Objective-To compare the efficacy of self management ofasthma with traditional treatment.Design-12 month prospective randomised trial. Setting-Outpatient clinics in Finland. Subjects-115 patients with mild to moderately severe asthma.Interventions-Patient education and adjustment of anti-inflammatory therapy guided by peak flow measurements.Main outcome measures-Unscheduled admissions to hospital and outpatient visits, days off work, courses of antibiotics and prednisolone, lung function, and quality oflife.Results-The mean number of unscheduled visits to ambulatory care facilities (0 5 higher in the self management group than in the traditionally treated group. In both groups admissions for asthma were rare. Conclusions-Self management reduces incidents caused by asthma and improves quality oflife. IntroductionDeaths from asthma have been associated with underestimation of its severity, delays in starting treatment in exacerbations, and unsatisfactory routine management and treatment of asthma.' 2 Potentially preventable factors are common in deaths from asthma, and 73% of admissions to hospital for acute asthma could be avoided with proper prior medical care.'3 At least 40% of people with asthma do not react appropriately when symptoms of asthma worsen and over half of the patients admitted with acute asthma have had alarming symptoms for a week before admission.45 In its study of deaths due to asthma in the early 1 980s the British Thoracic Association recommended that patients should measure their own peak flow rates and treat deteriorating symptoms

A new inhalation synchronised dosimeter triggered by low inspiratory flow rates has been assessed. The methacholine challenge test using dosimeter nebulisation with controlled tidal breathing was compared with continuous nebulisation using De Vilbiss No 40 nebulisers with deep inhalations in 11 asthmatic subjects. Within subject PD20 FEV, values were lower with the dosimeter method than with the continuous nebulisation method (geometric means 158 and 588 Mg). The repeatability of the dosimeter method with controlled tidal breathing was studied in 11 asthmatic subjects, and the 95% range for a single measurement was ± 0-72 doubling doses of methacholine. The dosimeter method has greater efficacy because aerosol is delivered during the first part of an inhalation, minimising loss of aerosol outside the respiratory tract. The dosimeter technique combined with controlled tidal breathing appears to be a useful method for carrying out standardised non-specific bronchoprovocation tests.

Many patients with persistent asthma can be controlled with inhaled corticosteroids (ICS). However, a considerable proportion of patients remain symptomatic, despite the use of ICS. We present systematically evidence that supports the different treatment options. A literature search was made of Medline/PubMed to identify randomised and blinded trials. To demonstrate the benefit that can be obtained by increasing the dose of ICS, dose-response studies with at least three different ICS doses were identified. To demonstrate whether more benefit can be obtained by adding long-acting β 2 -agonist (LABA), leukotriene antagonist (LTRA) or theophylline than by increasing the dose of ICS, studies comparing these options were identified. Thirdly, studies comparing the different "add-on" options were identified. The addition of a LABA is more effective than increasing the dose of ICS in improving asthma control. By increasing the dose of ICS, clinical improvement is likely to be of small magnitude. Addition of a LTRA or theophylline to the treatment regimen appears to be equivalent to doubling the dose of ICS. Addition of a LABA seems to be superior to an LTRA in improving lung function. However, addition of LABA and LTRA may be equal with respect to asthma exacerbations. However, more and longer studies are needed to better clarify the role of LTRAs and theophylline as add-on therapies.

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