Asthma Action Plans

Synonym: Self management plan or programme, although, "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 up or down treatment in line with clinical signs and symptoms.

Ideally patients should be empowered with prior 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 their 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 in-patient admission for asthma. Despite clear recommendation by national guidelines,⁵ action plans have been poorly taken up by both by health care teams and patients. Health care professionals seem more attuned to the pharmacological management aspect of guidelines: a recent Scottish survey showed only 23% asthmatic patients received an action plan compared to 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 discussion5 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) 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 flow (PEF) triggered. In children, there is some evidence that symptom triggers are preferable.⁸ When based upon peak flow, percentage personal best PEF (assessed once treatment optimised and update regularly) should be the trigger for action rather than percentage predicted PEF.
• Written instructions - traffic light systems (see the National Asthma Council of Australia for an example⁹) have not been shown to be superior to standard instructions.
• Two to three action points - no clear advantage to more.
• Specific advice as to action to take if asthma deteriorates (e.g. PEF<40% best seek emergency help; PEF<60% best start emergency course of oral steroids; PEF<80% best recommencing/increasing 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 mcg/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 mcg/day) should be advised to increase their dose substantially (usually by adding in a high dose inhaler, e.g. to 1200 mcg/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.

• Resources - PILs and proforma action plans can be downloaded or ordered. Ensure that these are high quality and ideally non-promotional. See internet and further reading.
• Get all team members are on-board, 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 (i.e. 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 e.g. teenagers, pre-school children, working adults, the elderly.

Action plan templates are available from many different sources. The current BTS/SIGN guideline include 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