Copper Brush Dandruff

and Psychological Treatment in Asthma

BEHAVIORAL ASSESSMENT OF PATIENT ASTHMA

Given the multiple interactions between physiological variables, cognitive, behavioral and emotional changes that occur in the asthmatic response, behavioral assessment must be conducted from a multidimensional perspective. Moreover, the various components involved in the demonstration asthma are relatively idiosyncratic pattern, so it is required that the evaluation is done individually, looking in each case the profile of physical and psychological characteristics associated with the disease. Finally, given the variability that characterizes bronchial asthma, it is essential to conducting regular assessments to estimate the baseline of the patients and / or changes that may occur after surgery, and isolated measurements can give rise to interpretations distorted lack of reliability and validity.

Areas and assessment tools

Assessment of patient's clinical situation
The first step in the assessment should aim to collect relevant data that reveal the patient's clinical situation. The clinical history can access this data summary and systematic. The physician is responsible for the diagnosis of asthma. In the medical history is collected, further data evaluating the physiological component that includes both the assessment of bronchial hyperactivity in the estimation the degree of obstruction posed by airways. For this purpose the procedures used are bronchial provocation tests with chemicals. The degree of bronchial responsiveness is inversely proportional to the concentration of methacholine used and is closely related to levels of disease severity.
To estimate the degree of constriction that occurs in the bronchial tree has different techniques. The instruments used for obtaining these measures are the body plethysmograph, spirometer and peak flow meter.
The body plethysmograph is the most sophisticated and reliable available. Provides information of increased flow resistance in the airways and its specific conductance level. It is characteristic of asthma episodes, increased Raw and decreased Sgaw. The data are highly reliable, but its management is complex and expensive, so its use is not common.

1. spirometer is a simple instrument that can detect the following parameters: forced vital capacity (FVC), maximum amount of air that can be exhaled;
2. The maximum expiratory flow during the first second of forced exhalation (FEV, or FEV)
3. peak expiratory flow (MMEF), which refers to the peak expiratory flow between 25% and 75% of vital capacity.

These parameters usually decrease during the crisis, but may be normal in periods of remission. The point ranges indicative of bronchial obstruction in reductions range from 15 to 25% depending on sex and patient height, although most authors agree put in equal or above 20% the diagnosis bronchial spasm. Have emerged recently
peak flow meters as a new method to assess lung function. Their use is becoming established, by the simplicity of its use and easy to use. These instruments consist of a mouthpiece attached to a gauge that indicates the peak expiratory flow (PEF) or amount of air exhaled by the subject in the initial 0.1 seconds following a maximal expiration, expressed in liters / sec.
A second aspect which appear in the medical record is the identification of stimuli that trigger asthma episodes. To test the effect of precipitating the crisis that act through allergic mechanisms used immunological tests, the most used skin tests and tests in vitro. Another method is the specific bronchial provocation tests. Consist in the administration of the substance under consideration by inhalation and subsequent assessment of changes in lung function of patients, considering that the substance used is a trigger of bronchospasm after administration when the parameters spirometric down at least 20%.
Finally, medical history records the frequency and severity of seizures for each patient in the evaluation period. The number of emergency visits and the frequency and duration of hospitalizations constitute valid and easily measurable indicators of patient status asthmaticus. Data collected
in the medical history provided valuable information, so that wherever possible should be consulted by the psychologist. However, the review of the record in any way replace the clinical interview, as this is the first contact between the client and the psychologist serving a dual role, first lets you set the foundation for patient-therapist, On the other hand it is an assessment tool that allows a first approach to the patient's subjective experience of their disease. The content of this interview, include:

1. The presence of possible triggers of the crisis;
2. The frequency and intensity of crises and
3. the type of treatment that followed, and the way it is administered.

For information on the subject's ability to recognize which are the stimuli that trigger asthmatic responses during the interview may ask patients to bring those stimuli or situations that remind haberles caused flare-ups. It is important to report all precipitating remember (not only the most important). When patients have developed the list of precipitants are asked to describe at least one experience with each precipitant.
Given the variable and episodic characterizes asthma, the data concerning the presentation of symptoms obtained by interview are at low reliability. Therefore, in addition, can be used self-reports, in which should include the frequency and severity of symptoms, PEFR values \u200b\u200band drug administration.
have also developed different questionnaires to measure the frequency and severity of symptoms. Richards et. developed a scale to measure five areas:

1. frequency of symptoms;
2. seizure severity;
3. the degree to which symptoms affect the patient's current medication
4. required, and
5. the occurrence and severity of adverse effects to the medication.

this questionnaire data correlated with asthma severity assessed by doctors in the emergency department. Moreover, Usherwood and others developed a 17-item questionnaire. Although these instruments have clinical utility are still required more data about their validity, reproducibility and / or responsiveness.

Assessment of asthma care behaviors

The assessment of asthma care behaviors required to estimate not only if the patient takes the correct medication dose but also to assess how As patients follow treatment recommendations in terms of stimulus control or proper conduct for the handling of the crisis. This has been used various direct and indirect techniques that vary in precision, sensitivity and specificity.
Direct techniques provide objective and reliable data being the most commonly used biochemical methods and observation.
biochemical tests used to assess adherence to drug treatment and include blood tests, urine or saliva. Provide a direct and objective assessment of adherence but require specialized equipment, may interact when given Several drugs vary according to time of sample collection in relation to oral intake, may interact with food and snuff, can be an intrusive and painful process (in blood) and also indicate only sporadic rather than adherence provides information on the pattern of adhesion over time. The observation
using members of the family of the patient or medical staff trained in monitoring processes that evaluate the bond behavior. It is used to evaluate the administration of inhalers but not to assess adherence to treatment recommendations or conduct adequate environmental control. BELIEVE (1993) suggests that observation can alter the normal routine of the patient and his family, and observers require constant training and control.
Although direct measures are objective and not subject to manipulation, the methods are often expensive and difficult to apply. Therefore, in clinical practice commonly used indirect measures, but may lead to erroneous conclusions. Indirect measures are most commonly used clinical trial, the patient's self-reports, electronic medication monitors, measure or count of medication and self-reports.

1. clinical trial: the clinical assessment of adherence the treatment regimen is the most widely used indirect method because it is fast and not expensive, it can also be used to supplement other objective measures. However Davis studies showed that physicians overestimate the extent to which patients and families attach to trtamiento.
2. patient self-reports, are widely used for its ease of collection, rapid analysis and low cost, are also useful to examine the relationship between exacerbations of the illness and adherence to asthma management recommendations. It is necessary to train the patients to act as accurate observers of their behavior, although even in these cases, patients tend to overestimate adherence and reactivity may occur.
3. electronic medication monitors, are devices that use microprocessors to record and store the date and time of day a medication container is opened or activated. Provide information about the frequency of drug administration of n, interval between administrations and in some cases the dose. Presented as the high cost and inconvenience that can cause reactivity. Also, do not confirm that the medication is taken, only infer their administration.
4. medication count measures : used to assess the amount of medication remaining between consultation and consultation, and thus infer their administration during the time interval. Although assessment procedures are inexpensive and easy to manipulate the numbers, there is no precise indication of the dose and do not provide information about daily patterns of medication use.
5. AutoReport : to identify behavioral patterns associated with the development of asthma have been developed various types of self-reports. The APBC (list of behavioral problems in asthma) developed by Greer, is a structured interview that can be applied to both children and parents and provides a behavioral profile of the patient to detect the relevant behavioral deficits or excesses. For use in adult asthmatic population was adapted APBC leading to RAPBC.

Another questionnaire designed to assess the degree to which children with asthma are effective in the implementation of care behavior of the disease is the Abaqa (Questionnaire for the behavioral measure of asthma). This is a 178-item questionnaire which asks children to indicate on a scale with five response alternatives (from "never" to always "how often carried out a series of self-care behaviors.
To measuring the competence of families in management of childhood asthma Taylor et al. Developed a structured interview in which children aged 5-11 years and their caregivers indicate what types of actions carried out by patients in different situations.
Self-reports provide information on a wide range of behaviors in a simple and inexpensive, but tend to overestimate adherence and some of them have low levels of reliability and validity.
As each of direct and indirect procedures outlined above have advantages and disadvantages, one method does not provide an accurate measure of adherence to medical prescriptions, as currently recommended combination of techniques for assessment and repeat predetermined time periods.

Evaluation of knowledge about asthma and its treatment
knowledge about the disease and treatment is an essential measure for the patient to perform self-care behaviors. To assess patient knowledge about the disease and its treatment can resort to the use of different questionnaires. Recently, interest has been paid to psychometric properties of questionnaires and, now, you can have some reliable and valid, including Knowledge Questionnaire (AKI) for children and asthma knowledge questionnaire (AKQ) for adults. Despite
the reliability and usefulness of these questionnaires, structured nature and limited in the number of topics to assess, from getting complete information about the misconceptions about the nature of asthma and its treatment strategies. To solve this problem, Mesters and others suggest the use of focus groups that allow the inclusion of free response. Their joint application to the questionnaires, favors obtained quantitative and qualitative data that enable the identification of problem areas in the level of knowledge of patients and the changes that have occurred after an intervention program.

Assessment the degree of accuracy in the perception of symptoms
is a prerequisite for the proper development and management of bronchial asthma patients identified by errors in perception of symptoms and the type of perceptual bias in them. Fritz et al. Perceptual accuracy defined as the degree to which the subjective assessment of symptoms and asthma severity corresponds to the objective assessment of bronchial obstruction.
To carry out an objective assessment of the degree of bronchial obstruction can use the peak flow meter. This is the best instrument in the process of accuracy assessment perceptive as it can be used by the patient and allows frequent measurements. Allows both subjective and objective assessments are expressed in the same units. You can also use análogovisuales scales on which the patients identified in a line of 10 cm. the degree of respiratory distress ranging from "very severe symptoms" and "absence of symptoms." In children under 7 years is preferable to use systems of categories, including some cases with the support of drawings.
Once the patient has met a sufficient number of pairs of objective and subjective estimates can be used several indices to assess the degree of accuracy in the perception of symptoms. The correlation coefficient was the statistic most commonly used. However, it presents the disadvantage that requires a large number of estimates and the correlation tends to be low if there is enough variability in the average rates, so that could be confused with a statistical artifact.
To overcome these limitations, and subject to the availability of the same units of measurement on the subjective and objective scales, can be used to calculate the arithmetic difference according to the following formula:

differences all observations are estimated absolute values \u200b\u200bto determine the extent of error in the perception of symptoms.
To assess the direction of perceptual bias is calculated by the ratio between the total cases of overestimation (subjective estimate> value PEFR) and underestimation (subjective estimate \u0026lt;value PEFR): Σ
overestimates / underestimates Σ

Finally Fritz et al adapted for children with asthma the method developed by Cox et al. for diabetic patients. We build a distributed graphics system in areas that are placing the different pairs of subjective values \u200b\u200band objectives. The magnitude of perceptual error is calculated using the radio A / (D + E), and type of bias using radio perceptual D + B / E + C.
The various indices available for assessing the accuracy in the perception of symptoms is still under development

Assessment of attitudes toward the disease

As mentioned, negative attitudes toward asthma treatment interfere with the implementation of appropriate behavioral strategies for managing the disease, so it is essential to early identification of attitudes that may be hampering the course of treatment to contribute to better clinical asthma. In this line have been a number of instruments.
In adult patients was the first instrument to assess RIOS attitudes toward the disease of asthma patients in inpatient. It measures 6 dimensions of disease-related attitudes: optimism, negative consideration of health personnel, specific internal consciousness or degree to which patients attend physical signs, external locus of control, stigma, psychological and authoritarian attitudes towards illness and hospitalization . To adapt this questionnaire to the general population in outpatient AOS was developed that assess 3 aspects: vulnerability, perceived quality of care and recognition and control of symptoms. Population has been adapted to English showing good psychometric properties.
From a different perspective Assessment Questionnaire was developed of .... of Sibbald assessing the attitudes and beliefs of patients with asthma about the disease including feelings about asthma, attitudes to the crisis, perceived effect of asthma on the patient and family, attitudes toward medication, and attitudes toward the doctor and care received.
Based on social learning theory, Tobin et al. developed an instrument to measure perceived self-efficacy in controlling seizures in patients with asthma.
Finally, Wigal et al. developed the KASE-AQ. The only instrument specifically
developed for children with asthma was the SES that assesses the efficacy of children and adolescents between 10 and 18.

Assessment of emotional states that affect morbidity and mortality
to assess panic-fear in the perception of symptoms can be used subscale of the ASC Panic-Fear, 9 response items, with 5-level Likert from "never" to "always."
Although ASC was developed for hospitalized patients has been adapted to other populations. The results provide good psychometric properties. Application in English asthmatic patients also reported good levels of internal consistency. To assess personality
Dirks et al. developed a scale from the MMPI and the intensity scale and the Barron Ego Unit. This established 15-item scale with a dichotomous response format. The application of this scale English asthmatic population, presents a moderate level of reliability and factor structure consists of 5 factors.
Finally, to assess depression have employed different instruments, however, it seems appropriate to use instruments such as the BDI (Beck)

Assessment of quality of life
The procedure commonly used to evaluate the effect of disease in the patient and / or their families are questionnaires that can be of two types: generic scales that assess health status without regard to the type of pathology presented by patients, and disease-specific scales, created to be applicable to a particular condition. Both types of instruments have different advantages and disadvantages.
generic instruments: SIP is widely used but has disadvantages as its long extension: 136 items, focusing on severe functional deficits that are not applicable to most asthma patients, so that the SIP does not have good sensitivity characteristics asthma. The SF-36, is being used increasingly psychometric robustness and relative simplicity, which currently makes it the instrument of choice to measure generic health status in asthma.
As regards the specific instruments, different questionnaires have been developed, which differ in the aspects of health evaluated, and with differences in its psychometric properties. The instruments
quality of life for adults are the AQLQ.
In the case of children, although it was initially used instruments that evaluated the quality of life of asthmatic children from the perspective of doctors and caregivers. Have now been discarded because of evidence that perception of parents and doctors about the extent and how asthma affects the child is not related to the patient's own self. Why different instruments have emerged that assess children's perception of the impact of the disease, such as the CWC. From 4 to 7 years (ACCa) of 8 to 11 years (CAQB) and 12 to 16 years (CAQC). Lastly
asthma not only affects the patient but also to their families, so it is also important to evaluate the involvement of the family system.
Because there are different instruments to assess quality of life, the choice of the questionnaire to apply for each patient should be carried out taking into account the objective intended to assessment and psychometric properties presented.

General Guide of the evaluation protocol

Since various areas involved in the development and clinical course of asthma and given the various tools available to evaluate each of them, we propose an evaluation protocol aims to simplify the evaluation process to seek a balance between obtaining complete and accurate information and its applicability in clinical settings. This protocol should be considered as a guide as a flexible guide pecualiares must adapt to the characteristics of each patient.
The first step in the evaluation process should include consideration of patient history, which appears in summary form the estimate of their clinical condition and the results obtained from the various diagnostic tests and evaluation. In the clinical history includes also information on pharmacological therapy which is currently undergoing the patient has received treatment in the past, and the frequency and duration of asthma attacks, hospitalizations and emergency room visits.
Following this review that allows a first approach to the clinical and physiological components involved in asthmatic response, it is necessary to identify the behavioral variables associated with the disorder.
This process can be initiated with the use of an interview obtained information on the precipitating and aggravating asthma, the methods used by the patient to manage symptoms, others' reactions to the symptoms and impact of asthma in lifestyle. An example of a structured interview for asthma has been proposed by BELIEVE. The unreliability are advised to use the interview format that retains its usefulness as a tool to guide the clinician regarding specific questions and issues to explore. Thus maintaining the flexibility and nature interactive as well as presenting great value for establishing a personal relationship between therapist and client. In the appendix included at the end of the chapter contains a copy of this interview.
The information must be completed which can be obtained by completing self-registration sheets asthmatic episodes, as well as through the use of peak flow meter.
For information on deficits or excesses exhibited by the patient with asthma to control their disease can use the (log of attacks / asthma episodes) (believe). This self-registration page is completed by patients after experiencing an asthma attack and provides information on the perceived severity of the crisis, monitoring of medical prescriptions in the last 24 hours, and location and time of onset of the crisis, the type and amount of medication taken to control symptoms and behavioral sequence exhibited by the patient and / or your family.
must then proceed to identify the cognitive and emotional variables associated with the asthmatic response. We have an extensive battery of psychological tests to be selected in accordance with the characteristics of patients.
To estimate the level of knowledge about the disease and its treatment may AKI used for children and adults AKQ.
Determination of fear, panic can be performed using the PM of the ASC subscale and scale of the MMPI PM selecting the version that suits the characteristics of the patient. To assess depressed mood can use the BDI.
The presence of maladaptive attitudes toward asthma can be assessed using the Respiratory Illness Opinion .... (Kinsman) or others, depending on whether hospitalized adults, adults or children on an outpatient basis. Lastly
assess the impact on quality of life of patients, if the aim is to make comparisons between patients, or assess the patient's situation in relation group policy can be used as a generic instrument SF-36. On the contrary, if the objective is to identify more precisely the problem areas and assess the effects of the intervention seems more appropriate to use specific instruments AQLQ if adults and children PAQLQ if
The approximate duration of this evaluation process is one month, during which they may take place two evaluation sessions with the therapist, an hour-long, requiring the patient to perform certain tasks in the self-registration in the intersessional periods.

PSYCHOLOGICAL TREATMENT IN ASTHMA

The conceptualization of asthma as a disease characterized by a state of bronchial hyperreactivity on various environmental stimuli that affect or psychological episodes causing bronchospasm, posed as the ultimate goal of completely eliminating its treatment, or else permanent modification of the substrate of hypersensitivity in the airways. However, the therapeutic procedures available to us today, do not allow the achievement of this goal, so that efforts are directed to keep symptoms under control, preventing the onset of the crisis by reducing its severity, allowing person to lead as normal a life as possible. To this end, pharmacological treatment is presented as an unavoidable therapeutic for patients with asthma. However, the significant impact that psychological factors can play, it must be attached, in many cases, different strategies of psychological intervention to medical therapy which is unusually subject asthmatics. The most widely used behavioral strategies in the treatment of asthmatic patients were relaxation training, various forms of biofeedback, operant techniques and self-management programs. In recent years it has reduced the use of the former, consolidated self-management programs as the most frequent.

intervention strategies and their effectiveness

Relaxation response to the fact that emotional arousal can precipitate asthma attacks or exacerbate the symptoms and impact on management behavior disease, has attempted to test the effectiveness of relaxation techniques as an adjunct to medical therapy. The results have been mixed. There are also discrepancies in the reports on the effectiveness in reducing the frequency and intensity of symptoms, and that while in some studies no significant changes, others show significant improvements.

biofeedback biofeedback techniques have been widely used in the treatment of asthma, seeking to improve lung function through direct control by the BF of the degree of airway obstruction, or by indirect control through the involvement of various systems related to the diameter of the airways.

1. biofeedback techniques for the direct control of the size of the bronchial lumen. No relationships were found between good response to treatment and the presence of precipitating crises emotional or personality dimensions such as neuroticism and extraversion, so far remain undetected characteristics of asthmatics who might benefit from this type of intervention. BF
2. techniques for indirect control of the size of the bronchial lumen. BF
• specific relaxation of facial muscles: Based on the assumption that the tension in the facial muscles would be related to respiratory resistance, we tried to test the efficacy of BF EMG of facial muscles to reduce muscle tension facial and affect lung function in asthmatics. Kotses et al. A series of studies in which asthmatic children trained in decreasing tension in the facial muscles improved lung function after treatment, while maintaining the results after five months of monitoring. Mab, Wais et al. working with adults with asthma also showed an improvement. But it is unclear the ultimate mechanism by which this intervention might be effective, since some studies found no relationship between decreases in frontal EMG and improvement in lung function. BF
• for increased sympathetic activity and decreased parasympathetic activity: Maher BF Harding and acceleration used for the treatment of cardiac asthma on the basis of vagal predominance increases bronchomotor tone in the first symptoms of the asthmatic response. Suggested that the voluntary control of the vagus nerve would, in the early stages of a crisis, as director effective inhibitor of bronchospasm. These authors used heart rate in response to control, based on anatomical and functional relationship of the vagal innervation of the heart and lungs. Harding and Maher showed that the subjects undergoing the training of cardiac acceleration in BF showed significantly larger mean PEFR, that subjects had been trained to maintain your heart rate, although the magnitude of changes in PEFR were exposed to the BF had a large intersubject variability. BF
• for training in diaphragmatic breathing, chest EMG BF has been used to reduce patterns of hyperventilation that can accompany states of emotional arousal that precipitate or aggravate bronchospasm. Peper et al. have developed a method to train patients in the use of diaphragmatic breathing, which include verbal instructions, assistance instructor's manual, visual feedback of the volume of air inspired and EMG BF chest and shoulders, with good results. In addition, Peper and others conducted a study that used the prescription of symptoms (patients were induced asthma attacks) and resorted to diaphragmatic breathing to help abort the crisis. The results indicated that this procedure served to improve the development of asthma by reducing symptoms, medication use and emergency room visits. BF
• for sensory discrimination training to modify the sensitivity to respiratory sensations: The results indicated that subjects were effective in improving the discrimination of the degree of airway obstruction.

Operant conditioning techniques
When symptomatological manifestations of asthma and / or certain behaviors that adversely affect the course of the disease, remain as a result of inadequate application of reinforcement contingencies, is extremely useful for the implementation phase strategies based on operant conditioning to allow altering the relationship between behaviors and harmful consequences. The techniques used are the extinction, differential reinforcement of other behavior and response cost and time out. These strategies need to identify and remove the reinforcers that maintain maladaptive behaviors, establish alternative or incompatible behaviors and apply them appropriate reinforcers contingently. Although operant methods has proven effective in reducing and even at times eliminate the problem behavior, the information obtained largely from case studies, suggesting that despite its undoubted value, it should be noted with caution.

self-management programs for self-management programs or self-control in bronchial asthma, try to give the patient the entire behavioral repertoire that needs to manage their condition and maintain your fitness in the best possible conditions. Self-management programs appear cn the order to respond the important questions that asthma patients and their families involved and to provide them with the skills needed for effective disease management.
The first attempts to involve the patient with asthma in their own therapeutic process, the field appeared more focused on health education. Subsequently, due to the remarkable progress of drug treatment that led to the reduction of time spent in the hospital, it became necessary to develop programs that include, in a more systematic and brief, the patient information needed in and out of hospital . However, it was observed that in some patients, providing new information and the subsequent acquisition of new knowledge, not ensuring the subsequent execution of learned behaviors in everyday life. Therefore, after 1977, there are numerous publications that are proposed and evaluated different programs for asthma, including behavior modification techniques within diverse educational experiences.
These programs have been developed as an adjunct to medical treatment for the achievement of targets for therapy of established asthma. Keep

1. pulmonary parameters close to normal.
2. maintain normal levels of activity.
3. Prevent symptoms chronic.
4. prevent recurrence of exacerbation, and
5. avoid adverse effects to the medication.

seek therefore, provide the patient's ability to prevent the onset of crisis, managing crisis and maintaining good social skills related to asthma management, including communication with the doctor, people at school or work environment, family and friends .
To achieve these objectives are combined educational procedures and behavioral control, which typically include self-observation, self-registration, self-instruction, relaxation and training in decision making, although many of the programs developed have a weak theoretically based and cover a limited number of behavioral strategies without ensuring that patients have acquired skills that have been trained.
self-management programs for asthma have been applied using both formats individually or in group and carried out in hospitals, medical centers, emergency services, schools and even in the same household.
These discrepancies between the different programs in the types of strategies that will shape and format, the population and the application context, explain the differences presented in efficiency and the type of variable that affect. Some programs in children have been found useful to improve self-care behaviors, to meet the demands, improve school attendance and / or changes in the implementation and use of health services, especially emergency visits and hospitalizations.
In adults, have proved effective in increasing levels of knowledge about asthma, improve adherence to drug treatment and cause declines in the use of medical services.
The study of the effects that occur with the implementation of the programs has proved effective for increasing changes in knowledge about the disease, being useful to affect morbidity when properly applied behavioral strategies and patients who receive them have deficits self-care.

Guide to the implementation of the intervention program

interindividual variability that characterizes the signs of asthma and idiosyncratic pattern of the relationship between physiological, behavioral and emotional and clinical course of asthma, along with findings from research on the differential effectiveness of cognitive-behavioral strategies, has led to gradual abandonment of the search for the best intervention for asthmatic patients, focusing on identifying the most effective strategy in terms of patient characteristics.
In mild and / or knowledge gaps about the disease is necessary to conduct an educational program that addresses the pathophysiology of asthma, identification of precipitants and prodromal signs, rules to reduce or eliminate the crisis precipitating and the steps the patient should be used in case of crisis. This educational process can be carried out by medical personnel, or programs in small groups, which also allows these patients to obtain social support and other benefits derived from interaction with others with similar medical problems. Even if the program takes place in the group must meet the needs of each patient. Thus, information should be provided in a way appropriate to the age and cultural level of patients. In addition, the interview takes place during the evaluation phase can help the recognition of the precipitants and prodromal signs in each patient. Parallel to the recognition of the triggers should be provided the relevant rules for control. For this, the maximum expiratory flow monitor to determine and better recording of PEFR in each asthmatic and from this value can establish a management plan that sets guidelines for action in each case. This plan is provided through information in the form of verbal and written instructions and can take different forms.
In patients with moderate or severe asthma and / or in patients with self-care skills deficits and poorly controlled asthma, this program may be insufficient and require different educational program include behavioral strategies. There is no consensus on what should be the components included in self-management programs.
From the social learning model these aspects must be addressed through the following behavioral strategies:

1. self-registration, provide useful information to increase self-control asthma. The self-reports include: registration of physical signs and symptoms; record PEFR twice daily, making daily maintenance medication, registration and possible precipitating crisis. The observation and recording of disease-related factors and situations that occur allow patients to establish cause-effect relationship between these factors and the exacerbation of asthma.
2. Stimulus control: that will eliminate, or otherwise reduce the presence of a history of bronchospasm and thus alter the probability of occurrence of the asthmatic response. You can use several strategies for stimulus control, gradually narrowing the range of stimuli that can lead to bronchospasm, behavioral change strings, and insert pauses in these chains. The strategy used should be selected on the basis precipitating type in question so as to achieve maximum control over that particular trigger.
3. Techniques for the appropriate use of medication, proper control of the disease rests largely on taking prescribed medication. Some patients need to be trained in the correct use of inhalers using modeling techniques, shaping and strengthening for the implementation of the behavioral sequence correct. In addition, a large percentage of patients must be worked on adherence to drug treatment. Adherence to medication may improve further if we consider the following behavioral strategies:
• Completion of the self-registration.
• Targeting specific, realistic and achievable, in terms of medication to take.
• Providing feedback and using positive reinforcement about taking medication.
• Establishing behavioral contracts, in which they combine the formal establishment of therapeutic goals with the strengthening of achieving these goals.
• Using "key" to reduce the neglect of taking medication, whether direct key (the patient stops the medication near objects so commonly used) or indirect clues (signs places the patient as a reminder)
• Using social support
• Patient preparation to face and benefit from relapse, anticipating high-risk situations and ensuring that the patient has the right skills. In any case, the episode of relapse should be considered as an opportunity to acquire information and learn ways to prevent situations of future nonadherence.
• Using problem solving techniques. Training
4. discrimination of symptoms in patients who have difficulty in the perception of the degree of airway obstruction or those in which discrimination has an inappropriate symptoms: the maximum expiratory flow monitors are a tool of unquestionable value. For training, patients in the accurate estimation of the degree of bronchial obstruction carries out the daily record of PEFR and asthma symptoms for several weeks. The objective measure of PEFR acts as a broncho-degree feedback. However, if the poor perception of symptoms involving perceptual and emotional aspects, as noted above, it is necessary to attach the therapeutic strategies to modify the variables involved are described below.
5. Modification of the social environment: social support is an important factor. Whenever possible, is important to include family intervention program, and / or significant others for the patient, it will be of assistance in changing their behaviors and attitudes.
6. Improving self-efficacy is important for patients to acquire feelings of self-efficacy on asthma care behaviors. Learning tasks and implementation of behavior must be designed so that the patient obtains a consistently high success rate.

These self-management programs can be applied in small groups, which also allows a cost-benefit, foster social support, contrasting the experiences of patients and to provide role models for the solution self-management of common problems. In addition, a high degree of individualization may not be necessary for a significant proportion of patients. However, if the peculiarities of the patient or the characteristics of the context of intervention, opting for a single intervention may be included in the program only those components relevant to each particular case.
When patients present emotional states that affect the clinical course of asthma is necessary to include techniques designed to specifically address these problems. In patients who have emotional crises precipitating relaxation techniques have proven useful in improving the evolution of disorder. Although relaxation training can be used as the sole intervention technique, commonly included as a component in self-management programs.
In patients with high levels of panic-fear techniques can be used DS or cognitive-behavioral therapy for panic disorder. The use of the DS sets out three steps:

1. Patients are trained in progressive muscle relaxation procedure;
2. situations associated with asthma are listed in a hierarchy, from least feared to the most stressful and
3. relaxation is associated with exposure in imagination to the feared situations.

cognitive-behavioral treatment for panic disorder begins with an informative component which deals with a detailed description of the feelings of panic and the role of catastrophic interpretations of symptoms and fear. This information provides the context to distinguish the feelings of panic-related symptoms of asthma, using additional training to identify and categorize the different bodily sensations. Then be used cognitive techniques to help patients modify catastrophic cognitions. In addition, the patient is trained in techniques such as rehabilitation breathing and relaxation technique, after which must be carried out a program of exposure to feared elements such as conditions associated with the crisis and their own bodily sensations. In interoceptive exposure., Given the lack of research, we recommend a close collaboration between the psychologist and the pulmonologist when opting for your application.
Finally, in patients whose asthma symptoms, or disease-related behaviors are acquired or maintained by operant conditioning processes must be carried out an intervention based on operant conditioning techniques to get reduce or eliminate the behavior problem.
Different intervention techniques displayed can be applied in addition to or as the sole treatment modality in terms of psychological factors involved in the asthmatic response in patients.

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