This summary can only feature some major points from the GINA guide, which contains detailed advice, including numerous tables. Patients and their relatives may wish to visit the Internet site where the full guide - NIH Publication No. 02-3659A - is posted: http://www.ginasthma.com/gina_pocket.pdf . Robert Griffith, Editor.

Asthma is becoming increasingly common, especially in children. It is easily diagnosed with the help of a careful history of symptoms, physical examination, and a few simple tests of respiratory function; it's important for the doctor to exclude the possibility of croup, bronchitis, a heart attack, or vocal cord malfunction. These guidelines are concerned with the treatment of asthma, and how to prevent attacks, as far as possible.

Peak flow meters

It's necessary to be able to assess the severity of asthma at different times, to be able to manage it effectively. Peak flow meters measure the peak expiratory flow (PEF) - the maximum rate at which the subject can expel air from the lungs using as much force as possible - which is a good indication of the degree of obstruction to air flow. The patient can do these tests themselves, at home.

Daily PEF measurements for 2-3 weeks are useful for establishing a diagnosis and planning treatment. Predicted values are supplied with the meter, based on age, weight, etc: and the patient's values are expressed as a percentage of predicted value. (Alternatively, they can be expressed as a percentage of the patient's personal best PEF, which is the highest number the patient can achieve over a two week period when the asthma is under good control. Good control is when the subject feels good and has no asthma symptoms or are at the best they can be.)

Long-term PEF monitoring is useful for evaluating response to treatment, and to give a warning of worsening before symptoms occur.

Spirometry is a more complicated measurement that's done in a respiratory lab. It measures the forced expiratory volume during one second (FEV-1), which can be used in a similar way to the PEF.

Severity

The severity of asthma determines the type of treatment needed. There are 4 levels of severity:

	Symptoms/Day	Symptoms/Night	PEF %
Intermittent	Less than 1/week	Less than 2/month	80% or more*
Mild Persistent	More than 1/week, but not daily	More than 2/month	80% or more
Moderately Persistent	Daily Interferes with activity	More than 1/week	60% - 80%
Severe Persistent	Continuous Limits activity	Frequent	below 60%

* percentage of predicted PEF

Patients at any level of severity - even intermittent asthma - can have severe attacks at times.

Management of asthma

There are six steps in the successful management of this condition: education, monitoring severity, avoiding risk factors, a long-term medication plan, a plan for treating attacks, and good follow-up care.

Education

This implies getting the patient actively involved in managing their asthma, based on the following:

• knowledge of their own risk factors,
• how to take their medications correctly,
• knowing which medications are used for long-term control ('preventers' or 'controllers' )and which are for relieving an attack ('relievers'),
• how to monitor their severity using symptoms and a PEF meter, and
• how to take action when asthma is worsening, seeking medical help if necessary.

A written plan is highly desirable. It should be completed by the doctor and the patient, working together. Samples can be found at these sites:
http://familydoctor.org/handouts/696.html
http://blueprint.bluecrossmn.com/images/Asthma_Action_Plan.pdf
http://www.chestnet.org/downloads/education/patient/guides/asthma_control/actionplan.pdf

Monitoring severity

Long-term PEF monitoring at home is the best way to recognize early signs of worsening of asthma - a reading less than 80% of one's personal best is an alert. Regular doctor's visits are necessary, when the following check-list can be discussed:

• Are you meeting your asthma plan management goals?
• Are you using your inhaler, spacer, and peak flow meter correctly?
• Are you taking your medications, and avoiding your risk factors, according to plan?
• Do you have any concerns?

If necessary, medications can be adjusted, and the management plan modified to suit new circumstances.

Avoiding risk factors

Common risk factors and ways to evade them are given below:

Risk Factor	Avoiding Action
Domestic dust mite allergens	Wash bed linen weekly, keep pillows and mattress in air-tight covers, replace carpets with linoleum etc, use vinyl, leather or wood furniture. Vacuum with a filter.
Tobacco smoke	Avoid all tobacco smoke
Allergens from furry animals	Ban animals from home, or at least bedroom.
Cockroach allergen	Clean suspect areas regularly, and spray.
Outdoor pollens and molds	Windows and doors shut when counts are high
Indoor mold	Reduce dampness in the home.
Physical activity	Don't avoid exercise - use an inhaler first!
Drugs	No beta-blockers, aspirin, or NSAIDs if these cause symptoms.

One can consider allergy injections to attempt desensitization to grass, other pollens, dust mites, animal dander, etc. if avoiding the allergen is not possible, or medications fail to control the symptoms of exposure.

Long-term medication (preventers/controllers)

The number of medications used is increased (stepped up) as greater control is needed, and decreased (stepped down) when the condition is under control.

Anti-inflammatory drugs, in particular inhaled steroids, are at present the most effective preventers. It's best to obtain control promptly with a high level of treatment (e.g. addition of an extra drug to the regular therapy the patient is taking), and then step down.

Stepping up is necessary if control isn't achieved and sustained within a month. Stepping down can be done if control is sustained for at least 3 months. And once the asthma is under control, treatment should be reviewed every 3-6 months.

Preventer medications include:

• Glucocorticosteroids - inhaled, tablets, or syrup
• Sodium cromoglycate - inhaled
• Long-acting beta-2 agonists - inhaled, tablets
• Sustained release theophylline - oral
• Antileukotrienes - e.g. montelukast, pranlukast

Treating asthma attacks (relievers)

Never underestimate the severity of an attack; a severe attack may be life-threatening. Seek medical care if the patient is:

• breathlessness at rest
• hunched forward position
• talking in words rather than sentences
• agitated, drowsy, or confused
• respirations over 30/minute, or pulse over 120/minute
• PEF less than 60% of personal best even after initial treatment
• no improvement within 2 hours after oral glucocorticosteroid
• response to bronchodilator treatment is not sustained for 3 hours

Prompt treatment with reliever medications is needed, starting with an inhaled beta-2 agonist in adequate doses e.g. Albuterol, Fenoterol, Salbutamol. Oral steroid therapy is begun early. Other reliever drugs may be used as required.

Reliever medications include:

• Short-acting beta-2 agonists - usually inhaled; also tablets, syrup
• Anticholinergics - inhaled: e.g. ipratropium, oxitropium
• Short-acting theophylline - intravenous infusion
• Epinephrine/adrenaline - by injection

The following are not recommended for acute asthma attacks:

• sedatives
• mucolytic agents - they may worsen cough
• physical therapy to the chest
• hydration with large volumes of fluid
• antibiotics - unless there is a bacterial infection

Regular follow-up care

Once asthma is controlled, the patient should make regular follow-up visits to his physician, or the clinic that is helping to manage his/her asthma. The interval - between 1 and 6 months - varies with the individual and the ease with which the condition is controlled.