Recently, two new concepts in the treatment of asthma have emerged. First, inflammation is the key to airway hyperreactivity. Second, medication can be most effective when linked to the peak expiratory flow rate (PEFR). Both concepts are important to understand when dealing with asthma in yourself or in someone you love.
Asthma is a disease in which there is an intense inflammatory reaction in the airways. This inflammatory reaction plays a key role in increasing spasms and narrowing of the airways. Treatment of this inflammation can be undertaken from two perspectives.
Avoid Inflammatory Agents
Agents that are known to cause airway inflammation in asthma include allergens, infectious agents and certain noxious gases. Other substances can trigger asthma once the inflammatory reaction has begun. These include cigarette smoke, exercise, odors, laughter or even crying.
A clear understanding of which agent may contribute to a person’s asthma is the first step in avoidance. A physician who is a specialist in the assessment and diagnosis of asthma can help identify the agents that trigger an attack. Once identified, every effort should be made to reduce exposure. This may include encasing pillows, mattresses and box springs in covers that prevent dust from escaping; removing carpet from the bedroom; placing the indoor cat or dog outdoors; and limiting exposure to second-hand smoke. Practical and simple avoidance measures such as these, when based on a thorough assessment by a qualified specialist, can go a long way toward helping control troublesome asthma.
In addition to avoidance measures, individuals with frequent or constant asthma will require the use of an inhaled antiinflammatory medication. There are two general types of medication that a doctor may prescribe for this purpose:
- Inhaled Corticosteroids (AeroBid, Azmacort, Beclovent or Vanceril). These medications help reduce airway inflammation by acting directly on the tissues and cells involved in the inflammatory reaction.
- Inhaled Cromolyn Sodium (Intal). This medication reduces airway inflammation by blocking the development of the inflammatory reaction as well as working directly on the inflammatory process. Many physicians prefer to try this medication first in the treatment of children with asthma.
Peak Expiratory Flow Rate (PEFR)
If you take in the deepest breath you can, then blow it out as fast as possible, the highest rate of air flow from your lungs is called the peak expiratory flow rate (PEFR). If asthma medications are required on a regular basis, the daily measurement of the PEFR may be beneficial. The key word is peak and refers to the fact that the measurement must be performed at maximal effort. This is similar to blowing out the candles on a birthday cake as fast as possible-in less than one second!
In many patients, regular measurement of peak flow can result in a more effective use of medication, better control of symptoms, fewer visits to the doctor, fewer trips to the emergency room and fewer hospitalizations. In addition, the PEFR can serve as an early warning system for the detection of an impending flare-up of asthma, thus permitting more timely and effective intervention.
Studies of children and adults have shown that one cannot rely on the presence or absence of symptoms in the assessment of the severity of asthma. That’s simply not good enough. During the development of an asthma attack, a significant reduction in lung function occurs before the patient feels any symptoms: chest tightness, coughing, wheezing or shortness of breath. In addition, as an asthma attack responds to treatment and symptoms are no longer present, lung function may not return to normal for several days or even weeks.
Unrecognized constant obstruction may also be a concern. In some patients, diminished lung function on a daily basis for a prolonged period of time may result in a more severe and permanent form of airway disease. The message is clear: monitor lung function at home on a regular basis.
Monitoring PEFR at Home
When asthma occurs, the air passageways of the lungs narrow. This narrowing reduces the rate at which air can be exhaled from the lungs. A fall in the PEFR indicates increasing narrowing of the airways. Several manufacturers make devices specifically designed to allow the measurement of PEFR in the home.
PEFR-Driven Treatment Plan
Patients using the PEFR-driven treatment plan should do so under the guidance of a physician. This plan assumes the patient is required to take medication on a daily basis for control of asthma.
The first step is to determine your personal-best PEFR. Record PEFRs each morning and evening for a week or two when symptoms are under good control. The highest PEFR achieved during this time can serve as the personal best PEFR. The treatment plan is based upon this value. Patients record the morning PEFR before taking their inhaled bronchodilator and their evening PEFR after taking their inhaled bronchodilator. This allows the physician to compare the lowest (which should be the morning) PEFR and the highest (usually the evening) PEFR of the day.
Once you establish your personal-best PEFR, the PEFR-driven treatment plan acts like a traffic light, indicating green (good), yellow (caution) and red (danger).
- The Green Zone (90100% of PersonalBest PEFR): At this level there is little risk of developing an acute attack of asthma. Full activity is encouraged, and there is no change needed in the usual daily medication.
- The Yellow Zone (5090% of PersonalBest PEFR): At this level, there is significant risk of an asthma attack or one is already in progress. The treatment program should be changed to permit more frequent use of an inhaled bronchodilator, an increased dose of inhaled antiinflammatory medications (corticosteroids or cromolyn sodium) and possibly the short-term use of corticosteroids by mouth. Any change in treatment must be approved and monitored by the physician. Activity should be reduced when PEFR function is in the yellow zone.
- The Red Zone (Less than 50% of PersonalBest PEFR or less than 150 L/minute in adults): If the PEFR is in the red zone, the doctor should be called immediately. In extreme circumstances, emergency care may be necessary.
If asthma care requires daily or near daily medication, the goal of management is to maintain lung function as close to normal as possible. When lung function can be controlled at levels close to your personal best, improved activity and lifestyle can be achieved. Talk to your doctor about a PEFR-driven treatment plan that involves a combination of inhaled bronchodilatory medications, inhaled anti-inflammatory medications and oral corticosteroids. Talk to your doctor about a PEFR-driven treatment plan that involves a combination of inhaled bronchodilatory medications, inhaled anti-inflammatory medications and oral corticosteroids