Asthma diagnosis, treatment, management

Asthma and Allergy Center of Chicago, SC
www.AsthmaAllergyChicago.com
www.Research4Health.com
Ver517
PERSPECTIVES IN ASTHMA CARE
©
John MacTaggart
DISCLAIMER: 99% OF THIS DOCUMENT IS ORIGINAL TEXT. SOME IMAGES HAVE BEEN
HIJACKED, OTHERS ARE PUBLIC DOMAIN. THE INFORMATION CONTAINED HEREIN IS FOR GENERAL
EDUCATION PURPOSES FOR PATIENTS OF THE ASTHMA AND ALLERGY CENTER OF CHICAGO, AND NOT
SPECIFIC RECOMMENDATIONS OR INSTRUCTIONS FOR INDIVIDUAL MEDICAL CARE.
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ASTHMA: WHAT’S UP.DOC?
Ok, everyone agrees, if it looks like a duck, walks like a duck, and sounds like a duck,
it must be a...? So far, we can describe a lot about what asthma looks and sounds like
but we are still at a loss to exactly define what is asthma?
We really don’t have a good idea of how many people have some form of asthma but
estimates range from 10-25% of the entire population. You may be asking yourself,
why don’t we know how many people have asthma? In fact, you’re probably asking
how do you even know that you have asthma?...Well, keep reading.
Let’s clear up a few things first. All asthma is asthma. Just stop confusing yourself
by listening to people who use the terms such as “wheezy asthma”, “cough asthma”,
“allergic asthma”, “non-allergic asthma”, “hyper-reactive airway disease”, “nocturnal
asthma”, “exercise-asthma”, etc..
Doctors may use different words to associate a particular symptom or trigger some
people may have with their asthma but in the end…a duck is a duck. For someone
who has asthma, it is more clinically useful to designate asthma as either
Intermittent or Persistent.
Intermittent Asthma is characterized by:
1. Normal lung function and no symptoms in the absence of exposure to a
specific trigger (say a cat or a cold).
2. When asthma is triggered, lung function worsens and symptoms may
develop.
3. With treatment, intermittent asthma is completely reversible (we’ll talk
about lung function tests later).
Persistent Asthma is characterized by:
1. Abnormal lung function in the absence of ongoing asthma treatment,
whether or not they have symptoms.
2. With treatment, lung function may or may not normalize for people with
persistent asthma.
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Asthma typically starts before the age of ~ 35. If you are 50 years old and just
developed your first-ever breathing problems of your life, you don’t have asthma;
it’s some other illness causing the problem.
Surprise...asthma runs in families. So do you want to know what are the chances of
someone becoming asthmatic if one or both of their parents have asthma?
Let’s quote population statistics:
6.5% of families in which neither parent have asthma have a child with
asthma.
28% of families in which one parent has asthma have a child with asthma.
63% of families in which both parents have asthma have at least one child
with asthma.
In other words, when surveys compare children in the population whose parents do
not have asthma, children with 1 parent who has asthma are 3-6 times more likely
to develop the condition, and children with 2 parents with asthma are 10 times
more at risk than those without parents with asthma.
Wait a minute! So just what is the actual risk for each of your children developing
asthma? Unfortunately, no one can tell you the actual risk for your individual
children. Were talking population statistics here, not individual prediction. Some
individuals inherit the potential to get asthma but then must be exposed to
something else to express their full asthma potential. What that something else may
be for each individual (and the risk for asthma) remains unknown.
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MORE BS (basic science)
Asthma is commonly described as a chronic disease or a syndrome (a group of
diseases) in which the small and medium sized tubes through which air and oxygen
move in and out of your lungs show some degree of reversible blockage.
Asthma has 2 major components: airway inflammation, and airway constriction
or bronchospasm”.
Inflammation simply means that the lining of the lung tubes appear red and swollen.
Bronchospasm refers to tightening (or constriction) of the smooth muscle around
the outside of the lung tubes.
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Whether or not you have symptoms, untreated asthmatic lungs have some ongoing
inflammation and bronchospasm. During asthma attacks, these processes worsen,
symptoms appear and activity limitation occurs; ultimately, in the worst case
scenario leading to, as they say on television…death.
Cells involved in asthma inflammation
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DIAGNOSIS
How do you know if you have asthma? This is not some great philosophical
question. Let’s see if you can get the point by using some analogies.
Can a doctor tell you what your blood pressure is by listening to your heart or
feeling your pulse? How about a doctor knowing your temperature by feeling your
forehead?
Obviously, then a doctor can know your level of lung function by listening to your
lungs or asking you how you’re breathing…. ridiculous!
So, how do you know if you actually have asthma? You have to use the right tool to
measure lung function; a simple office test called spirometry. This test should be
available in every single doctor’s office that treats people with asthma.
"Spirometry should be undertaken in all patients with Asthma. It remains
THE STANDARD for diagnosing and monitoring Asthma. All physicians who
care for Asthma patients should have access to spirometry for routine care of
their patients"
World Health Organization, National Heart, Lung, and Blood Institute, American
Thoracic Society, American Academy of Asthma, Allergy& Immunology, American
Academy of Family Physicians, American Board of Internal Medicine, American Academy
of Pediatrics
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Spirometry assessment of pulmonary function is NECESSARY
for the diagnosis of asthma because medical history and physical
examinations are not reliable means of excluding other diagnoses
or of characterizing the status of lung impairment”
[NHBLI Expert Panel 2. Guidelines for the Diagnosis and Management of Asthma]
YOU CANNOT ACCURATELY DIAGNOSE ASTHMA WITHOUT DOING SPIROMETRY.
Spirometry can and should be done on every single person to clearly establish the
diagnosis of asthma, then, repeated regularly to determine response to therapy and
the course of the disease. It is a very simple test that can usually be performed even
on young children, typically after the age where they are coordinated enough to
blow up a balloon. Peak flow meters (see below) are not accurate enough to be used
to diagnose asthma.
Repeat After Me:
Doctors must do spirometry to diagnose me with asthma, and regularly
thereafter to determine my response to treatment
In infants and younger children in whom it is not possible to do lung function tests,
we currently do not have any other widely available, simple tests to help in
diagnosis and treatment. For these young children, the diagnosis of asthma relies
upon a history that shows repeated or persistent breathing problems that respond
to specific medications, without evidence of other underlying respiratory disease. It
is important to realize that children can have active asthma and have few symptoms.
Any repeated respiratory symptom (cough, shortness of breath, etc.) which may
occur with routine activity (laughing, crying, colds, or exercise) may actually be
signs of asthma.
Doctors must take an accurate clinical history to determine if you have asthma, and
whether there is evidence for other commonly associated diseases such as allergies,
eczema, or nasal/sinus polyps. It is important to determine if you may have other
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conditions that could give you asthma-like symptoms such as acid reflux (GERD),
sinus disease, chest wall inflammation (costochondritis), or other non-asthma lung
disease. Records of any previous treatment may be of benefit in determining
current and future therapy.
If you have any other active medical conditions such as heart disease, high blood
pressure, skin disease, or allergies it is important to inform your doctor. All
medications have potential side effects and your doctor needs to know all of your
current medications (including over-the-counter) in order to limit adverse drug
interactions and side effects from asthma therapy.
If you haven’t had a chest x-ray, one should be done at sometime in your asthma
evaluation to look at the anatomy underlying your lung function. Other blood tests
including a CBC, thyroid, liver, vision/glaucoma, and bone density tests may be part
of your assessment. Your doctor may order Allergy testing if your clinical history
and exam indicate potential allergy triggers for your airway disease.
Finally, you’ll need a complete physical examination. The airways start with your
nose and mouth. Your doctor needs to determine if there are signs of inflammation
in these areas (let’s not forget your eyes and skin too). As anyone with asthma
knows, upper airway problems always lead to problems with asthma.
Although there is nothing specific on physical examination that can differentiate
allergic from non-allergic tissue inflammation, the absence of findings is important.
Not all inflammation of the airways is allergic; infections, irritants, drugs, pregnancy,
hypothyroidism, acid reflux, and nasal polyps are some of the other non-allergic
conditions that may be associated with symptoms and physical findings similar to
those caused by allergies.
ASTHMA TRIGGERS
For each individual, there are a variety of things that may cause acute asthma
worsening. The common cold, seasonal or animal allergies are the most frequent
asthma triggers among asthmatics. Non-allergic triggers such as cigarette smoke,
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poor air quality, hairspray, paints, fumes, and other irritants may cause some
individuals asthma to worsen.
Normal activities such as exercise, laughing, crying, or sleep should not cause acute
asthma problems. If your asthma worsens with these activities, it indicates that
your asthma is not properly controlled.
TREATMENT
Asthma: Medication or Device?
Asthma care shouldn’t be all that difficult but then neither should doing your taxes.
Basically, there are two primary classes of asthma medications:
anti-inflammatory and anti-bronchospasm (and some other treatments we’ll
mention later).
Within each of the medication classes, all the medicines have essentially the same
benefit. The great majority of asthma patients should have complete control using
an anti-inflammatory therapy once or twice daily and occasional use of an anti-
bronchospasm agent. Is that you? your child?...why not?
Well, here’s the problem. The best asthma treatments today are given via inhalers
(or for very young children via nebulizers). In reality, doctors don’t actually
prescribe asthma medications for their patients, they prescribe devices (inhalers or
nebulizers) that have medicine in them.
The real problem is that most doctors don’t understand how to effectively
deliver medications from inhaler or nebulizer devices into their patients’
lungs or how to properly instruct patients how to use the devices..
how embarrassing.
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It sounds silly but consider this: if you put gasoline into the back
seat of a car does it work as well as if you put it in the gas tank? Asthma medications
in inhalers need to get into the lungs to work effectively. There are distinct
advantages and disadvantages for different asthma inhalation devices. Inhaler
devices should be matched to each individual to obtain the best results.
There are a variety of different inhalers and inhaler accessory devices on the
market. Below are just a few examples:
INHALER EXAMPLES
EXAMPLES OF ADD-ON DEVICES FOR INHALER USE
Now let’s get on to a discussion of some of the different asthma medications
currently available…..
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MEDICATIONS
The most effective asthma medications for control of persistent asthma are those
that act long-term to reduce the underlying airway reactivity. Reduction in the
airway reactivity leads to improvements in lung function, fewer symptoms, and the
ability to perform normal daily activities.
Discuss all prescribed medications with your doctor; the risks of therapy should not
outweigh the potential benefits.
1. Short-Acting Beta 2-Agonists (SABAs)
“Rescue Inhalers or Nebulizers”. These are the medications with which most
asthma patients are most familiar. They are the inhaler or “pump” that
people pick up for immediate symptom relief. These medications are
available in liquid, pill, inhaler, and nebulizer forms. If you use a short
acting beta 2-agonist more than twice weekly it indicates that your
asthma is not under control.
Proper dosing and use of inhaled corticosteroid (ICS) or combination inhaled
corticosteroid-long-acting beta 2-agonist therapy (ICS/LABA) should
virtually eliminate the need for the use of rescue, short-acting beta 2-agonist
medication in all virtually all asthmatics. Some brand names include:
Albuterol HFA, Proventil HFA, ProAir HFA, Xopenex HFA, and Maxair.
2. Inhaled Corticosteroids (ICS)
Considered to be the most effective preventive, anti-inflammatory, long-term
therapy for all levels of persistent asthma. There are no real differences in
benefit among the different medications but actual results seem to vary due
to the use of different inhalation devices for the different medications. The
majority of asthma patients can be well controlled with once or twice daily
use of the appropriately inhaled medication. These medications are
generally well tolerated and safe. Simple mouth rinsing after use can prevent
white fungus patches in the mouth. Some brand names include: Flovent HFA,
Flovent Diskus Pulmicort, Asmanex, QVAR, Alvesco, AerobidHFA.
3. Inhaled Long-Acting Beta 2-Agonists (LABAs)
These agents exert an anti-bronchospasm effect for anywhere from 8-24
hours. There is some concern regarding use of these agents with and without
the use of an inhaled corticosteroid. Some patients using these agents alone
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as regular preventive therapy may be at increased risk of side effects,
including death. As this issue still remains, the FDA does not approve the use
LABAs for asthma as single therapy but does approve the use in combination
with inhaled steroids. Some brand names include: Serevent, Foradil, Arcapta,
Vilanterol, Striverdi.
4. Inhaled Combination Corticosteroid-Long-Acting Beta 2-
Agonists (ICS/LABA)
The addition of long-acting anti-bronchospasm agents (beta 2-agonists) is
beneficial in those patients who, in spite of adequate inhaled corticosteroid
use, continue to have activity interference, symptoms, and a need for rescue
asthma inhalers. Many patients are needlessly prescribed combination
therapy due to failure to adequately deliver inhaled steroids (most often due
to poor inhaler technique). Some brand names include: Advair, Symbicort,
Breo, Dulera.
5. Other Stuff
a. Anticholinergics
Inhaled medications primarily used to treat COPD, although may be
beneficial for many asthmatics. Short acting anticholinergics are not FDA
approved for asthma but are clearly useful instead of short-acting beta 2-
agonists for people who cannot take usual SABA rescue medication.
Some brand names for short acting agents include: Atrovent, Atrovent
HFA, Robinul, Combivent (a combination of Atrovent with Albuterol).
Spiriva, a long-acting anticholinergic agent (LAMA) is FDA approved for
use in patients uncontrolled on ICS/LABA therapy. Some brand names of
other LAMAs include: Spiriva, Turdoza, Seebri, Incruse.
b. Inhaled Cromolyn
Basically, extremely poor medications compared to inhaled steroids for
long-term preventive control. These agents work best when used
immediately prior to allergen (animal) exposure to prevent allergen
(animal) induced asthma attacks. They may also have a limited role as
additional agents to beta 2-agonists for prevention of exercise-induced
asthma. Available only for nebulizer use in the US, the only brand name
is: Intal.
c. Methylxanthines
Basically, after 50 years of use, a class of medications still looking for a
reason to be prescribed. Once a mainstay of therapy, the use of these
medications has fallen into disfavor due to a high level of side effects and
inadequate benefit. Due to widespread misuse, these medications should
only be prescribed by a specialist familiar with the risks. Some brand
names include: Theophylline, Slobid, Theodur, Theo24, and Uniphyl.
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d. Leukotriene Modifiers
These medications act as poor anti-bronchospasm agents but are
marketed to doctors as anti-inflammatory-like treatments. They do not
offer the benefits of inhaled corticosteroid therapy, and add nothing to
asthma control for those patients properly dosed with inhaled
corticosteroids. Studies demonstrate that people using these agents have
poorer asthma control compared to those using inhaled corticosteroids.
Two brand names currently marketed include: Singulair, and Zileuton.
(Note, many asthma specialists consider Zileuton to be a potentially
dangerous drug due to risk of liver toxicity). Singulair is also marketed
for the treatment of allergies; in reality, it provides little benefit for the
treatment of allergies.
e. Immunomodulators
i. Omalizumab (Xolair): Indicated for “allergic” asthma 6 and older
ii. Mepolizumab (Nucala): Indicated for severe asthma 12 and older
with “eosinophilic phenotype”
iii. Reslizumab (Cinqair): Indicated for severe asthma 12 and older
with “eosinophilic phenotype”
By altering underlying cellular signals, immunomodulators may shut
down the series of events associated with asthma inflammation. If you’re
thinking these forms of therapy are be expensive, you’re right (and likely
why big pharma is so excited in their prospects). Immunomodulators are
considered “add-on” therapy; added to patients uncontrolled with
ICS/LABA treatment. Let’s put it this way, if you are a candidate for one
of these treatments you should have really, really bad asthma.
e. Allergy Vaccine Therapy: “Allergy Shots”
Allergy shots, actually the oldest “immunomodulators”, are not
considered a primary therapy for asthma. In properly selected allergic
patients, allergy vaccine therapy may reduce airway inflammation. No
additional benefit (improvement in lung function and reduction in
concomitant therapies) has been clearly demonstrated in patients on
inhaled corticosteroid therapy with moderate or severe persistent
asthma.
f. Systemic Corticosteroids
The use of systemic steroid therapy has dramatically fallen since the
introduction of inhaled corticosteroids. Risks of systemic steroids (high
blood pressure, cataracts, avascular necrosis, skin thinning, fractures,
muscle wasting, etc.) tend to generally outweigh their benefit for long-
term preventive use. Systemic steroids are generally reserved for short-
term “burst” therapy for treatment of severe asthma attacks in and out of
the hospital. The long-term side effects are not commonly associated
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with short-term use. Some drug names include: Medrol, Prednisone, and
Prelone/Prednisolone.
MYTHS…and some truths:
1. I can feel when my asthma is worsening.
Ugh! The longer you have asthma, the less you are actually able to sense what’s
going on with your asthma. Your body learns to adjust to not breathing properly
and you loose the ability to actually sense your asthma worsening; that’s why
checking lung function (home peak flows and office spirometry) is so important to
controlling asthma. How many problems do you need to have with your asthma
before you learn the message?
2. My doctor says that I don’t need to have regular breathing
tests.
Your doctor likely doesn’t understand how to manage asthma. You need to insist
that you get the care you deserve; for asthma, that means regular breathing tests
(spirometry) as a measure to assess your asthma control.
3. Allergy shots can cure asthma.
The truth? There are no current cures for asthma. Allergy shots may be
indicated in a few select patients to control or reduce hayfever or animal allergies
that may trigger asthma but allergy shots are not a primary treatment for asthma.
Furthermore, there is little evidence to support the rumor that allergy shots can
prevent asthma from developing in people with hayfever.
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4. Inhaled corticosteroid medications will stunt my child’s
growth.
Listen closely...Poorly controlled asthma can delay growth in young children
before puberty. What about the effects of inhaled corticosteroid on height prior to
puberty? The best studies done to date indicate that a population of children
treated with inhaled steroids may be at risk for, on average, about
1 cm (less than ½ an inch) difference in height (early in asthma treatment).
Ok, now let’s see, uncontrolled, asthma can affect a child’s height and interfere with
them playing sports, sleep, attending school, and doing things kids normally do..OR,
use inhaled corticosteroid asthma therapy, your child does the normal things kids
do without problems (or causing you to miss work and sleep), and potentially have
~ ½ an inch difference in height prior to puberty? Clearly, the message should be to
use inhaled corticosteroids under proper supervision from your doctor.
5. If I get pregnant, I can’t still use my regular asthma
medications
First, the short easy answer, then read on…In pregnancy, the preferred inhaled
corticosteroid is budesonide (Pulmicort), and the preferred short-acting beta 2-
agonist is albuterol…but keep reading.
If you have asthma and it is not properly controlled during your pregnancy, you may
increase the risks of preeclampsia, pre-term birth low-birth weight in your infant,
and the potential for “perinatal mortality”.
According to the NAEPP 2005 expert report on managing asthma during pregnancy:
“It is safer for pregnant women who have asthma to be treated with asthma
medications than to have asthma symptoms and exacerbations”
With regard to other inhaled corticosteroid medication use, the report states that:
“although budesonide [(brand named Pulmicort and Rhinocort Aqua)] is the
preferred inhaled corticosteroid, it is important to note that no data indicate
that the other preparations are unsafe during pregnancy”.
Discuss monthly monitoring of your asthma with your doctor to prevent asthma
worsening and to monitor for medication side effects. If you have allergies, ask your
doctor to prescribe allergy medications that are generally recommended as safe
(GRAS) during your pregnancy.
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6. If untreated, asthma will become increasingly severe over
time
First, regardless of asthma severity, anyone with asthma may be at risk of having a
life threatening attack if asthma is not properly treated.
Second, there is little evidence showing that asthma, treated or untreated, actually
progresses from mild to more severe overtime. What?
Third, the terms mild”, “moderate”, and “severe” asthma really have little meaning
in routine asthma care. These terms are mainly derived from clinical asthma drug
studies where it is useful to divide asthmatics into different groups in order to study
the effects of different drug treatments. Wait, this is getting way too complicated...
Basically, the terms mild, moderate, and severe asthma more accurately reflect
current asthma treatment and the quality, or lack of quality, of medical care rather
than some intrinsic characteristic of the disease.
ASTHMA MANAGEMENT
THE PRIMARY GOALS OF ASTHMA TREATMENT ARE:
1. ALLOW EVERYDAY ACTIVITIES WITHOUT INTERFERENCE FROM
BREATHING PROBLEMS
2. NORMALIZE LUNG FUNCTION AND PREVENT FUTURE WORSENING
3. MINIMIZE MEDICATION SIDE EFFECTS
It’s easy to treat asthma, the problem is treating people who have asthma. People
tend to get in their own way.
Effective control of asthma does not just happen
you must actively participate in your care.
If your doctor prescribes a specific inhaler and a specific device to use with the
inhaler, follow the directions. Do not accept any medication substitutions or
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different devices from your insurance or pharmacy unless your doctor has
previously agreed to the change.
At each visit you should tell your doctor:
1. Whether you are experiencing any limitations or interference with your
activities due to breathing problems,
2. How often you are using rescue medication, and,
3. Whether you are experiencing any possible medication side effects.
Peak Flow Meters
PEAK FLOW METERS: WHAT AND WHY
A peak flow meter can be a very useful tool for most asthma patients to achieve and
maintain asthma control. Peak flow meters allow you to measure how fast you can
expel air from your lungs. When asthma worsens, the peak flow reading may
decline hours or days before symptoms develop. Peak flow meters cannot and
should not be used to diagnose asthma; only spirometry should be used to
diagnose asthma.
Symptoms do NOT accurately indicate how well asthma is controlled, nor
when an asthma attack occurs, how severe the attack might be.
In fact, some asthma patients start to feel better during a severe asthma attack even
though their lung function is getting worse.
Having a peak flow meter, knowing when to use it and what the readings mean
about your asthma are critical to your long-term asthma control.
Furthermore, your doctor should provide you with a written Asthma Action Plan.
The Plan is a written set of instructions on how to change asthma medications to
prevent and reverse attacks, based upon changes in the peak flow readings.
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Is there a downside to checking peak flows? As a monitoring tool, peak flows can
actually be misleading in ~ 25% of asthmatics. Spirometry can determine the
accuracy and reliability of peak flow measurements for each asthmatic and whether
a peak flow meter can be beneficial in asthma home monitoring.
ROUTINE OFFICE CHECK-UPS
Regular re-assessment of your lung function using Spirometry in the doctor’s
office is essential to determine whether your medications are working properly, to
monitor for possible medication side effects, and for the doctor to explain how to
safely make changes in your treatment. It is also an opportunity to have your peak
flow meter checked to determine if it is working properly. Over time, peak flow
meters lose their accuracy, resulting in false and misleading readings.
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YOU KNOW THAT YOUR ASTHMA IS
WELL CONTROLLED WHEN:
1. YOUR PEAK FLOWS ARE AT OR ABOVE YOUR BEST BASELINE
2. YOU RARELY USE ANY RESCUE MEDICATION (LESS THAN
TWICE WEEKLY)
3. YOU CAN RUN, BIKE, LAUGH, CRY, PLAY, SLEEP, KICK THE DOG,
(JUST KIDDING) AND JUST DO ALL THE NORMAL STUFF THAT
PEOPLE DO AT YOUR AGE, WITHOUT ANY BREATHING
PROBLEMS
4. THE HORSE IS OFF THE COUCH
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R
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B
B
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R
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1. Allow your asthma to get out of control for even 1 hour
2. Exercise if your peak flows are not normal or your asthma
is out of control
3. Go to bed having problems with your asthma (it will
always get worse over the period of sleep)
4. Skip doses of your daily preventive medicine because you
feel good (it’s always harder to remember to take
medicine when you feel good)
5. Forget to post your asthma action plan where you can
always see it (take a pic on your cellphone)
6. Forget to carry your rescue medication with you at all
times
NEVER!
EVER!