Get off the asthma tightrope

America's leading specialist shows six sufferers how

Tom Plaut, M.D., is a nationally recognized expert in the treatment of asthma. His work with thousands of patients has led him to create a very specific treatment program that demands an educated, disciplined approach in exchange for a lifestyle virtually unrestricted by the effects of the disease.

The author of Children with Asthma: A Manual for Parents (Pedipress, 1988) and One Minute Asthma: What You Need to Know (Pedipress, 1991), Dr. Plaut serves as an asthma consultant to HMOs, physicians and health organizations, and is an editor of the American Journal for Asthma and Allergy for Pediatricians.

Recently, Dr. Plaut visited Prevention and participated in a roundtable discussion with six asthma sufferers: Anne Marie Crown, Andrea Davitt, Susan Brown, Cemela London, Wendy Ronga and Maryann Smith. The focus was on the real-life problems of asthma sufferers and on the latest techniques they can use to better control their disease.

EYE-OPENING ASTHMA TALK
Dr. Plaut: If your asthma is under excellent control, you can do anything. You should be able to run as long and as hard and as fast as you want. You should not have symptoms more than twice a week. You should not wake up coughing with asthma. You should not need to go to a doctor or hospital because of an emergency. You should not have any significant side effects from your medication. Almost everyone should be able to achieve excellent control over his asthma. If you do have constant symptoms, either you or your doctor does not know enough about asthma in general or about your asthma in particular. I totally agree with the National Heart, Lung and Blood Institute recommendations that if a patient is not responding optimally to asthma therapy, he should seek consultation with a specialist.

I see far too many people settling for less than excellent results. Of course, patients must do a lot of work to achieve excellent control. Before their first visits, I expect patients (or parents) to read my 300-page book, fill out a questionnaire and write the story of their asthma. After the initial consultation, they measure peak flow daily for a period of at least two months and keep detailed diaries so they can learn more about asthma as they track their progress at home.

If patients don't want to do this work, it makes no sense for them to see me, since my program is successful only with their diligent participation.

Maryann: I have a lot of trouble breathing almost every day. I use a bronchodilator a lot. My doctor is a pulmonary specialist. Shouldn't he know better methods to treat me?

Dr. Plaut: Most doctors taking care of asthma started and finished their training before good asthma treatment was available. Unless they have made a real effort to keep up with this progress, they won't be up to date. The changes are unbelievable. If you're having asthma symptoms more than twice a week, not related to strenuous exercise, even though you're taking the medication your doctor prescribes, you need to get a second opinion. Look for a doctor with a particular interest in asthma. He's more likely to take the time to keep up to date on improved routines that can help you.

Susan: So what should we look for when we're searching for a good asthma doctor?

Dr. Plaut: You should look for four things. First, a good asthma doctor gives you written instructions. If he doesn't, he isn't serious about asthma.

Asthma instructions should be very detailed regarding dose, timing, technique of administration and the side effects of each medicine. These details are hard to remember! A good asthma doctor uses preprinted forms and individualizes them for you. A doctor who gives scribbled instructions is not serious about caring for asthma. You should go elsewhere.

Second, a good asthma doctor teaches you how to use a peak flow meter. (This is a simple, tubelike device that measures the fastest rate at which you are able to blow air from your lungs.) Measuring your peak flow is the most important thing you can do to check your asthma status at home. It helps you detect an asthma attack starting before you can perceive a change in your breathing.

Third, a good asthma doctor shows you how to take your inhaled medicines and watches you inhale the medicine to check your technique.

Fourth, a good asthma doctor expects patients to achieve excellent control of asthma and works with them as partners to achieve this goal.

You can call a local hospital and ask if a doctor on staff does these four things. If not, try another hospital. Don't settle for less. Some people want an asthma doctor who is close by, to be available for frequent emergencies. I recommend that you find an asthma doctor who can prevent emergencies. If you find a good doctor within 100 miles, you're doing well. Once you have achieved excellent asthma control, you may not have to see the doctor more than every 3 to 12 months.

Maryann: I've never used a peak flow meter at home. How can that help?

Dr. Plaut: A peak flow meter detects the signs of asthma in your lungs long before you perceive that you're having trouble breathing. Many people are poor perceivers. They don't recognize that their windpipes are tightening up until they are having serious difficulty breathing. Other people are so used to having breathing problems that they have no idea what a full breath feels like. I give my patients a four-color asthma diary [see page 96 for ordering information] for recording their peak flows, medicines and symptoms on a daily basis. We go over this diary together at each appointment and analyze it for asthma triggers, the effectiveness of our treatment routine and possible medicine side effects.

There are three "asthma care zones." In the green zone, people are breathing at 80 to 100 percent of their best ability and can be fully active. In the yellow zone, they're at 50 to 80 percent of their capacity. They need to start taking more medicine and avoid triggers and strenuous activity until they get back into the green zone. If they drop to the red zone, which is below 50 percent of their capacity, they're in trouble. They need to take rescue medicines, such as inhaled albuterol and oral prednisone, and see their doctors right away. With proper care, they shouldn't be in the red zone. So if they are, their doctors really need to talk with and examine them before deciding on further treatment.

Maryann: This sounds so complicated. How can I know what medications to take when? Aside from my prescribed puffs, I just kind of give myself a puff when I'm feeling wheezy.

Dr. Plaut: Exactly! You have no idea how you're doing or what you're doing. If you can hear yourself wheezing, you're in the yellow, caution zone. If you use a peak flow meter every day, you can detect problems before you get into the uncomfortable, wheezy stage. Your doctor needs to work out a complete plan with you that tells you exactly how many doses of medicine to take, in what order and under what circumstances. And you need to keep track of your medicines, peak flows and changes in symptoms.

Anne Marie: This is all new to me. I'm beginning to understand. I was very surprised when you said there should never have to be an emergency visit.

Dr. Plaut: You're surprised because, from what I can tell, you're living every day in the yellow zone, the caution zone. So when you meet up witha trigger, whether it's smoke or stressor an allergy, you drop right into thered zone--the danger zone--andneed help fast. If you were livingin the green zone and you came incontact with a trigger, you wouldn't drop so far and you'd have time to help yourself.

Anne Marie: So how do I figure what my best peak flow is? How do I know I am between 80 and 100 percent of my best lung power? I'm not even sure I know what that's like.

Dr. Plaut: I'm glad you asked me because that is an essential part of my treatment plan. You have to determine your personal-best peak flow--the best possible airflow you can get from your set of lungs. When do you test for that? When you feel good? Of course, but just because you're feeling fine doesn't mean you can blow your best peak flow.

On the first visit I check peak flow and then prescribe an oral steroid, prednisone, for seven days, to reduce inflammation as much as possible. I also prescribe inhaled albuterol, two puffs, three times a day for seven days, to relax the muscles around the windpipes. And I have patients check peak flow twice a day. Many patients see their peak flow climb even though they felt good before treatment. That's because many people with mild chronic asthma have inflamed airways even without symptoms.

A 14-year-old boy came into my office with a wheeze that I could hear 10 feet away. I asked him how he was breathing and he said "fine." His mom said this was the way he usually sounded. His peak flow was 170. It should have been in the 400s! I put him on prednisone and albuter-ol for seven days.

One week later his peak flow was 350. A week later it went up even higher than that! His mom told me he was more active than he had been anytime in the past three years. Up to this point Bill and his mom had low expectations for what he could do with asthma. He had been unnecessarily handicapped for years.

Susan: That's so scary. Is that why we hear more and more about deaths from asthma?

Dr. Plaut: In my opinion, 90 percent of asthma deaths are preventable. People don't die because they have asthma. They die because they don't get proper treatment. Often, neither the patient nor the doctor realizes that he's in trouble. Ordinarily, asthma problems come on slowly. They give plenty of warning to the person who is monitoring peak flow. Early treatment will prevent most asthma deaths.

Let's move on. You all have chronic asthma and you all use metered-dose inhalers (MDIs), right? Let me ask you, how many puffs in a canister?

Cemela: I think there are 200.

Dr. Plaut: How do you know when the canister is empty?

Cemela: I put it in water and see if it floats. If it floats, it's empty.

Dr. Plaut: That's a perfect example of how fast asthma information changes. The float test doesn't work with the cromolyn inhaler because the powder in the MDI valve stem swells up when it comes in contact with water. This blocks medicine from leaving.

How many puffs are there in your canister? Some medicines come in different sizes. Of course a particular canister lasts longer if you use four puffs a day than if you use eight puffs a day. I recently saw a man whose asthma was well controlled with Aerobid, an inhaled steroid. Recently he started having problems. Together we tried to figure out what was going wrong. Had he been exposed to an allergen, cigarette smoke or cold air? Did he have an infection? We couldn't figure it out. Then I asked him when he started using his latest canister. It had 100 puffs of medicine in it and he'd been using it for 30 days, two puffs, three times a day. At six puffs a day he should have thrown it away on the seventeenth day, but he had never calculated the discard date. He started having trouble after the twentieth day. Even though he could still hear the puff and could see some mist come out, he'd been using an empty inhaler for two weeks. In an experiment, I found I could get 39 additional puffs out of an inhaler after the medication was used up. So what do you do?

Anne Marie: I keep a yellow sticky note paper on my inhaler, and I make a slash every time I use it. I throw the inhaler away when I've reached the maximum puffs.

Dr. Plaut: That's excellent! You're really organized! But there's an easier way. Say you're using cromolyn (a medication that blocks inflammation of the windpipes), eight puffs a day. It is easy to calculate: a 200-puff canister lasts 25 days. Simply throw it away on day 25. Of course, it depends upon the dose you're taking and the size of the canister. Some MDI canisters have 80 puffs, some have 100 puffs, some have 200 or 240. It's important to know how many puffs your canister has! The day you start to use it you should write the discard date; that is, write--on the canister--the date to throw the inhaler away.

I teach every patient to use a metered-dose inhaler (MDI) with a holding chamber. Hardly anyone gets full benefit from using the MDI alone. There are too many things to coordinate: position, timing, slow breath in, holding for 10 seconds. I work very hard to convince doctors that an inhaler that isn't used right will not be effective. As an example, I puff the inhaler into my ear and then ask the doctors whether that will work. Sure they laugh, but they get my point.

To get the most benefit from an inhaler, you must use it with a holding chamber. That's all there is to it. A holding chamber is a tubelike device that you attach to the inhaler. The spray enters the chamber that holds the medicine, allowing you to breath in slowly, over a period of five seconds. If you inhale the medicine too quickly, say in two seconds, it hits the back of the throat and never makes the turn down into the windpipe.

Here's something you probably don't know. The droplets coming out of your inhaler range in size from 1 micron to 40 microns. A micron is a millionth of a meter. It's tiny. Only the droplets between 1 and 5 microns can get down into your windpipes, where they will be effective. A puff from your metered-dose inhaler squirts many medicine particles into your mouth that are too large to get into your airways. However, these large droplets are absorbed from your mouth into your bloodstream and can cause adverse effects. If you use a holding chamber, the larger droplets will remain in the chamber and then you mainly breathe in the small droplets that will do you some good. This means you get less tremor or shakes from your albuterol, and you get fewer side effects from your inhaled steroids. [Editor's note: Inhaled steroids are like the steroids normally made by the adrenal gland. They are not the muscle-building steroids that athletes use.]

Andrea: What about theophylline?

Dr. Plaut: Ten years ago, I prescribed theophylline for every one of my patients. Now, I rarely prescribe it. Theophylline does not prevent asthma attacks, and inhaled albuterol--Proventil and Ventolin--is safer and much more effective in treating them.

Wendy: I have terrible allergies that really keep my head stuffy and cause me to wheeze a lot. I prefer taking an oral bronchodilator, Proventil. I just feel like I need something long acting and powerful.

Dr. Plaut: Both Proventil and Ventolin are adrenaline-like bronchodilators. It's rarely necessary to take one of these medicines by mouth. Remember what I said about oral medicines versus inhaled ones? The inhaled medicines go straight into your windpipes where you need them. When you swallow albuterol, you have to take 10 times as much as when you inhale it from a metered-dose inhaler. This higher dose causes more side effects. Oral medicines go to your stomach, where they are absorbed into your blood. Once in the blood, the medicine is distributed throughout the body instead of only to the lungs. Patients often need to take two or three doses of an adrenaline-like medicine during an asthma attack. This is safe with an inhaled medicine but is not safe if you're using the oral preparation at 10 times the dose.

Let me say it one more time. People with asthma really do need to communicate with their doctors. If their doctors don't want to communicate at the level I'm suggesting, then I feel they need to find new doctors.

FOLLOWING THROUGH
Dr. Plaut's advice was not lost on the participants at the discussion, especially Maryann. Maryann had had almost constant symptoms, was living on the edge of the danger zone and constantly used her bronchodilator inhaler. After listening to Dr. Plaut, she decided to look for a new doctor rather than continue seeing her pulmonary specialist. Under the supervision of an asthma specialist, she began taking anti-inflammatory drugs to bring her asthma under control and learned to use a holding chamber and a peak flow meter.

"I am so grateful for that meeting," she said three months later. "I am 80 percent better than I was. I no longer live in the red zone! I'm not cured, but every day is so much better and I no longer have sleepless nights."

Wendy, who was taking an oral bronchodilator, visited her doctor, who stopped the oral medication and prescribed inhaled steroids to reduce inflammation. "At first I didn't think stopping the oral medication made any difference at all in my asthma, for better or worse. And I thought, gosh, I was taking all that medicine into my body for all those years for nothing! Then I realized that my heart wasn't beating as rapidly as it had been, and after a while I realized I just feel better all around. The anti-inflammatory inhaler has really helped reduce the amount of wheezing I experience. It seems so simple now.

"It makes me angry that my doctor didn't keep up with new medications. Patients really have to keep themselves informed."

For more information, contact any of the following organizations: American Lung Association, GPO Box 596, New York, NY 10116-0596, or call (800) LUNG-USA; National Heart, Lung and Blood Institute Information Center, P.O. Box 30105, Bethesda, MD 20824-0105, or call (301) 251-1222; National Jewish Center for Immunology and Respiratory Disease, 1400 Jackson St., Denver, CO 80206, or call (800) 222-LUNG. Copies of Dr. Plaut's four-color Asthma Peak Flow Diary are available from Pedipress for $10 for 100 sheets, including shipping and handling. Send check or money order to Pedipress, Inc., 125 Red Gate Ln., Amherst, MA 01002.

DIAGRAMS: Using a holding chamber (left) delivers asthma medicine more efficiently. A peak-flow meter (right) lets people with asthma get a jump on an impending attack.

CHART: An asthma diary helps the asthmatic person and her doctor develop an effective treatment plan that puts the patient in control of her disease.

PHOTO: Dr. Tom Plaut

ILLUSTRATION

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By Maggie Spilner

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