The National Asthma Education and Prevention Pro-gram’s EPR-3 emphasizes patient education and the forging of an ongoing active partnership between the patient and the treating healthcare provider in order to ensure optimal asthma treatment. The clinician has, without question, a continuing responsibility to educate every patient about their own asthma and to teach what constitutes good asthma control, how to identify and treat flares of asthma symptoms, how prescribed asthma medication works, and what doses are indicated. Under-standing so much information may seem daunting at first, but it need not be. Learning self-management of asthma is a feature of effective asthma care and leads to improved outcomes.
An asthma action plan is a component of the ongoing teaching and information exchange between patients and the healthcare team. It consists of a written and personalized set of instructions for self-mon-itoring and asthma management. The most recent EPR-3 asthma guidelines advise that clinicians “provide all patients with a written asthma action plan that includes two aspects: (1) daily management and (2) how to recognize and handle worsening asthma.” The action plan should ideally be crafted at the time of the patient’s first visit and should be subject to review and revisions at follow-up visits. The written plan emphasizes asthma control, regular use of maintenance medications, patient observations and self-monitoring, and provides written guidelines for treatment of increasing symptomatology and exacerbated asthma.
Previous asthma treatment guidelines, such as the 1997 and 2002 NAEPP reports, advocated that each patient be provided two documents, both a written individualized daily self-management plan, and an asthma action plan. The practical, real-life use of two plans quickly became confusing and cumbersome all around. The 2007 EPR-3 guide-lines recognize “confusion over the previous guidelines’ use of different terms” and advocates for a single written asthma action plan. The key feature of any written asthma plan is that it is individualized.
Just as two people with asthma will have different manifestations of their disease, so, too, will they have different treatments and different action plans. A person whose intermittent asthma typically exacerbates when he is suffering from a chest cold, for example, will likely have instructions in his plan to begin taking inhaled steroid medication if he notices exertional breathlessness and a drop in his PEF values. Another person, whose asthma symptoms are triggered by late summer ragweed allergy, will perhaps have to restart her leukotriene receptor antagonist medication and her prescribed inhaled medicines when she notes increased cough as ragweed counts rise.
Another point to remember is that if you have been provided with an action plan, it should be reviewed and revised (as needed) at every visit. Sample asthma plans can be found on the Internet. Simply use your favorite browser and type “written asthma action plan” in the search window. Alternatively, you can review a sample asthma action plan on the CDC Web site at www.cdc.gov/asthma/actionplan.html. Despite the strong recommendations of the NAEPP, as well as enthusiastic support from professional medical societies and managed care insurance companies, writ-ten asthma plans are not universally popular in the asthma community.
Polls show most asthma patients prefer having a written plan of action. Many doctors, however, especially physicians practicing in private practice rather than in clinic or hospital settings, dislike written asthma plans. The most common reason for a person with asthma not following a written action plan is quite simply that his or her physician has never pro-vided one! Written action plans are particularly recommended for persons (of any age) whose asthma is classified as either moderate persistent or severe persistent, who have a history of severe exacerbations, or whose asthma is poorly controlled. Studies of written action plans, both in the United States and abroad, have yielded inconsistent results; nevertheless, the consensus of several recently published studies is that implementation of an asthma action plan leads to fewer emergency room visits and lower asthma hospitalization rates. Most patients, especially children, clearly benefit from written asthma plans.
Other studies suggest that it is not the written plan itself that improves out-comes, but rather the effects of the focused attention of the physician, self-management asthma education and teaching, and the enhanced interaction between patient and healthcare provider. In other words, as long as the proper information on recognizing symptoms, tuning in to loss of asthma control, and appropriate medication adjustment is provided and understood, the outcome is improved regardless of whether instructions are given in writing as part of a plan or verbally during an office visit or in a telephone conversation.