Asthma Action Plans

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonym: self-management plan or programme; 'action plan' is often used in preference as it is perceived as less daunting to patients and more engaging to children, parents and carers

Asthma is a chronic condition where optimal control is obtained by stepping treatment up or down in line with clinical signs and symptoms.

Ideally, patients should be empowered with previous advice from health professionals to:

  • Recognise worsening asthma.
  • Be able to self-initiate therapeutic adjustments.
  • Know how and when to access the medical system.

There is good evidence for the efficacy of action plans:[1][2]

  • As part of self-management education, action plans improve health outcomes in adults with asthma. Outcomes examined include hospital admissions, emergency medical contacts, days missed from work, nocturnal asthma symptoms and quality of life.[3]
  • The evidence is strongest in those with the most severe disease, following management in secondary care and in those with recent exacerbations.
  • There is a relative lack of evidence in primary care.
  • A meta-analysis of self-management in children and adolescents (2-18 years) also showed improved lung function, reduced morbidity and utilisation of healthcare resources.[4]

Written personalised asthma action plans are recommended as part of patient education and self-management.[5] They should form standard care for all people with asthma, but should always be offered prior to discharge, following inpatient admission for asthma. Despite clear recommendation by national guidelines,[5] action plans have been poorly taken up both by healthcare teams and patients. Healthcare professionals seem more attuned to the pharmacological management aspect of guidelines: a 2007 Scottish survey showed only 23% of asthmatic patients received an action plan compared with 67% receiving the correct add-on therapy.[6]

There is inevitably wide variation in education/self-management programmes and, whilst there is evidence supporting the efficacy of these types of programme in general, there is no individual component that has been shown to be effective in isolation. Successful components include:[7]

  • Structured education, reinforced with written personal action plans.
    Core content for educational programme or discussion[5]
    • Nature of disease.
    • Nature of treatment.
    • Patient's treatment goals.
    • How to use treatment.
    • Skills for self-monitoring.
    • Negotiation of the asthma action plan (with view to 3. above).
    • Recognising and managing acute exacerbations.
    • Avoiding triggers.
  • Specific advice as to how to recognise loss of asthma control. Action points can be symptom or peak expiratory flow rate (PEFR) triggered. In children, there is some evidence that symptom triggers are preferable.[8] When based upon peak flow, percentage personal best PEFR (assessed once treatment has been optimised, and updated regularly) should be the trigger for action rather than percentage predicted PEFR.
  • Written instructions - traffic light systems (see the National Asthma Council of Australia for an example[9]) have not been shown to be superior to standard instructions.
  • Two to three action points - no clear advantage to having more.
  • Specific advice as to the action to take if asthma deteriorates (eg when PEFR <40% it is best to seek emergency help; when PEFR <60% it is best to start an emergency course of oral steroids; when PEFR is <80% it is best to recommence/increase inhaled steroids) appropriate to clinical severity.
    • Evidence supports the safe use of patient-held prednisolone tablets for use when symptoms/peak flow deteriorate substantially.
    • Once patients are already using moderate-to-high daily doses of inhaled steroids (>400 micrograms/day), increasing these further is unlikely to be an effective, rapid strategy and patients should be directed to move straight to oral steroid rescue treatment.
    • Patients on low-dose (200 micrograms/day) should be advised to increase their dose substantially (usually by adding in a high-dose inhaler, eg to 1,200 micrograms/day) as there is poor evidence for the efficacy of the 'double-up' maintenance approach that has been widely used.[10]
  • Specific advice as to when to seek medical review.

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  • Resources - patient information leaflets and proforma action plans can be downloaded or ordered from various websites. Ensure that these are high-quality and ideally non-promotional.
  • Ensure that all team members who are on board are convinced by the benefits of providing written action plans and offering consistent advice.
  • Consider which patients to target - sometimes targeting those who are likely to benefit the most (ie those with poorly controlled, moderate or severe asthma) via diagnostic or prescription term searches is more realistic initially. Changes in control markers can be audited to review progress.
  • Determine whether delivery of education and action plans should be part of routine care or done individually/in groups in dedicated clinic time. Extra consultation time may be required but this may be balanced against a reduction in unscheduled GP appointments in the longer-term.
  • An acute consultation offers the chance to check what action a patient has already taken to manage an exacerbation. Consider further reinforcement or refining of the existing action plan and the need for routine follow-up to consolidate progress.
  • Education and advice should be individualised. Explore patient ideas, concerns and expectations. Linking patient goals to brief simple education is most likely to be acceptable to patients.
  • Different approaches may be required for different patient groups, eg teenagers, preschool children, working adults, and the elderly.

Action plan templates are available from many different sources. The current British Thoracic Society/Scottish Intercollegiate Guidelines Network guideline includes the Asthma UK action plan in its annexes.[5] There is not a specific standard action plan available for children currently.

Example of an asthma action plan

Patient name:
Date of birth:
Next of kin:
Contact numbers:
Usual doctor/asthma nurse:
Contact numbers:
Best peak flow:
Asthma triggers:
Drug allergies:
Date of last update:
When my asthma is well controlled:
  • I have no regular daytime symptoms (cough, wheeze, chest tightness, shortness of breath).
  • I have no difficulty sleeping because of my asthma symptoms.
  • My asthma does not interfere with my usual activities (eg work, study, housework).
  • My peak flow is above 85% of personal best.
What should I do?
  • Continue your usual treatment.
  • If you are always in this box, see your doctor or nurse to review stepping down treatment.
My usual treatment My preventer/reliever medications are:
When my asthma is getting worse: Moderate symptoms:
  • I need my reliever puffer every 3-4 hours or more often.
  • I am having constant wheezing, coughing, chest tightness.
  • I am having difficulty with normal activity.
  • My peak flow is between 50 to 75% of personal best.
What should I do?
  • Acute treatment - bronchodilator (eg salbutamol 4-6 puffs) via spacer or nebuliser. Repeat every 10-20 minutes if necessary.
  • Monitor response - symptoms and peak flow. If deteriorating, seek medical help. If improving/stable, seek medical review within 48 hours.
  • Step up usual preventative treatment - traditionally advice has been to double inhaled steroids in an acute exacerbation although the efficacy of this has been questioned by some.[12][13] This approach is less effective in those already on high-dose maintenance inhaled steroids (eg >400 micrograms/day) who should should move directly to oral steroids. With those on low-dose inhaled steroids (eg 200 micrograms/day), advise to increase substantially (eg to 1,200 micrograms/day).[5]
  • Oral prednisolone 40-50 mg oral dose for at least 5 days. See your doctor or nurse within 24-36 hours of starting such a course.
  • When your symptoms have returned to being well controlled, switch back to your usual treatment after 3 days.
How to recognize emergency asthma:
  • I am having great difficulty breathing.
  • My reliever puffer is giving little or no improvement.
  • It is difficult to speak or walk due to severe shortness of breath.
  • Symptoms are getting worse quickly.
  • I am feeling frightened.
  • My peak flow is less than (50% of personal best).
What should I do?
  • Take your reliever puffer. If there is no immediate improvement, contact a doctor urgently and, if one is not available, call 999 for an ambulance or go straight to hospital.
  • Sit upright and stay calm.
Emergency treatment
Whilst waiting for doctor/ambulance:
Take 1 puff of salbutamol via spacer every 5 minutes or until symptoms improve.
Updating my action plan:
  • I should see my nurse/doctor for a regular asthma review at least once a year. My next one is due:
  • If your medication has been increased, see the nurse or doctor after a month to review progress.
  • If your symptoms have been very well controlled over at least 3 months, arrange a review as it may be possible to step down your treatment.

Further reading & references

  1. No authors listed; Action plans in asthma. Drug Ther Bull. 2005 Dec;43(12):91-4.
  2. Asthma, Prodigy (2007)
  3. Powell H, Gibson PG; Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2003;(1):CD004107.
  4. Guevara JP, Wolf FM, Grum CM, et al; Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003 Jun 14;326(7402):1308-9.
  5. British Guideline on the Management of Asthma; British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines (SIGN), 2008
  6. Wiener-Ogilvie S, Pinnock H, Huby G, et al; Do practices comply with key recommendations of the British Asthma Guideline? If not, why not? Prim Care Respir J. 2007 Dec;16(6):369-77.
  7. Gibson PG, Powell H; Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004 Feb;59(2):94-9.
  8. Zemek RL, Bhogal SK, Ducharme FM; Systematic review of randomized controlled trials examining written action plans in children: what is the plan? Arch Pediatr Adolesc Med. 2008 Feb;162(2):157-63.
  9. Detailed examples of asthma action plans, National Asthma Council of Australia
  10. Reddel HK, Barnes DJ; Pharmacological strategies for self-management of asthma exacerbations. Eur Respir J. 2006 Jul;28(1):182-99.
  11. Cleland J and Price D; Implementing self management plans for asthma. 2004. Prescriber 15; 76-79
  12. FitzGerald JM, Becker A, Sears MR, et al; Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax. 2004 Jul;59(7):550-6.
  13. Harrison TW, Oborne J, Newton S, et al; Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004 Jan 24;363(9405):271-5.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Chloe Borton
Current Version:
Last Checked:
19/11/2010
Document ID:
279 (v6)
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