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

Key elements¹

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. 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 example⁹) 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 (e.g. 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, e.g. 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.

Practical steps^2,11

• 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 (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, preschool children, working adults, and the elderly.

Templates

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

Document references

1. No authors listed; Action plans in asthma. Drug Ther Bull. 2005 Dec;43(12):91-4. [abstract]
2. Asthma, Clinical Knowledge Summaries (2007)
3. Powell H, Gibson PG; Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2003;(1):CD004107. [abstract]
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. [abstract]
5. British Guideline on the Management of Asthma, British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), 2009
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. [abstract]
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. [abstract]
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. [abstract]
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. [abstract]
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. [abstract]
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. [abstract]

Internet and further reading

• Primary Care Respiratory Society UK (PRCS); Formerly the General Practice Airways Group (GPIAG); Home page

Acknowledgements