Treating asthma to control symptoms
TRAINING IN GUIDED ASTHMA SELF-MANAGEMENT
Guided management may involve varying degrees of independence, ranging broadly from patient-directed self-management to doctor-directed self-self-management. With patient-directed self-self-management patients make changes in accordance with a prior written action plan without needing to first contact their health care provider. With doctor-directed self-management, patients still have a written action plan, but refer most major treatment decisions to their physician at the time of a planned or unplanned consultation.
The essential components of effective guided asthma self-management are:123
• Self-monitoring of symptoms and/or peak flow
• A written asthma action plan to show how to recognize and respond to worsening asthma; and
• Regular review of asthma control, treatment and skills by a health care provider.
Self-management education that includes these three components dramatically reduces asthma morbidity in both adults123 (Evidence A) and children124 (Evidence A). Benefits include a one-third to two-thirds reduction in asthma-related hospitalizations, emergency department visits and unscheduled doctor or clinic visits, missed work/school days, and nocturnal wakening. It has been estimated that the implementation of a self-management program in 20 patients prevents one hospitalization, and successful completion of such a program by 8 patients prevents one emergency department visit.123,242 Less intensive interventions that involve self-management education but not a written action plan are less effective,243 and information alone is ineffective.238
Self-monitoring of symptoms and/or peak flow
Patients should be trained to keep track of their symptoms (with or without a diary), and notice and take action if necessary when symptoms start to worsen. Peak expiratory flow (PEF) monitoring may sometimes be useful:
• Short-term monitoring
o Following an exacerbation, to monitor recovery.
o Following a change in treatment, to help in assessing whether the patient has responded.
o If symptoms appear excessive (for objective evidence of degree of lung function impairment).
o To assist in identification of occupational or domestic triggers for worsening asthma control
• Long-term monitoring
o For earlier detection of exacerbations, mainly in patients with poor perception of airflow limitation.108 o For patients with a history of sudden severe exacerbations.
o For patients’ who have difficult-to-control or severe asthma
For patients carrying out peak-flow monitoring, use of a laterally compressed PEF chart (showing 2 months on a landscape format page) allows more accurate identification of worsening asthma than other charts.119 One such chart is available for download from www.woolcock.org.au/moreinfo/. There is increasing interest in internet or phone-based monitoring of asthma. Based on existing studies, the main benefit is likely to be for more severe asthma244 (Evidence B).
Written asthma action plans
Personal written asthma action plans show patients how to make short-term changes to their treatment in response to changes in their symptoms and/or PEF. They also describe how and when to access medical care.245,246
The benefits of self-management education for asthma morbidity are greater in adults when the action plans include both a step up in ICS and the addition of OCS, and for PEF-based plans, when they are based on personal best rather than percent predicted PEF246 (Evidence A).
The efficacy of self-management education is similar regardless of whether patients self-adjust their medications according to an individual written plan or whether the medication adjustments are made by a doctor243 (Evidence A).
Thus patients who are unable to undertake guided self-management can still achieve benefit from a structured program of regular medical review.
Examples of written asthma action plan templates, including for patients with low literacy, can be found on several websites (e.g. Asthma UK, www.asthma.org.uk; Asthma Society of Canada, www.asthma.ca; Family Physician Airways Group of Canada, www.fpagc.com; National Asthma Council Australia, www.nationalasthma.org.au) and in research publications (e.g. 247,248). Health care providers should become familiar with action plans that are relevant to their local health care system, treatment options, and cultural and literacy context. Details of the specific treatment adjustments that can be recommended for written asthma action plans are described in the next chapter (Box 4-2, p.75).
Regular review by a health care provider
The third component of effective asthma self-management education is regular review by a health care provider. Follow-up consultations should take place at regular intervals. Regular review should include the following.
• Ask the patient if they have any questions and concerns
o Discuss issues, and provide additional educational messages as necessary; if available, refer the patient to someone trained in asthma education.
• Assess asthma control
o Review the patient’s level of symptom control and risk factors (Box 2-2, p.29).
o Ask about flare-ups to identify contributory factors and whether the patient’s response was appropriate (e.g.
was an action plan used?)
o Review the patient’s symptom or PEF diary if they keep one.
o Assess comorbidities
• Assess treatment issues
o Watch the patient use their inhaler, and correct and re-check technique if necessary (Box 3-11 p.55).
o Assess medication adherence and ask about adherence barriers (Box 3-12, p.57) o Ask about adherence with other interventions, (e.g. smoking cessation)
o Review the asthma action plan and update it if level of asthma control or treatment have changed249
A single page prompt to clinicians has been shown to improve the provision of preventive care to children with asthma during office visits.250 Follow-up by tele-healthcare is unlikely to benefit in mild asthma but may be of benefit in those with severe disease at risk of hospital admission.244
PART D. MANAGING ASTHMA WITH COMORBIDITIES AND IN SPECIAL POPULATIONS