Asthma action plans

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

What is asthma?

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.

What is an asthma action plan?

There is good evidence for the efficacy of asthma action plans:^{1 2 3}

• 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.⁴

• 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 and reduction both in morbidity and utilisation of healthcare resources.⁵

All people with asthma (and/or their parents or carers) should be offered self-management education which should include a written personalised asthma action plan (PAAP) and be supported by regular professional review. An asthma action plan is a written plan is an essential component of effective self-management education. One systematic review identified the features of asthma action plans associated with beneficial outcomes as including:⁶

• Specific advice about recognising loss of asthma control, assessed by symptoms (such as asthma attacks) or peak flows or both.

• In children, symptom-based written plans are effective in reducing emergency consultations for asthma, although (in older children) peak flow-based plans may be as effective for other outcomes.

• Actions, summarised as two or three action points, to take if asthma deteriorates, including seeking emergency help, starting oral steroids (which may include provision of an emergency course of steroid tablets), restarting or temporarily increasing inhaled corticosteroid, as appropriate to clinical severity.

In adults, written personalised asthma action plans may be based on symptoms and/or peak flows: symptom-based plans are generally preferable for children. One widely used PAAP is produced by Asthma UK.⁷

The National Review of Asthma Deaths found that of the 195 deaths reviewed, only 23% of the patients had been provided with an asthma plan. One of the recommendations made was that every patient with asthma should have a PAAP.⁸

How to create an asthma action plan⁹

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:¹⁰

• Structured education, reinforced with written personal action plans.

• 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.¹¹ 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 are sometimes used.⁷

• Two to three action points - no clear advantage to having more.

• Specific advice as to the action to take if asthma deteriorates:

  • NICE advises that, for those who do not need admission, we consider quadrupling the dose of inhaled corticosteriods at the onset of an asthma attack. This may reduce the risk of needing prescribed oral steroids, and is something that patients can do at home whilst waiting for medical attention.²

  • Other advice on an asthma plan may include restarting an inhaled corticosteroid if it has been stopped, taking the reliever inhaler more often, and seeking medical advice.

  • The asthma plan is likely to be stratified depending on PEFR - the lower the PEFR, the more urgently medical advice should be sought. This may include calling 999 (or equivalent medical emergency number if non-UK) if there are features such as difficulty breathing that affects the ability to walk or talk, or if the PEFR is below a certain level.⁷

Asthma action plan steps²

• Resources - patient information leaflets and proforma action plans can be downloaded or ordered from various websites. Ensure that these are high-quality and non-promotional.

• Ensure that all team members are convinced by the benefits of providing written action plans and are 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 elderly patients.

Asthma action plans must be reviewed and updated regularly.^{12 8}

Asthma action plan templates

Written asthma action plan templates are available from many different sources. The current British Thoracic Society/Scottish Intercollegiate Guidelines Network guideline gives the Asthma UK action plan as an example and includes a link to it in the guideline - Asthma UK also provides an action plan for children.⁶

Example of an asthma action plan