Asthma is a complex disease affecting millions of adults and children directly and indirectly through poor health, physician and clinic visits, hospitalization, medication costs, and lost days at work or school. To successfully manage asthma and reduce its impact, the patient and the health care team must work together. Asthma self-management is a major component in this concept of teamwork and is described in the most recent guidelines produced under the National Asthma Education and Prevention Program (NAEPP). These guidelines (released in 2007 as the Expert Panel Report- 3 or EPR-3) provide the best in evidence-based medicine to address diagnosis and management of asthma.1 This article will explore the idea of self-management and discuss how it can be improved.
What Is Self-management?
Self-management requires a partnership between the patient and the physician or other health care professional who is trained in asthma diagnosis and management. Self-management includes three parts: self-assessment (or self-monitoring), self-adjustment, and self-treatment. All three are performed by patients if they are old enough to understand and apply these concepts, or they may be partly or totally the responsibility of an asthmatic’s parent or caregiver.
Self-assessment relates to the patient’s perception and evaluation of symptoms such as chest tightness, wheezing, shortness of breath, and cough. Another issue associated with self-assessment is control; the patient should understand what constitutes each level of control (defined as well controlled, not well controlled, or poorly controlled) and be able to gauge their own level of control based on symptoms. Self-assessment may also include measuring peak expiratory flow (PEF). Some patients are termed “poor perceivers,” people who cannot perceive that their asthma is getting worse; they are not aware that symptoms are becoming more frequent and/or intense. PEF is a valuable tool for these individuals since the PEF measurement is objective and is useful in picking up early signs of the patient’s change in condition.1 If one expands the concept of self-assessment, one can also include patients’ assessment of their environment for possible triggers that make asthma worse.
Self-adjustment involves the patient’s understanding of the significance of changing symptoms or PEF and being able to make adjustments in the selection of appropriate medications, the dosage needed, and the frequency of treatment. Self-adjustment is driven by proper and thorough self-assessment. Improper or inadequate self-assessment will trigger improper or inadequate changes in medications. The environmental aspect of assessment should drive self-adjustments in behavior to reduce exposure to asthma triggers or take action to totally remove the triggers from the environment.
Self-treatment involves the patient taking the right medications in the right dose and frequency with the correct technique. Inhaled medications have various delivery devices that require different procedures to administer the medication correctly. Examples include a powered meter-dose inhaler for albuterol, or the Diskus for fluticasone/salmeterol, or the Twisthaler for mometasone furoate, or a compressor-driven nebulizer for unit-dose liquid medications. Some of these devices require several steps to prepare the medication, and several require specific inhalation techniques for proper inspiratory flow, placement of the device in the mouth, head tilt, breath hold, and inclusion of a mouth rinse after the procedure.
Patient Education for Self-Management
Patient education is of utmost importance for proper self-management. The EPR-3 guidelines call for education to be given every time the patient has any encounter with any provider of care.1 A written asthma action plan (WAAP) is the foundation for proper and complete asthma education2 (see Figure 1). The EPR-3 states that the WAAP should be developed in partnership with the patient and is very useful in patients who have moderate or severe asthma, a history of severe exacerbations, or poorly controlled asthma. Partnering in developing the WAAP helps motivate the patient to follow the plan, since they have input. The WAAP should tell the patient how to maintain control on a daily basis and when and how to treat an exacerbation. The levels are usually divided into three areas (often following green, yellow, and red zones similar to traffic light signals) to reflect the patient being in good control with few to no symptoms, not in good control (increasing symptoms), and being in poor/dangerous control (a severe asthma attack or life-threatening condition with unrelenting, serious symptoms). The WAAP should be written at the appropriate reading level (many have recommended that this be around the fifth to sixth grade)3 and in the patient’s native language to maximize readability. Incorporating illustrations and pictures can also improve adherence to the plan as understanding is increased. The WAAP should be reviewed with the patient on a frequent basis and revised as needed to remain current. For children, the WAAP should be shared with the child’s school and posted at home (often part of the information on the refrigerator). The WAAP carries enough importance that the EPR-3 recommends all patients receive one and the lack of a written asthma action plan is considered one of the risk factors for death from asthma1 (see Figure 2).
One study examined the use of WAAPs in an inner-city community health center of a large metropolitan area in the United States. Childhood asthma prevalence in the area served by the health center runs about 3 times the national average. The researchers found that, of a group of 428 subjects who participated in the research project, 116 (27%) had a WAAP. Of those who had a plan, 80% described the WAAP as extremely useful, and 71% looked at the plan daily or when their child was sick or when they were giving the child medicine.4 In a systematic review of research that examined the relationship of WAAPs to asthma exacerbations, five of eight published research studies showed that when WAAPs were included in the patient education/self-management plan, they were associated with significant reductions in several areas including missed school days, acute episodes, nighttime awakenings, hospitalizations, and emergency department and acute care visits.5 A Cochrane review evaluating the use of self-management plus regular review and a WAAP opposed to usual care (in adult patients) found that the patients in the former group had “1) more regular physician visits; 2) fewer emergency department visits and hospital admissions; 3) slightly better lung function and peak flow measurements; 4) fewer medications overall; and 5) less use of rescue medication.”3
Self-management and patient education should include training in how to take the inhaled medications, information on what to expect from taking the medications (address what do they do), and what the triggers of asthma are and how these can be minimized or removed from the environment. Asthma education and the issue of self-management (including the written asthma action plan) should be provided for the school. The EPR-3 guidelines recognize that the scope and depth of this education may be better handled by providing key messages and essential skills in the first encounter, then reinforce and expand the education and skills in subsequent visits. Outpatient visits, emergency department visits, and hospital stay should all include asthma education and discussion of self-management. Use of the Internet and personal computers, laptops, netbooks, cell phones, electronic calendars, and other digital devices or interactive approaches can be used to remind patients to perform a self-assessment and take medications on a regular basis.6
Asthma self-management should be an integral part of all asthma patients’ care plans. Their knowledge, understanding, and skill set should be reviewed and improved with every encounter with a health care professional. Often this is overlooked, but respiratory therapists can stop this problem. The EPR-3 can be used as a resource to increase one’s expertise. A quote from the EPR-3 says: “The Expert Panel encourages using health professionals and others trained in asthma self-management education to implement and teach asthma self-management programs.”1 Becoming a well-rounded expert in asthma education and management should be a goal for all therapists, because we often have the best opportunities to make a real change in the asthmatic patient’s health.
Bill Pruitt, MBA, RRT, CPFT, AE-C, is a senior instructor and director of clinical education in the Department of Cardiorespiratory Sciences, College of Allied Health Sciences, University of South Alabama, Mobile, and a PRN therapist at Springhill Medical Center and Mobile Infirmary Medical Center in Mobile. For further information, contact [email protected]
- National Heart, Lung, and Blood Institute. The National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed March 4, 2011.
- Rank MA, Volcheck GW, Li JT, Patel AM, Lim KG. Formulating an effective and efficient written asthma action plan. Mayo Clin Proc. 2008; 83:1263-70.
- Jones MA. Asthma self-management patient education. Respir Care. 2008;53:778-86.
- Braganza SF, Sharif I. Use of written asthma action plans. Journal of Asthma & Allergy Educators. 2010;1:155-57.
- Kessler KR. Relationship between the use of asthma action plans and asthma exacerbations in children with asthma. Journal of Asthma & Allergy Educators. 2011;2:11-21.
- Penza-Clyve SM, Mansell C, McQuaid EL. Why don’t children take their asthma medications? A qualitative analysis of children’s perspectives on adherence. J Asthma. 2004;41:189-97.