This site is intended for health professionals only

The goal is for patients to be in control of their asthma

Marilyn Eveleigh
BA(Hons) PGCE RGN SCM RHV NP FWT FRSH
Nurse Adviser in Primary Care and Public Health
Independent Respiratory Trainer

The UK has the highest number of young adults in Europe reporting asthma symptoms, and the incidence of asthma in children is six times higher than it was 20 years ago, with large-scale surveys indicating a 12.5% to 15.5% prevalence.(2)

Research indicates that acute presentations in primary care are decreasing,(3) but still more than 18,000 first or new cases presented to GPs in the UK in 2000. Manual social groups have the highest mortality and require the greatest number of consultations for asthma, with Afro-Caribbean children having the greatest consultation rates of any of the ethnic groups.(4) One study has shown that 50% of healthcare costs are utilised by the 22% who had an asthma attack,(5) indicating a reduction in acute management could provide better use of NHS resources.

Unfortunately, although mortality is decreasing, there are still 1,500 deaths annually, including around 25 children. One-third occur in those under 65 years of age. This is equivalent to one death from an acute attack every six hours.(6) Confidential enquiries indicate that many deaths could have been prevented, with poor adherence to medication and suboptimal care being key factors.(7)

A survey on the needs of people with asthma in the UK in 2000 (NOPWA) indicated available care and medication are not relieving symptoms in a significant number of people. Many report waking with wheeze one or more times a week, and 40% of sufferers who are at Step 3-5 of the BTS Guidelines (requiring steroid and/or add-on therapy) report daily symptoms.(8) The survey also indicated that almost 2.5%, or 130,000 patients, could have their treatment stepped down after clinical review.

There is a huge potential to improve the quality of life for asthmatics,(9) with 75% of hospital admissions and 90% of asthma deaths being preventable.(10) In the NOPWA study,8 29% had not been shown how to use an inhaler, less than 50% knew how to recognise the onset of an asthma attack, with only 56% being ­confident of what to do in an attack.

Self-management plans
There is increasing evidence that patients who take responsibility for their asthma with written self-
management plans - or Action Plans - provided by a healthcare professional improve health outcomes.(11-13) These Action Plans are particularly useful for patients under secondary care and for those with a recent exacerbation. It is highly likely that the new British Thoracic Society Guidelines for the Management of Asthma, due in late 2002, will outline the importance of this evidence and consider it best practice for all patients to have a written, individualised self-management plan.

The Action Plans can be based on symptoms or peak flow measures, depending on patient age and ability. The Action Plan must include clear instructions for patients when there is a deterioration in their asthma control. Options for action should include using reliever (blue inhaler) medication as first line, increasing regular steroid medication, and may often include the provision of an emergency oral steroid tablet course and/or immediate attendance at a specialist unit. All Action Plans should include basic information on:

  • What to do in an emergency.
  • What inhaler to use and when.
  • What dose to take.
  • How to recognise deteriorating asthma.

The Action Plan is best tailored to the patient's attitude, aptitude and approach. It can be a simple card with basic instructions or a more detailed programme where the patient can adjust their medication according to symptoms and objective peak flow measures. It may be beneficial to outline the avoidance of trigger factors as well as the importance of smoking cessation.

The importance of patient education in taking control cannot be underestimated. There is good evidence to support the use of trained asthma nurses and doctors to incorporate asthma Action Plans as part of a structured educational programme for every patient.(14,15)

Self-management plans encourage patients to take a more active role in their asthma control. Few asthma attacks are without a worsening of symptoms over time, thereby offering an opportunity for early and appropriate intervention by the patient. Delay in seeking advice and a change in treatment have been implicated in asthma deaths.(16)

[[NIP07_table1_23]]

Use every opportunity
The introduction, review and reinforcement of Asthma Action Plans can be made at every opportunity an asthma patient presents - be it in the surgery, the pharmacy, the hospital or A&E department. Healthcare professionals should use the consultation to enquire about the action the patient would take if their asthma was deteriorating. This provides the opportunity to test out the patient's existing understanding and confidence, as well as filling in knowledge gaps. There is some evidence to suggest that nurses are more likely to issue Action Plans.(17) Surgeries should develop a recording mechanism to enable an audit of patient-held Action Plans to be made.

Education is not a single event but a process of learning and confidence building for patients and carers. Healthcare professionals have a responsibility to ensure they offer timely and consistent advice and support to patients. Enquiring, and expecting asthma patients to have an Action Plan will generate a climate of expectation in patients to have their own.

Materials
The National Asthma Campaign provides small cards as well as written instructions for patient use. The details provided by the healthcare professional in conjunction with patient goals make them into individualised Action Plans. The Be in Control materials are free, patient-tested, well researched and nonpromotional. There is also a patient sheet entitled Ask the Right Questions, which is an excellent aide-mémoire for healthcare professional to clarify basic advice patients should have. Healthcare providers can produce their own materials but should ensure the Action Plans are written, tailored and practical for patient use.

The goal should be for all patients to have their own written Action Plan. However, variations in the uptake of asthma care by patients will affect the success of this. Competence, commitment and compliance vary in all patients as well as literacy and interpersonal factors, which will be a barrier to education and self-management.

British Thoracic Society guidelines
The BTS is due to publish its updated guidelines in autumn 2002 in conjunction with the Scottish Intercollegiate Guidelines Network (SIGN). They cover all aspects of asthma care, in all age groups across primary and secondary care using evidence- based methodology, graded by the strength of the evidence. All appropriate clinicians are urged to acquire a copy, ensuring asthma patients receive consistent, transferable and appropriate management.

Reference

  1. Joint Health Surveys Unit. Survey for England 1996. London: The Stationery Office; 1998.
  2. National Asthma Campaign. National Asthma Audit 1999/2000. London: NAC; 2000.
  3. Fleming DM, et al. Declining ­incidence of episodes of asthma: a study of trends presenting to general ­practitioners in the period 1989-98. Thorax 2000;55:657-61.
  4. Office for National Statistics. Available from URL: http//www.statistics.gov.uk
  5. Hoskins G, et al. Risk factors and costs associated with an asthma attack.Thorax 2000;55:19-24.
  6. Office for National Statistics. Morbidity statistics from general practice: patient records. London: The Stationery Office; 1999.
  7. Mohan G, et al. A confidential enquiry into deaths caused by asthma in an English Health Region: implications for general practice. Br J Gen Pract 1996;46:529-32.
  8. Greater expectation? Finding of the National Asthma Campaign's representative survey of the needs of people with asthma in the UK. Asthma J 2000;5(3).
  9. Schmier J, et al. Impact of asthma on health related quality of life. J Asthma 1998;35:585-97.
  10. Partridge M. Self management plans for patients with asthma. Practitioner 1991;235:715-21.
  11. Hoskins G, et al. Do self management plans reduce morbidity in patients with asthma? Br J Gen Pract 1996;46:169-71.
  12. Beilby JJ, et al. Reported use of asthma management plans in South Australia. Med J Austral 1997;166:298-301.
  13. Gibson PG, Coughlan J. Self management education and regular practitioner review for adults with asthma. In: Cochrane Collaboration. Cochrane Library. Issue 4. Oxford: Update Software, 2000.
  14. Madge P, et al. Impact of a nurse led home management training programme in children admitted to hospital with acute asthma: a randomised controlled trial. Thorax 1997;52:223-8.
  15. Lahdensuo A, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996;312:748-52.
  16. Brewis RA. Patient education.Resp Med 1991;85:457-62.
  17. Pinnock H, et al. Acute asthma survey - patient questionnaire.Asthma J 2000;5(3).

Resources
National Asthma Campaign
Asthma Helpline T:08457 010203
T:020 72262260 W:www.asthma.org.uk