The current BTS/SIGN asthma guideline emphasises that the diagnosis of asthma is a clinical one with no standardised definition of the type, severity or frequency of symptoms, nor of the findings on investigation that invariably leads to a diagnosis of asthma.1 However, central to all definitions of asthma is the presence of variable airflow obstruction. Documenting a history of changes in airflow obstruction either after bronchodilator treatment (reversibility) or spontaneously (variability) is an essential part of an asthma diagnosis, as well as contributing to assessment of asthma control.

The variability of asthma in an individual has led to management strategies that educate and empower patients, or parents, to adjust their own therapy within a framework agreed with their clinician. This approach of ‘guided self- management’ has been shown to be effective in adults and children.2 ,3

Clark and Gong note that using a self-management approach acknowledges that clinicians cannot provide direction for every disease contingency. For effective disease control, patients need to exercise a high degree of independent decision making about adjusting their treatment. To do so, patients need to develop their own skills in self-management. Self-management is underpinned by the behavioural theory of self-regulation that has at its heart a cycle of ‘observation—judgment—reaction/s’.4 It is by repeated iterations of this cycle that patients develop their personal repertoire of asthma management strategies.

Two important questions necessarily arise. First, what observations best allow the patient/parent to monitor their asthma? Studies of self-management training programmes have commonly based asthma plans on assessment of symptoms and/or peak flow monitoring.2 ,3 ,5 ,6

Then, second, how best do clinicians ensure that patients are appropriately guided towards effective disease control? One problem is that, over time, a large number of patients fail to take prescribed medications in …