Asthma Action Plans

(Note, "Action plan" is used in preference to "self-management plan" as it is perceived as less daunting to patients and is felt to be more appropriate working across age groups and engaging parents and carers as well as adult patients.¹)

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.

Written personalized asthma action plans are recommended as part of patient education and self-management in current SIGN/BTS Guidelines.¹ They should form standard care for all people with asthma, but should always be offered prior to discharge, following in-patient admission for asthma.

In the past, action plans have been poorly taken up and criticized for being overly complex - reflecting the need for good patient-centred communication and patient partnership to bridge the gap between evidence-based guidelines and work with individuals.

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 (see below), there is no individual component that has been shown to be effective in isolation. In particular, duration, intensity and format for delivery vary. Usual care can be raised to a standard that incorporates many of the key features of successful programmes.
Successful programmes include:

• Structured education reinforced with written personal action plans.
• Specific advice as to how to recognise loss of asthma control (although this may be assessed by monitoring symptoms and/or peak flow).
• Specific advice as to action to take if asthma deteriorates (eg. seek emergency help, start emergency course of oral steroids, recommencing/increasing inhaled steroids) appropriate to clinical severity.
• Specific advice as to when to seek medical review.

Written individualized action plans, as part of self-management education, improve health outcomes in adults with asthma. Hospital admissions, ER visits or emergency visits to the doctor, days missed from work, nocturnal asthma and quality of life are all improved by self-management.⁵The 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 utilization of healthcare resources.⁶

• Ensure adequate availability of 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.
• Ensure all team members are on-board, convinced by the benefits of providing written action plans and will offer 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.
• Discuss whether delivery of education and action plans should be part of routine care or delivered individually/in groups in dedicated clinic time etc. 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. Similarly, consultations for URTI or other known trigger can be used to rehearse action plans in case of further deterioration.
• Education and advice should be individualized. Patient ideas, concerns and expectations should be explored. 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, pre-school children, working adults, the elderly.

Action plan templates are available from many different sources. Some are listed below in the internet and further reading section. There is not a specific standard action plan available for children currently.

Example of an asthma action plan: