Asthma self-management: controller, reliever, action plan

Asthma is a chronic inflammatory disease of the airways whose symptoms come and go while the inflammation does not, so it is controlled between attacks by an inhaled corticosteroid-containing treatment that treats the inflammation and not by the reliever that eases the symptom, and the nurse teaches the patient the difference between the two inhalers in the patient's own words -- the maintenance inhaler taken as prescribed on the days the patient feels well as much as on the bad ones, because it works slowly on the inflammation and stopping it because the asthma seems settled brings the attacks back, and the reliever taken when symptoms come and before exercise and never as the daily treatment, because a short-acting beta-agonist on its own opens the airway while leaving the inflammation untreated, and the patient treated with a reliever alone, or reaching for it on most days, or getting through three or more canisters of it in a year, is the patient at risk of a severe attack and of dying of asthma however well they feel -- knows that in the preferred regimen the reliever is itself a low-dose combination of an inhaled corticosteroid with formoterol, so that every dose taken for a symptom also treats the inflammation and one inhaler can serve as both maintenance and reliever, that a combination inhaler built around any other long-acting bronchodilator is a maintenance inhaler only and is never used for relief, and that the patient on such an inhaler is not given the corticosteroid-formoterol reliever alongside it; assesses control at every contact by asking about the past four weeks -- daytime symptoms on more than two days a week, any waking at night with asthma, a short-acting beta-agonist reliever needed for symptoms on more than two days a week, which is not how the anti-inflammatory reliever is counted though how often it is needed is still weighed at review, and any limit on activity -- and separately about the risk that a patient with few symptoms still carries: an attack in the past year, reliever over-use, an inhaled corticosteroid not prescribed or not taken or taken with poor technique, smoking or vaping, a confirmed food allergy and low lung function, because symptom control and future risk are two different things and the one does not prove the other, and the patient's own idea of control, often how quickly the reliever works, is not the clinician's; checks technique by watching the patient use each inhaler against a checklist rather than asking whether they know how, demonstrates the correction and re-checks it at the next contact because errors return within weeks, keeps the number of different devices to the minimum, and asks about adherence with the empathic question that expects missed doses and then looks at the dose counter and the refill dates rather than accepting a yes, because most patients use their inhaler wrongly without knowing it and about half do not take the maintenance treatment as agreed; trains the patient in guided self-management -- self-monitoring of symptoms, with peak flow judged against the patient's own best rather than a predicted value where it is used, a written action plan, and regular review -- where the plan, on paper, on a screen or in pictures and never spoken alone, states the patient's usual medicines, how to recognize worsening asthma, exactly how to change the reliever and the maintenance treatment when it comes -- more doses of the anti-inflammatory reliever with the usual maintenance continued, or in a plan with a short-acting beta-agonist reliever a short-term step-up of the maintenance corticosteroid -- when a course of oral corticosteroid is started and that it is never automatic, and when and how to get urgent care: when the reliever is needed beyond the plan's daily limit or is not lasting, when the patient is not better within a couple of days of following the plan, or when the attack is severe; reduces the modifiable risks -- stopping smoking and vaping and avoiding others' smoke, treating obesity, rhinosinusitis and reflux, asking about exposures at work and about reactions to nonsteroidal anti-inflammatory drugs, encouraging rather than restricting exercise, and rinsing and spitting after the corticosteroid inhaler and using a spacer with a pressurized inhaler to limit thrush and hoarseness -- arranges the review within a few months of any change in treatment and within the week after any attack, and judges the plan by whether control has been regained and the attacks have stopped, knowing that treatment is stepped down only after months of good control, in steps and with a written plan for restarting it, that the inhaled corticosteroid is never stopped altogether, and that an attack that needed urgent care or an oral corticosteroid is a signal to review the treatment, the technique, the adherence and the plan rather than a stroke of bad luck.