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Asthma Part 4: Treatment and Control
There is no cure for asthma. Aim of management is to achieve control of the disease. This includes the following:
Prevent chronic and recurrent symptoms like nocturnal coughing
Reduce the use of medications
Maintenance of lung function
Maintenance of regular activities
Preventing severe asthmatic attacks requiring hospital stays or visits to the Emergency Room
Practical tips to control asthma:
Control other conditions that can aggravate asthma
Avoid known allergens
Maintain an active lifestyle
Have an action plan in the event of asthma attacks
The asthma action plan should include the medications regime, avoidance of triggers, tracking of asthma attacks, and actions to be taken if asthmatic symptoms become more severe despite treatment. Eg When to proceed to the Hospital Emergency Department for treatment
Medications for Asthma
Asthmatic medications can be broadly divided into medications that exert long term control and medications that provide rapid relief from asthmatic symptoms.
Both types of medications aim at reducing airway inflammation to control asthma.
Initial treatment depends on how severe your asthma is. Follow up treatment depends on how well the patient follows the asthma action plan and how effective the action plan is.
Note though that the asthma action plan will vary with changes in your lifestyle and social environment because different social exposures result in exposure to different allergens in your environment.
Adjustment of medication dosage should be at the discretion of your primary physician. If you have adjusted the dose of medication on your own, you should let your primary physician know immediately to facilitate proper titration of medication dosing with each visit to the doctor.
The doctor will always aim to use the least amount of medicine necessary to achieve control of your asthma so it is imperative that the doctor be made aware of how much medications you have been using.
Certain groups of patients require more intensive titration regimes – these include pregnant women, young children, or patients with special needs.
Asthma Action Plan
Every Asthma Action plan should be crafted to the individual patient. The plan should include the medication regime, avoidance of triggers, tracking of asthma attacks and actions to be taken should symptoms of asthma become progressively severe.
It is best to work with your primary physician to draft your asthma action plan. The plan should describe all the above in detail.
In the case of children, parents and caregivers should know the child’s asthma action plan. This should include babysitters, workers at day care centers, parents, schools and organizers of outdoor children activities.
Avoidance of Triggers
An entire multitude of allergens have been documented to be linked to asthma. To the individual patient, the most important thing is to know what triggers asthma in you. Following that, know what steps to take when asthma is triggered.
Simple common sense is essential. For example, if you have a known allergy or sensitivity to pollen, please limit your exposure to pollen and stay indoors if needed. If you are sensitive to pets, or pet fur, please do not keep pets at home or allow pets to enter your bedroom.
Of note, physical activity can also trigger asthmatic attacks. However, it is recommended that asthmatics exercise on a regular basis because in the long run, exercise will help with control of asthma. Speak with your primary physician if you experience asthmatic attacks when engaging in physical activities. There are medications available to control asthma during exercise.
In the event your asthma correlates strongly to allergens that cannot be avoided (eg dust), your primary physician might advise on use of medications against allergies.
Medications for Asthma
Please consult with your primary physician for medications suitable for control of your asthma. Your primary physician will adjust the dose of medications as needed. If you have self adjusted the dose, you must inform your primary physician on your next visit.
Generally speaking, medications for asthma can either be in the form of a pill, an injectable, or as a nebulized drug consumed via use of an inhaler. Nebulized drugs are inhaled directly into the lungs where it exerts its effects.
Please note that use of inhalers will require a certain technique and should be taught by a doctor or a trained health care provider.
Medications targeting Long Term Control
Chronic asthmatics will need medications to achieve long term control of their asthma. These medications work slowly and reduces airway inflammation.
Inhaled corticosteroids are most commonly used for long term control of asthma. They act by reducing inflammation in the airways of the lungs. Use of inhaled corticosteroids daily will greatly reduce the severity and frequency of symptoms.
The most common side effect of inhaled corticosteroids is oral thrush. Use of a spacer when using the inhaled corticosteroid can reduce the incidence of oral thrush. Check with your primary physician if you are unsure of how to use a spacer. Simple rinsing of the mouth after cosuming inhaled corticosteroids can also reduce the incidence of oral thrush.
Patients who have severe asthma might need to consume oral corticosteroids instead of inhaled corticosteroids to achieve sufficient control of their asthma. Unlike inhaled corticosteroids, which can be taken for years, oral corticosteroids will have significant side effects if used for prolonged periods.
Long term use of oral corticosteroids increases the risk of diabetes, osteoporosis, cataracts, and abnormal metabolic activity.
Consult with your primary physician to measure the risks and benefits before consuming oral corticosteroids.
Other long term medications:
Cromolyn – This drug prevents airway inflammation and is used as a nebulized drug delivered via an inhaler.
Omalizumab – This drug is a form of immunotherapy and acts against Immunoglobulin E (anti-IgE) which triggers narrowing of airways. This medication is usually given as an injection once or twice a month and prevents the immune system from reacting to triggers of asthma. It is, however, not a first line treatment for asthma and might not be offered upfront by your primary physician.
Inhaled long-acting beta2-agonists – These medications are usually taken together with inhaled corticosteroids to achieve a synergistic effect on expanding the lumen of the lung airways.
Leukotriene modifiers – These are oral medications that reduce airway inflammation.
Theophylline – Theophylline can be consumed orally or via an injection and acts to open the lung airways.
Please note that there is a likelihood of symptoms rebounding if long term medications are suddenly ceased. Also, all long term medications will have side effects. Please discuss with your primary physician before commencing long term treatment regimes
Rapid Acting Medications
Short acting Beta 2 – Agonists are usually the first line medications in this group. They are often delivered in the nebulized form through an inhaler. They act by relaxing the muscles in the airways, thereby allowing more air passage through.
Rapid acting medications should be consumed as soon as symptoms appear.
Should the medication be required for more than 2 days a week, you should inform your doctor to formulate more strategies for your asthma action plan.
Asthmatics are advised to carry their quick relief inhaler with them at all times.
Of note, these medications do not reduce inflammation of the airways and hence cannot replace long acting medications.
Documentation of Asthma Progression
Regular use of the peak flow and regular visits to your primary physician will be the primary means of documenting progression of Asthma.
As a rule of thumb, asthma is well controlled if:
Symptoms occur no more than 2 days a week
Symptoms do not disturb sleep more than twice a month.
There are no limitations to your daily activities.
Quick-relief medicines are required less than 2 days a week.
Less than one severe asthma attack a year requiring oral steroids
Peak Flow Meter readings remain at 80% of baseline level
Peak Flow Meter
Your primary care physician will instruct on the use of the peak flow meter.
When used, the peak flow meter measures the maximum rate of flow of air out of the lungs during exhalation. Regular measurements will allow documentation of asthma progression and it is recommended that patient record their peak flow every morning.
During the initial phase after diagnosis, it is important to ascertain baseline peak flow. This is often touted as the patient’s “Personal Best” peak flow reading. Future control of asthma relies on this baseline. Good asthma control being maintenance of peak flow to at least 80% of baseline.
Regular peak flow readings also help predict impending asthmatic attacks. Progressively deteriorating peak flow readings often indicate an impending attack and should be incorporated into the Asthma Action Plan.
Frequent medical reviews with your primary physician every fortnightly is the norm during the initial phase of treatment. Once asthma is controlled, your primary physician might elect to see you across a longer stretch of time.
During the medical reviews, important information required by your primary physician include:
Frequency of Asthma Attack
Changes in Symptoms
Changes in Peak Flow Readings
Changes in daily activities like exercise tolerance
Difficulties with adherence to the Asthma Action Plan
Problems with current medications
Seek Medical advice if:
Regular medications fail to treat an asthma attack.
Peak flow readings falls to less than 50% of baseline
Proceed immediately to the nearest Hospital Emergency Room if:
You experience severe shortness of breath to the stage where walking becomes difficult
Your lips and tongue turn bluish
Asthma – A Lifelong Issue
There is no cure for asthma. Successful management of asthma requires the patient to take an active role in the control of asthma by conforming to an asthma action plan.
Your primary physician is your best partner to develop your asthma action plan. The action plan will keep you reminded of your medication regime, triggers, and protocols to follow when asthmatic symptoms develop or worsen. Even children should be involved in the creation of their action plan because it is the individual effort that counts in the long term care of asthma.
Asthma will not be going away. But it can be controlled.
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