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Individual reprints of this article are not available. Address correspondence to Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905
Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.
The National Asthma Education and Prevention Program (NAEPP) recommends that all patients with asthma (regardless of severity) receive a written asthma action plan (WAAP).
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
We searched MEDLINE using the key words asthma, action plan, self care, patient care planning, anti-asthmatic agents, and patient education. On the basis of this review, we have synthesized practical suggestions for formulating an effective and efficient WAAP with the primary care physician as the intended audience.
Asthma is a chronic disease with intermittent or episodic worsening of symptoms. Asthma exacerbations can lead to absenteeism, presenteeism, urgent care and emergency department (ED) visits, hospitalizations, discomfort, dissatisfaction with care, and death.
The WAAP is a contingency plan to aid the patient in decreasing the severity and duration of an asthma exacerbation. A WAAP is only one part of asthma self-management; other components include scheduled visits for asthma, monitoring of rescue medication use, and education in how to monitor symptoms and lung function and how to use medications. These and other features of high-quality asthma care are summarized in a Centers for Disease Control and Prevention review.
A WAAP does not direct the patient to self-diagnose asthma, and the symptoms listed in a WAAP can result from confounding or comorbid illness; therefore, the WAAP is optimal when accompanied by physician supervision and an ongoing educational program.
It is a misconception that a self-management program has to be complicated and personnel-intensive; rather, it can focus on educating the patient in how to use the WAAP. Self-management should be part of the treatment plan for any chronic disease because it empowers patients, reduces dependency, and minimizes the response time so that the morbidity and pain due to episodic exacerbations can be reduced.
We agree with the NAEPP's recommendation that WAAPs should be formulated for most if not all patients with asthma.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
As part of a comprehensive asthma management plan, the principal aim of a WAAP is to help patients recognize asthma exacerbations early and initiate prompt treatment. To facilitate issuance of a WAAP, an electronic version should be made available either in the electronic medical record or as a form with prefilled options (in portable document format [PDF]) for ease of customization to a patient's condition.
THE ROLE OF SELF-MANAGEMENT IN ASTHMA
Patients with chronic diseases need a positive attitude, self-efficacy (ie, the level of confidence a patient has in handling the disease), and knowledge. Self-efficacy and a positive attitude have been correlated with adherence (and also with a lower number of hospitalizations).
Knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma.
Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies.
The patient must be actively involved in the formulation of a WAAP. This is an opportunity to encourage patient participation and buy-in, to solicit treatment preferences, and to discuss specific responses on the basis of the WAAP.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
all share certain features. First, patients have to monitor their symptoms or peak expiratory flow (PEF) to detect deviations from the usual state of controlled asthma. Second, reminders of warning signs and symptoms as well as potential precipitating factors or personal triggers are included. Third, patient-initiated treatment options to restore control are explicitly provided in writing. Fourth, expected response time, danger signs, and contact information are included (Figure). Written asthma action plans must have clearly defined action points that teach the patient to recognize and respond to an exacerbation. These action points should be customized to the patient's personal triggers (eg, seasonal allergies, viral infections) for buy-in and ease of teaching. Action points can be simplified using various forms, including a “traffic light” system of green, yellow, and red zones indicative of increasing severity of exacerbation (Figure). In general, action points help patients determine when to use a medication, what medication to use, how much of the medication to use and for how long, and what to expect of an asthma exacerbation.
TABLE 1Components of Poor and Good Written Asthma Action Plans
Poor action plan
Good action plan
Action points
Too many decision points for patients to navigate
2 to 4 clearly specific action points: when, what, how much and how long, and what to expect
Readability
Poor readability (ie, not tailored to patient population)
Clear, unequivocal, brief, appropriate language describing how to increase treatment
Elements
No description of expected results from the interventions
Description of how long to increase treatment
When to call for help
No mention of severe signs or symptoms that warrant immediate medical attention
Clear instructions on when to obtain additional advice
Customization
A static and generic plan not customized to patient's specific situation. It rarely changes and is not addressed at most visits for chronic asthma care
Contact information included; feedback incorporated on a regular basis
Language and literacy level should be considered if a WAAP is to be successful. For children, alternative WAAP forms focusing on parent education and signs that a parent can visually recognize (such as intercostal retractions) are available.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
If the printed word is not the accustomed source of information, an alternative, such as a visual or pictorial version of an asthma action plan, should be considered.
Another option would be to incorporate an early telephone call to a nurse or other health care professional for worsening asthma symptoms; the office or school nurse could then use the WAAP to give timely verbal advice. This is just one example of how a WAAP can facilitate dialogue between various caregivers and care sites.
PATIENT MONITORING
Although an action point can be based on monitoring of symptoms or PEF, the Formoterol and Corticosteroids Establishing Therapy (FACET) study clearly showed that patients primarily depend on symptoms to decide when to initiate prednisone therapy.
The basic assumption of symptom-based monitoring is to detect any deviation from the normal state of good control. It is difficult to establish a WAAP when asthma is poorly controlled, adding to the patient's confusion and the work for the physician and support staff. Frequent office visits may be necessary to establish asthma control before the WAAP can be optimally formulated. A WAAP is not a substitute for physician follow-up of patients with poorly controlled asthma.
Asthma control questionnaires are convenient and may help overcome problems of variable symptom perception. The use of asthma control questionnaires also simplifies symptom monitoring for patients and for educators. They focus the patient instruction process and identify which symptoms to monitor very concretely.
Of the 3 questionnaires cited by the NAEPP, we recommend the Asthma Control Test (ACT) over the Asthma Control Questionnaire because it does not require arithmetic division by the patient.
The Asthma Therapy and Assessment Questionnaire has not been as rigorously studied in terms of reliability, responsiveness, and reproducibility in adults. The ACT asks patients to assess their symptoms during the previous 4 weeks; the total score indicates whether asthma is controlled.
The ACT can be incorporated into regular physician visits and can be used for long-term home monitoring. An example of an ACT can be found at www.asthmacontrol.com.
MONITORING OF PEF
Peak expiratory flow is an objective assessment of airflow that has been used for self-management of asthma. Poor adherence to daily PEF monitoring suggests that this may not be a practical approach for most patients. However, a subset of “poor perceivers” who consistently underestimate the worsening asthma symptoms and airflow obstruction may benefit from a PEF-based approach.
A purely symptom-based management plan may result in overtreatment of some patients with anxiety who are panic prone and who perceive airflow obstruction when none exists.
We recommend using a symptom-monitoring approach with the option of PEF to confirm obstruction whensymptoms of worsening control are detected. Choosing which method (PEF monitoring or symptom monitoring or both) to anchor the WAAP is best made by a physician familiar with the patients' preferences.
If PEF monitoring is part of the WAAP, we suggest using a persistent decrease (2 readings, 24 hours apart) of 20% from a patient's personal best PEF as an action point. In the FACET study, 69% of patients had a decrease in PEF of 20% or more in the 14 days before an asthma exacerbation.
A physician caring for a patient with asthma should consider the patient's risk of fatal asthma. Risk factors include previous severe exacerbation, 2 or more hospitalizations for asthma in the past year, 3 or more ED visits for asthma in the past year, a hospitalization or ED visit for asthma in the past month, use of more than 2 canisters of short-acting β-agonist (SABA) per month, poor perception of airflow obstruction, sensitivity to Alternaria species, lack of a WAAP, cardiovascular disease, other chronic lung disease, low socioeconomic status, illicit drug use, and major psychological problems.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
Patients should be instructed to calltheir physicians if they do not respond to the treatment outlined in their WAAP. Patients with these risk factors benefit not only from a detailed WAAP but also from close follow-up each time they activate their action plan. This may initially result in more frequent physician visits but will ultimately pay dividends in terms of better outcome for the patient.
EDUCATING PATIENTS WITH ASTHMA ABOUT THEIR MEDICATIONS
Knowledge, self-efficacy, and attitude are important factors in self-management. It is important for patients to understand the purpose of the different medications involved in asthma. Ignacio-Garcia and Gonzalez-Santos
provide information intended to help patients understand their asthma medications (Table 3). Information regarding some of the most common asthma exacerbation medications follows.
TABLE 3Information Given to Patients Regarding Asthma Medicines Used in the Action Plan
Patient Instruction. Use your rescue medications when short of breath.
When. Patients should be instructed to use their rescue medicines when they have symptoms of dyspnea at rest or during exertion, cough, chest tightness, wheezing, or a decrease in PEF from baseline of more than 10% to 20%.
What. Short-acting bronchodilators include albuterol, pirbuterol, or levalbuterol metered-dose inhalers. Recently, the propellant for inhaled short-acting bronchodilators has been changed from chlorofluorocarbons to hydrofluoroalkane for environmental reasons. Nebulization (compression with a machine) is an alternative mechanism of delivery of SABAs that is less portable than metered-dose inhalers and that does not necessarily improve medication delivery.
How Much and How Often. For mild baseline dyspnea, patients should use 2 to 4 puffs of albuterol every 4 hours. For severe dyspnea, patients should use 2 puffs ofalbuterol every 5 minutes up to 20 puffs (if no response in 1 hour, seek immediate medical attention); nebulized (compressed) SABAs can also be used.
Why No Relief. Increasing requirement for SABAs is a red flag that symptoms such as cough, dyspnea, or airway obstruction may be due to mucus or inflammation or are unrelated to asthma. Patients with poor improvement after SABA treatment should report this to the physician because it requires additional action.
Comment. Assessing SABA response determines the next action point in a well-formulated WAAP. Anticholinergic medication should not be used for immediate relief.
Inhaled Corticosteroids
Patient Instruction. Do not forget that asthma is inflammation of the airways and that it is important to continue your controller medication(s).
When. Patients should be instructed to continue their usual ICS doses during an exacerbation. The intermittent use of an ICS during exacerbation should be limited to patients with very mild asthma who have rare and mild exacerbations.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
This is especially important for patients requiring a high-dose ICS because they have to use more puffs to obtain the same effect with certain ICS preparations (beclomethasone, budesonide, triamcinolone, flunisolide).
Knowledge about systemic bioavailability is important for patients taking a high-dose ICS because risk of adverse effects may be higher in preparations with higher oral availability.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation.
Treatment plans using substantially higher ICS doses than the usual daily dose (eg, 2 mg/d of fluticasone) were effective in adult studies but ineffective in a pediatric study.
Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care.
Issues with using a high-dose ICS for exacerbations include cost, tolerability, and the difficulty in increasing ICS dose in patients who use a fixed ICS/LABA combination inhaler.
How Long. The maintenance dose of ICS necessary to attain asthma control should be continued throughout the exacerbation.
Why No Relief. Studies suggest that anti-inflammatory treatment should be started early.
Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care.
Poor technique and poor adherence are common reasons why ICSs are ineffective.
Bottom Line. An ICS should be viewed as a daily controller medication rather than as a treatment for asthma exacerbations.
Long-Acting β-Agonists
Patient Instruction. This medication is not intended as a quick relief or rescue medication.
When. Long-acting β-agonists (LABAs) are often part of patients' long-term asthma plan and are particularly effective at decreasing ICS dose and reducing mild exacerbation rates.
What. Unless accompanied by regular use of an ICS, LABAs such as salmeterol and formoterol should not be used for asthma unless accompanied by regular use of an ICS.
The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol [published correction appears in Chest. 2006;129 (5):1393].
Formoterol has an onset of action in minutes but is not currently approved by the Food and Drug Administration as a rescue medication. Short-acting anticholinergic medications have a role in ED management of asthma exacerbations but are not recommended for home management.
Research. Treatment approaches using a combined ICS/LABA on an as-needed basis to effectively control asthma have been supported by recent studies.
Additional studies are required to clarify the role of combined ICS/LABA in acute exacerbations.
Bottom Line. Using as-needed ICS/LABA combination products has not been approved by the Food and Drug Administration for treatment of acute asthma exacerbations.
Systemic Corticosteroids
Patient Instruction. It is important to start early to control an exacerbation; systemic corticosteroids are safe for short-term use.
When. Initiation of systemic corticosteroid therapy is determined by an action point in the WAAP (ie, when symptoms are severe and/or when the PEF decreases 20% from the patient's personal best on 2 readings taken 24 hours apart).
What. By clinical consensus, systemic corticosteroids are the first line of treatment for severe exacerbations or for those that cannot be controlled by increasing the SABA dose.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
Tapering. Tapering is only necessary for patients who are receiving long-term systemic corticosteroid therapy or for patients who receive frequent systemic corticosteroid bursts. Studies have shown that adrenal function typically recovers quickly.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care.
the high failure rate in the prednisone arm was attributed to delayed initiation. Patients should expect improvement in about 48 hours; however, for severe exacerbations, relief may take longer.
Only a small proportion of patients with asthma are resistant to corticosteroids.
Comment. Systemic corticosteroids are the preferred treatment for moderate to severe asthma exacerbations.
CONCLUSION
A WAAP is a useful asthma management tool that should include action points based on an agreed method of self-monitoring, the dosing and duration of increased treatment, and contact information to facilitate immediate medical attention if needed. Physicians should strongly consider formulating a personalized WAAP to help their patients with asthma recognize exacerbations early and treat them effectively.
National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3).
Knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma.
Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies.
A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation.
Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care.
The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol [published correction appears in Chest. 2006;129 (5):1393].
On completion of this article, you should be able to: (1) create an effective and efficient written asthma action plan, (2) describe the options for monitoring asthma using a written asthma action plan, and (3) review the rationale for the medications used in asthma exacerbations and be able to explain the differences in medications to patients in a way that facilitates proper use and adherence.
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