Asthma stepwise management, action plans and patient education
(By Dr. Funsho Festus Oloruntoba)
Virtually all international guidelines recommend using a stepwise approach to pharmacologic therapy to gain and maintain control of asthma and reduce both impairment and risk of exacerbations and progression.
Written asthma action plans not only help individuals track and implement the stepwise approach, it also allows asthmatics to daily monitor and adjust their medications in response to changing signs and symptoms, thus reducing their risk of exacerbations. Every asthmatic should have a written action plan.
The stepwise management plan organises asthma treatment into different steps or levels based on an individual’s signs and symptoms at a certain moment, and reflects increasing and decreasing intensity of treatment (dosages and/or number of medications) required to achieve and maintain asthma control.
The steps are determined on a case-by-case basis with respect to the age of the individual and severity of their asthma. The medication, dosage, and timing of the therapy are determined by the level of asthma severity assessed at the initiation of therapy and the level of asthma control needed for adjusting therapy.
By utilising the stepwise management plan, therapy can be stepped up or down as needed to maintain control. The goal of step-down therapy is to identify the minimum medication necessary to maintain control.
Asthma action plan
A written asthma action plan is a document developed jointly by the health care provider and the individual. The plan should include the individual’s daily treatment plans, key points to help them recognise changes in their condition, and steps they can take to manage these changes. The patients’ ability to self-adjust their medications in response to acute symptoms or changes in their PEF measurements is the basis of most written plans.
An asthma action plan should include two sections as a minimum: daily management and emergency response. The daily management section should incorporate directions for the daily management of their asthma including the names of medications, dosages, and times they should be taken. It should also include daily monitoring information, steps to control environmental allergens, and directions for avoiding any known triggers.
The emergency response section should include information on how to recognise symptom changes and the specific steps ( i.e, medications to take, dosage, and timing ) they should follow in response to these changes. It is critical that the plan includes information on the identification of signs, symptoms and PEF measurements that indicate the need for urgent medical attention.
Individuals with asthma and their immediate care providers must be provided with the red zone parameters that indicate the need for professional care beyond this point. It is a good idea that the written asthma plan also includes emergency telephone numbers for the physician, nearest emergency department, and any emergency transport system/service that individuals can call quickly to assist them.
The goal of asthma management is gaining and maintaining control so that the individual can lead a normal, active life. Students with controlled asthma can attend school and participate in sports without fear of their condition interfering. However, teachers,coaches, school administrators should be made aware of student’s condition and informed of the proper steps to take should asthma attack occur.
Even if the school district has a school nurse programme and/or an asthma response program/plan, it is a good idea to have a written plan and information available in the event of an emergency.
Whether an individual is a student or an adult, organising his or her health information when travelling is important. Filling out this form and also leaving a copy with a healthcare provider or emergency contact prior to departure can provide useful documentation in event of emergency.
In addition to developing the preceding documents, patient self-management skills and education play a critical role in gaining and maintaining control of asthma. The development of a partnership between the healthcare providers and the individual has been shown to be an effective strategy for improving asthma outcomes.
Whenever possible it is important to include the asthmatic individual in decision-making process and the development of a written asthma action plan. The components of a successful asthma education plan include:
· The individual’s ability to demonstrate an understanding of their triggers and symptoms.
· A discussion/implementation of action steps to minimise environmental triggers.
· The individual’s ability to demonstrate proper technique when taking their medications and completing their self-monitoring (peak flow, symptoms scores etc.)
· A written asthma action jointly developed by the practitioner and the individual
· An emergency plan that clearly outlines the steps to take when asthma symptoms are not responding to the written asthma action plan,
1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. Accessed April 2, 2009.
2. The Global Initiative for Asthma (GINA) 2009 Update of the GINA Report. Global Strategy for Asthma Management and Prevention. http://www.ginasthma.com. Accessed April 1, 2010.