What Is An Asthma Action Plan and How Can One Be Individualized for My Patients?
Aaron S.
Chidekel,
MD
An asthma action plan is a critical component of safe and high-quality asthma management. It represents a confluence of several important principles of guideline-based asthma care: clinical monitoring, medical management, and patient education. Every patient being seen for asthma should be given a written asthma action plan, but, unfortunately, studies have shown that many patients are not. The asthma action plan provides clear guidance to a patient or family about what should be done and when and for which level of symptoms or peak expiratory flow rates, and it provides the information to let them know who should be called for assistance and when it is time to call. In short, the asthma action plan is the written roadmap that guides a patient and family in the direction of safe and effective asthma self-management (Table 23-1). It is well worth the time in the office to craft one in writing for each asthma patient.
Written asthma action plans have been shown to be more effective than oral action plans, and this fact stresses the importance of putting onto paper or into an electronic medical record what it is that the patient needs to do to manage his or her own or his or her child’s asthma. Written action plans allow for the earlier detection of asthma symptoms and flares and thereby allow for earlier intervention. This timely and appropriate intervention translates into reductions in unscheduled visits to the office and emergency department and more importantly into decreased frequencies of hospitalization and death. Other important outcomes that have been enhanced through the use of written asthma action plans include the reduction in night-time asthma symptoms and in days missed from work or school. It is implied that the asthma action plan is combined with education regarding its use and that understanding of the action plan is confirmed with the patient at the time of its inception. This dual process of education and formulation of an asthma action plan is a critical combination to promote self- or family-directed asthma management that is safe and efficacious.
Asthma action plans can be based on symptoms, peak expiratory flow rates, or both. While there remains some controversy as to which type of plan may be most efficacious, this distinction is less important from a practical perspective. My personal opinion is that all asthma actions plans need to have a symptom-based component. Symptoms such as the frequency and severity of coughing, wheezing, chest tightness, night-time awakenings, and decreased activity tolerance are all important to include. Then, if the patient is using a peak flow meter, it can be incorporated as well. If the patient in question is too young or is resistant to using a peak flow meter, then peak flow values are not included in the asthma action plan. Perhaps the only time that it is critical to include peak flow readings in an asthma action plan is in those patients who are poor perceivers of asthma symptoms. It is important to define these patients with poor perception of asthma symptoms because they are at increased risk of adverse asthma outcomes and, in this case, the ongoing and structured use of peak flow monitoring is important. In general, peak flow zones are created in an asthma action plan based upon a person’s “personal best” peak expiratory flow rate. The green zone is defined as 80% to 100% of the personal best peak expiratory flow rate, the yellow zone is defined as 50% to 80% of the personal best peak expiratory flow rate, and the red zone is defined as 50% or less of the personal best peak expiratory flow rate. I usually start the action plan with the best peak expiratory flow rate obtained in the office and then have the patient use the peak flow meter for 1 to 2 weeks at home to further define his or her “real world” personal best and adjust the action plan accordingly.
As alluded to, most asthma action plans are modeled in zones using a “traffic light” analogy of green, yellow, and red zones to depict times of safety, caution, and danger (Table 23-2). This model is familiar to patients and parents and is easy to construct and envision. More important than the colors of the zones is the content that each zone contains. The components of an asthma action plan must communicate clearly, concisely, and efficiently how the patient should be feeling, what the peak flow reading should be, and what the patient should be doing in each of the zones of their action plan. If asthma control is slipping, it should be clear to the patient what actions to take and for how long to take them prior to calling for help. Medications and dosages should be documented for each zone, and the physician’s and other emergency phone numbers should be clearly listed as well. Action plans should also describe acceptable duration of symptoms for each level of the plan. For example, it may be acceptable for the patient to wait a certain amount of time at one level of the plan, but not at another. Many asthma action plans are available to use, and they are available in different languages so that the action plan can be provided in a patient’s native language. Specific action plan templates are available for children, daycare, schools, after exacerbations, and after exercise. Pick the resources that are most appropriate for your own practice, and implement them for your patients with asthma.
As part of ongoing asthma management, it is important to keep the action plan up to date. Asthma action plans should be reviewed with the patient and family at each follow-up visit and should be updated with new information reflecting changes in medications or other clinical parameters. Patient and family concerns with the action plan should be queried and addressed. This ongoing conversation helps to establish a partnership with the patient and facilitates effective 2-way communication. It also encourages adherence to therapy by investing the patient and family in the care process. In addition to keeping the action plan up-to-date, it is important that the action plan be a part of the patient’s medical record either in paper or electronic form, and in addition to providing a copy to the patient, it is also necessary to provide copies of the action plan to schools, daycare centers, summer camps, or any other place where the child will be spending significant time.
Summary
A written asthma action plan should be a part of the ongoing management of any child with asthma, and this evidence-based statement is strongly rooted in the medical literature. Action plans can be based on symptoms, peak expiratory flow rates, or a combination of these clinical parameters and should be individualized to the unique circumstances of the patient who is in front of you. Action plans should be kept current and represent a living document that provides guidance about the management of this important chronic disease. The collaborative process of action plan development further enhances the relationship between the patient and provider and improves the self-management skills of the patient and family. The asthma action plan, by combining the ongoing assessment of control with the process of patient education and medical management, is truly a cornerstone of guideline-based asthma care.
Suggested Readings
Lougheed MD, Lemiere C, Dell SD, et al. Canadian Thoracic Society Asthma Management Continuum—2010 Consensus Summary for children six years of age and over, and adults. Can Respir J. 2010;17:15-24.
Morris KJ. Asthma action plans: putting them to use. Retrieved from www.medscape.org/viewarticle/739738 on May 16, 2011.
National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. NIH publication no. 08-4051.
Rank MA, Volcheck GW, Li JT, Patel AM, Lim KG. Formulating an effective and efficient written asthma action plan. Mayo Clin Proc. 2008;83:1263-1270.
Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trial examining written action plans in children. Arch Pediatr Adolesc Med. 2008;162:157-163.