Key learning points
- Supported self-management for people with asthma reduces acute attacks and use of healthcare resources, and improves asthma control and quality of life
- Asthma action plans are an integral component of care, not an optional extra
- Action plans should include advice on maintenance treatment, recognising the early signs of deterioration, and the action to be taken
- It is essential that this advice includes when to seek urgent medical care
- Action plan templates with colour-coded action points can be personalised for different patients
Personalised asthma action plans are core components of supported self-management.1 They reinforce advice about living with asthma discussed, tailored and mutually agreed with a healthcare professional.2,3 Supported self-management for people with asthma reduces acute attacks and use of healthcare resources, improves asthma control and quality of life, and is recommended by national and international guidelines.4–6 A 2017 meta-review (including 270 randomised controlled trials) provides a comprehensive summary of the clinical and health economic evidence for supported asthma self-management.7 Implementation is challenging, but these health benefits can be achieved in the context of routine care.8
Action plan content
Action plans vary in detail, but the core content covers advice on maintenance treatment, recognising the early signs of deterioration, and the action to be taken.9 Actions should include emergency relief of symptoms, increasing preventer treatment and/or starting a course of oral steroids, and (crucially) when to seek urgent medical advice. The National Review of Asthma Deaths provides a stark reminder of the importance of including clear advice on contacting emergency medical care; 45% of the people died without receiving medical help.10
Colour-coded action points
Template plans, with colour-coded action points, can be downloaded from Asthma + Lung UK.
Green zone: asthma under control
Good control is defined as no symptoms, or very occasional short-lived day-time symptoms,4 and peak flows >80% of personal best. Maintenance treatment should be titrated to the lowest dose of preventer medication that keeps the patient free of symptoms.
Amber zone 1: asthma uncontrolled
Increasing symptoms, especially night-time symptoms or symptoms that interfere with activities indicate deteriorating control,11 confirmed by peak flows 60–80% of personal best12 (if the patient wishes to monitor lung function).13 Evidence in adults shows that a four-fold increase in inhaled steroids up to two weeks prevents the need for one in five oral steroid courses and is effective at all levels of maintenance treatment.14 This is a particularly important step in patients who have stopped or substantially reduced their inhaled steroids between attacks.4
Amber zone 2: asthma attack
Worsening symptoms, not relieved by a short-acting beta-agonist and/or no improvement with increased preventer medication and/or peak flows <60% indicate the onset of an attack.12 Treatment is a course of oral steroids; patients confident to do so may start an emergency course themselves – others may prefer to contact a healthcare professional practice first.
Red zone: emergency
Symptoms that are interfering with talking, not responding to treatment, requiring frequent reliever medication and/or peak flow <40% need urgent medical attention. Ensure the patient knows how to get emergency care, and what emergency relief they can use while they wait for assistance.4
Personalising action plans
This ‘standard’ action plan needs to be personalised to age group; literacy (a pictorial action plan is available to download from the Imperial College website);15 language (Asthma + Lung UK has action plans available to download in a range of languages); and cultural diversity.16 Clinical considerations are also important, such as trigger avoidance; co-existent rhinitis;17 asthma severity; maintenance regimen (advice will be need to be adapted for inhaled corticosteroids such as single inhaler, combination inhalers, maintenance and reliever treatment); and multimorbidity.18,19
Action plans typically focus on medical aspects of self-management (drug therapy, detection and management of attacks) but definitions highlight that self-management is a much broader concept of ‘living with’ a chronic condition.2,20 People with asthma live with a variable condition and make day-to-day decisions about managing their condition. Asthma action plans are a key strategy in supporting people to take appropriate decisions and are an integral component of care, not an optional extra.2
Professor Hilary Pinnock is professor of primary care respiratory medicine at The University of Edinburgh, Asthma UK Centre for Applied Research, NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Allergy and Respiratory Research Group and a general practitioner at Whitstable Medical Practice.
Conflicts of interest: Hilary Pinnock is a member of the BTS/SIGN British Asthma Guideline Development Committee and led the most recent update of the self-management section.
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