peak
flow checks are the key to the management of your day.” She
added that 90% of patients who came into the program did not
have an action plan when they started.
The good news is that more information, treatments, and
tools are available than ever before for self-monitoring and
management of asthma at home.
Thomas L. Petty, MD, often suggests that “modern medicine
should focus on prevention,” and that this opportunity should
not be missed with the treatment of asthma. Presently, we may
not be able to prevent asthma from occurring, but we can
definitely prevent the most adverse outcomes by implementing
preventative measures that focus on the patient’s role in
daily self-monitoring and managing asthma at home. Truly, an
ounce of prevention at home is worth a pound of cure at the
It is now time for the health care system, including
hospitals, insurance providers, clinicians, and asthma
patients, to work together toward the goal of making these
tools and the latest information available to patients and
families in the form of coherent, cohesive, and comprehensive
asthma education programs. N
John Wolfe, RRT, is an account manager for Lincare, Fort
Collins, Colo, and serves as the chairman of the Northern
Council for the American Lung Association of Colorado.
1. Berger WE. Allergies and Asthma for
Dummies. Foster City, Calif: IDG Books Worldwide Inc;
2000:53,141-144, 157, 213-226.
2. Wray BB. Taking Charge of Asthma. New York
City: John Wiley and Sons Inc; 1998:42-56, 90-120,
3. American Lung Association Asthma Advisory
Group. Edelman, NH, ed. Family Guide to Asthma and Allergies.
New York: Life Time Media Inc; 1998:18-32, 53-57, 75-89, 169,
4. Vavra J. Environmental pollution and
asthma. RT Magazine. 2000;13(3):106-107.