Developing an Asthma "Action Plan"
Why Consider an Asthma Action Plan?
Asthma is a dynamic condition: the narrowing of the air passageways that impairs breathing in asthma is variable. As anyone who has asthma knows, one's breathing can be fine one day and very difficult the next. In fact, under certain circumstances one's asthma can flare up in a matter of minutes. An example might be a woman with asthma who is sensitive to cat dander: if she visits a friend's home and is exposed to the dander of the friend's pet cat, within a brief while she may begin to develop cough, wheezing, tightness in the chest, and difficulty breathing. Another common trigger of asthma symptoms is a respiratory tract infection: a man with asthma who develops a "head cold" may have cough and nasal congestion for a few days, then awaken at 3:00 A.M. with shortness of breath and severe chest congestion. He uses his inhaled bronchodilator but obtains no relief. What should he do?
An easy answer to the question of "what to do" is to call your doctor. Oftentimes, this action is the correct response to a crisis or any period of difficulty with your asthma. However, there may be times when your doctor is not immediately available and when you need to act quickly, before making contact with him/her. In addition, there may be circumstances where you are confident of the right action to take and don't need professional advice. For example, the woman visiting her friend and friend's cat probably knows that the best course for her to take is to leave promptly from that apartment; her asthma symptoms may resolve quickly simply by removing herself from the cat dander to which she is allergic. She does not need consultation with her physician to know what she should do, at least as a first response to the problem.
The purpose of this pamphlet is to help you to consider what actions you might take in the event of an attack of your asthma: that is, if your asthma symptoms develop rapidly and your breathing becomes difficult. Although one cannot possibly anticipate all possible circumstances, it is good to consider in advance, in a general way, "what would I do if...." And to consider further, if you took such and such an action and still were not better, or possibly even worse, what would you do then. You may have family and friends who would like to be useful to you during an acute attack of asthma. We encourage you to share this pamphlet with them.
Developing an Action Plan
The best way to develop a plan of action for dealing with an asthmatic attack is to have a discussion about it with your physician. The plan that you and your physician develop will depend in part on how severe your asthma is, on what medicines you usually take for your asthma, and possibly on your past experiences with attacks of asthma. No single plan of action could be right for all persons and for all attacks. What follows is meant only as a broad guideline, one that you might use as a basis for discussion with your physician about your individualized action plan.
Understanding an Asthma Attack
To develop a strategy for dealing with asthmatic attacks, it is helpful to understand the processes going on in the lungs that cause the difficulty in breathing. An overview of this subject is provided in the pamphlet, What is Asthma?, prepared by the staff of the Partners Asthma Center. In brief, there are two mechanisms by which the air passageways become narrowed, limiting the flow of air into and (especially) out of the lungs: these two mechanisms require different forms of treatment. The one mechanism is contraction of the involuntary muscles that ring the bronchial tubes. Contraction of bronchial muscles can occur over a period of minutes and sometimes reverses on its own. An example is the wheezing and chest discomfort triggered in persons with asthma by exercise or exertion in cold air. Contraction of bronchial muscles is treated with bronchodilators: medications that cause the muscles to relax and thereby open the air passageways wider. Inhaled bronchodilators (such as Ventolin®, Proventil®, Alupent®, and Maxair®) begin to act within minutes; if taken by mouth, oral bronchodilator tablets or capsules take longer to begin working; the delay results from the necessity for the medication to be absorbed from the stomach into the blood and delivered via the bloodstream to the bronchial tubes.
The other mechanism by which breathing becomes difficult in an asthmatic attack is swelling of the bronchial tubes and plugging of the tubes with mucus produced by glands in the walls of the bronchial tubes.Swelling of the bronchial tubes and excess mucus production are the result of inflammation — in the same way that a lip swells if hit by a ball and the nose makes lots of secretions during a common head cold. Bronchodilator medications have no effect on this part of an asthmatic attack. Medications that reduce bronchial swelling and excess mucus production are called anti-inflammatory drugs; the most widely used anti-inflammatory drugs are corticosteroids (see the pamphlets, Asthma and Treatment with Inhaled Steroids and Asthma and Steroids in Tablet Form, prepared by the Partners Asthma Center). Inflammation of the bronchial tubes cannot be made to go away within minutes; it usually takes several hours or days to resolve. Steroid tablets (e.g., prednisone or Medrol®) are the most powerful anti-inflammatory treatment available, but they can have considerable side effects. Steroids taken by inhalation (e.g., Vanceril®, Beclovent®, Azmacort®, Aerobid®, Qvar®, Flovent®, or Pulmicort®) are not as powerful or as rapidly effective as the tablet form, but they have few undesirable side effects.
Recognizing an Asthma Attack
The first step in dealing with an attack of asthma is recognizing that an attack is present. Certainly if one is having a severe attack and "can't breathe," recognition of the attack poses no problem! However, at other times it is all too easy to minimize one's symptoms of an asthma attack — to attribute them to a "cold" or an "allergy," or to assume that "everything will just get better in a little while." Here is where a home peak flow meter often proves very useful (see the pamphlet Asthma and Peak Flow Monitoring). A peak flow meter is a portable and easily used plastic device that allows you to measure your breathing capacity and to determine accurately how severely it is impaired. It can demonstrate clearly whether you are having an asthma attack (because your peak flow will be reduced significantly from its usual) and alert you to how severe it is (based on how low your peak flow has fallen).
If you are dealing with an asthma attack without the benefit of a peak flow meter, you must rely solely on your symptoms. You can be guided in part by how short of breath you feel. In general, an asthma attack is severe when the peak flow is half of your normal value or less or when you feel short of breath with just light exertion (such as walking slowly or dressing).
The second step is to get away from triggers of your asthma, if at all possible. These may include furry animals, strong fumes, cigarette smoke, fresh cut grass, etc.
Treating an Asthma Attack
The best first treatment for an asthma attack is your inhaled beta-agonist bronchodilator (e.g., albuterol, Ventolin®, Proventil®, Maxair®, Alupent®, etc.). It works rapidly (within 5 minutes). For it to be effective, you must inhale the medication slowly and deeply into your lungs. The usual dose is two inhalations (or "puffs"), although for severe attacks you may obtain greater relief with 3 or 4 inhalations.
The long-acting inhaled bronchodilator, Serevent®, is not meant for this purpose
In an attack of asthma, it is safe for you to use your bronchodilator inhaler even if you had already taken it within the past few hours. In fact, if you are not getting better after the first treatment with your inhaler, you can use it again as often as every 20 minutes over the next one hour until the distress of the acute attack lessens. If you have an electric compressor and nebulizer available, you can administer your inhaled bronchodilator as a "wet aerosol" or mist breathed over 10-15 minutes. The same medications (Proventil®, Ventolin®, albuterol, Alupent®, Bronkosol®, and Tornalate®) are given in this manner.
Many persons who take a theophylline medication (e.g., Slophylline®, Slobid®, Uniphyl®, Theochron®, Quibron®, etc.) are tempted to take extra theophylline for an acute attack of asthma. This approach is less satisfactory because: 1) the theophylline takes longer to begin working and 2) if taken in excess amount, theophylline can sometimes cause quite serious side effects (if the level of theophylline rises too high in your blood).
Remember that none of the bronchodilator medicines treats the inflammation of the bronchial tubes. The biggest mistake that you can make in treating an attack of asthma is to rely solely on bronchodilators when your asthma attack is not getting better, or when it improves only briefly, then worsens again. Other medicines are needed to treat the swelling and excess mucus in the bronchial tubes — usually these are corticosteroids. Steroids will take time to act; inflammation will resolve only slowly. If your asthma attack is not much better after using the inhaled bronchodilators, it is a mistake to delay use of the steroids. In our opinion, this is the greatest danger from overuse of inhaled bronchodilators: delay in treatment with other needed medications.
Persons with a mild or moderate attack who have some initial improvement from their inhaled bronchodilator may begin use or increase use of inhaled steroids. For example, persons taking fluticasone (Flovent®) 2 puffs twice a day may increase to 4 puffs twice a day (or 2 puffs 4 times a day) until they are back to normal. As long as the attack remains under control (and the peak expiratory flow rate remains more than one-half of your normal or greater than 200 L/min), this strategy is acceptable, although often the improvement will be gradual. During this time you should continue to use your bronchodilators regularly, until the steroid medication takes effect
Managing Severe Attacks
For more severe attacks, or for attacks where the breathing (and PEFR) are getting worse rather than better, the steroids will need to be taken by mouth. You will need to begin a "short course of oral steroids" — or if you take oral steroids on a regular basis, the dose will need to be increased. Oral steroids are powerful medications with multiple possible side effects; their use should be undertaken in consultation with your physician. Often, if you have had a short course of oral steroids in the past, your physician may provide you with a prescription for prednisone or Medrol® to have at home for use in an asthmatic crisis such as described here. That is, he/she may prescribe oral steroids for use as part of your Action Plan. Beginning oral steroids in a timely fashion is often the most effective means to avoid deterioration to the point of needing hospitalization for severe asthma. If home measures are not working, you should go to your nearest emergency room or acute care facility for help. Have a plan as to where you will go in an asthma crisis and how you will get there; it would be good to share this plan with your family or friends. One final word of caution: an "action plan" is not meant to make patients into their own doctors nor to encourage you to stay home if your asthma needs emergency department care. You do not have to deal with asthma attacks by yourself. Through the Partners Asthma Center, a physician is available AT ALL TIMES to help you make good decisions regarding care of your asthma — or to make those decisions for you.