As I walk into Ms Smith’s room for a routine check-up for asthma, I ask her, “How do you think your asthma is doing?” She replies, “Dr. Close, I feel like I’m doing great.” Then, we will go into some specifics. I will ask her how frequently she has used her quick relief inhaler (ProAir, Ventolin, Proventil, or Xopenex) and she happily reports that she uses this 3 to 4 days per week. I will subsequently then ask her how often does asthma awaken her from sleep and she states, “Once or twice per week, and that is better.” She also reports to me that she has mild limitations in physical activity and she is pleased that she has “only had three flare-ups” of her asthma in the past year that have required treatment with steroids.
As Lee Corso on ESPN frequently says, “Not so fast my friend.” A recent study revealed that approximately 2/3 of patients who feel that their asthma is controlled, are not controlled by criteria outlined by new asthma control guidelines. The following are factors that should be considered:
• There are “rules of two” that generally state that if you have asthma symptoms twice per week or if symptoms for uncontrolled asthma awaken you from sleep more than twice a month, this is a “yellow flag”.
• Well controlled asthma should have little or no limitation on physical activity.
• Pulmonary functions should be normal with less than 20% variation.
• Frequency of prednisone use should be one or less per year. This does not mean that prednisone or systemic corticosteroids should not be used for exacerbations, just that the use of more than one a year should require further investigation about control.
• Frequency of short acting inhalers. If a short acting inhaler (used typically as 200 sprays) needs to be refilled more than twice (preferable once) per year, this is a sign of poor asthma control.
We recommend that a questionnaire called an Asthma Control Test (ACT) be used at every visit. There is a separate form for children ages 4 to 11, and a separate set of questions for 12 and up. This can give patients an idea if their asthma is controlled. It can be downloaded from various sources including American Lung Association website at www.ala.org.
The standard medication used for asthma control is in a class called inhaled corticosteroids. Examples include Asmanex, Flovent, Q VAR, Alvesco, and Pulmicort. If control is not obtained using these medications, then “dual controller” medications such as Advair, Symbicort, or Dulera should be considered. Singulair can be also considered to add on to these medications.
If you don’t feel you are controlled, please see your doctor!