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Formulating an Effective and Efficient Written Asthma Action Plan
CONCISE REVIEW FOR CLINICIANS FORMULATING A WRITTEN ASTHMA ACTION PLAN
Formulating an Effective and Efficient Written Asthma Action Plan MATTHEW A. RANK, MD; GERALD W. VOLCHECK, MD; JAMES T. C. LI, MD, PHD; ASHOKAKUMAR M. PATEL, MD; AND KAISER G. LIM, MD On completion of this article, you should be able to: (1) create an effective and efficient written asthma action plan, (2) describe the options for monitoring asthma using a written asthma action plan, and (3) review the rationale for the medications used in asthma exacerbations and be able to explain the differences in medications to patients in a way that facilitates proper use and adherence.
Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician’s busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient selfmonitoring) and treatment.
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ACT = Asthma Control Test; ED = emergency department; FACET = Formoterol and Corticosteroids Establishing Therapy; ICS = inhaled corticosteroid; LABA = long-acting β-agonist; NAEPP = National Asthma Education and Prevention Program; PEF = peak expiratory flow; SABA = short-acting β-agonist; WAAP = written asthma action plan
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he National Asthma Education and Prevention Program (NAEPP) recommends that all patients with asthma (regardless of severity) receive a written asthma action plan (WAAP).1 This is true especially for patients with a history of frequent and severe (near-fatal) asthma exacerbations.1 Unfortunately, only 25% to 56% of eligible patients receive a WAAP.2-6 We searched MEDLINE using the key words asthma, action plan, self care, patient care planning, anti-asthmatic agents, and patient education. On the basis of this review, we have synthesized practical suggestions for formulating an effective and efficient WAAP with the primary care physician as the intended audience. Asthma is a chronic disease with intermittent or episodic worsening of symptoms. Asthma exacerbations can lead to absenteeism, presenteeism, urgent care and emergency department (ED) visits, hospitalizations, discomfort, dissatisfaction with care, and death.7-9 The WAAP is a contingency plan to aid the patient in decreasing the severity and duration of an asthma exacerbation. A WAAP is only one part of asthma self-management; other compoMayo Clin Proc.
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nents include scheduled visits for asthma, monitoring of rescue medication use, and education in how to monitor symptoms and lung function and how to use medications. These and other features of high-quality asthma care are summarized in a Centers for Disease Control and Prevention review.10 A WAAP does not direct the patient to selfdiagnose asthma, and the symptoms listed in a WAAP can result from confounding or comorbid illness; therefore, the WAAP is optimal when accompanied by physician supervision and an ongoing educational program.11 When a WAAP is part of a comprehensive self-management program, studies report reductions in exacerbations in children and adults.11-13 The effect attributable to the WAAP alone is unknown.14 It is a misconception that a self-management program has to be complicated and personnel-intensive; rather, it can focus on educating the patient in how to use the WAAP. Self-management should be part of the treatment plan for any chronic disease because it empowers patients, reduces dependency, and minimizes the response time so that the morbidity and pain due to episodic exacerbations can be reduced. We agree with the NAEPP’s recommendation that WAAPs should be formulated for most if not all patients with asthma.1 As part of a comprehensive asthma management plan, the principal aim of a WAAP is to help patients recognize asthma exacerbations early and initiate prompt treatment. To facilitate issuance of a WAAP, an electronic version should be made available either in the electronic medical record or as a form with prefilled options (in portable document format [PDF]) for ease of customization to a patient’s condition.
From the Division of Allergic Diseases (M.A.R., G.W.V., J.T.C.L.) and Division of Pulmonary and Critical Care Medicine (A.M.P., K.G.L.), Mayo Clinic, Rochester, MN. Individual reprints of this article are not available. Address correspondence to Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
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THE ROLE OF SELF-MANAGEMENT IN ASTHMA Patients with chronic diseases need a positive attitude, selfefficacy (ie, the level of confidence a patient has in handling the disease), and knowledge. Self-efficacy and a positive attitude have been correlated with adherence (and also with a lower number of hospitalizations).15 A review of interventions targeted to effect behavioral changes found that 57% of the studies used a combination of education and a WAAP.16 One study found that appropriate oral corticosteroid therapy was initiated in 77% of patients with a WAAP.17 A study of children of low socioeconomic status found that medication adherence was improved in strategies that included a WAAP.18 The most common reason patients do not have a WAAP is that their physician did not give them one.4 One survey found that 90% of patients who used a WAAP found it to be helpful.4 Another study reported that patients who used their WAAP customized it according to their personal perception of disease severity.19 The patient must be actively involved in the formulation of a WAAP. This is an opportunity to encourage patient participation and buy-in, to solicit treatment preferences, and to discuss specific responses on the basis of the WAAP. ANATOMY OF A WAAP Although several versions of the WAAP exist,1,20,21 all share certain features. First, patients have to monitor their symptoms or peak expiratory flow (PEF) to detect deviations from the usual state of controlled asthma. Second, reminders of warning signs and symptoms as well as potential precipitating factors or personal triggers are included. Third, patient-initiated treatment options to restore control are explicitly provided in writing. Fourth, expected response time, danger signs, and contact information are included (Figure). Written asthma action plans must have clearly defined action points that teach the patient to recognize and respond to an exacerbation. These action points should be customized to the patient’s personal triggers (eg, seasonal allergies, viral infections) for buy-in and ease of teaching. Action points can be simplified using various forms, including a “traffic light” system of green, yellow, and red zones indicative of increasing severity of exacerbation (Figure). In general, action points help patients determine when to use a medication, what medication to use, how much of the medication to use and for how long, and what to expect of an asthma exacerbation.9 The patient should additionally be educated about signs of severe and life-threatening exacerbations.22 Table 1 summarizes the characteristics of poor and good WAAPs.11 Table 2 provides a checklist, 1264
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intended for physicians and patients, that summarizes key aspects of using a WAAP. Language and literacy level should be considered if a WAAP is to be successful. For children, alternative WAAP forms focusing on parent education and signs that a parent can visually recognize (such as intercostal retractions) are available.1 If the printed word is not the accustomed source of information, an alternative, such as a visual or pictorial version of an asthma action plan, should be considered.23 Another option would be to incorporate an early telephone call to a nurse or other health care professional for worsening asthma symptoms; the office or school nurse could then use the WAAP to give timely verbal advice. This is just one example of how a WAAP can facilitate dialogue between various caregivers and care sites. PATIENT MONITORING Although an action point can be based on monitoring of symptoms or PEF, the Formoterol and Corticosteroids Establishing Therapy (FACET) study clearly showed that patients primarily depend on symptoms to decide when to initiate prednisone therapy.24 The basic assumption of symptom-based monitoring is to detect any deviation from the normal state of good control. It is difficult to establish a WAAP when asthma is poorly controlled, adding to the patient’s confusion and the work for the physician and support staff. Frequent office visits may be necessary to establish asthma control before the WAAP can be optimally formulated. A WAAP is not a substitute for physician follow-up of patients with poorly controlled asthma. Asthma control questionnaires are convenient and may help overcome problems of variable symptom perception. The use of asthma control questionnaires also simplifies symptom monitoring for patients and for educators. They focus the patient instruction process and identify which symptoms to monitor very concretely.25 Several validated asthma questionnaires are available to help patients and physicians quickly quantify the degree of asthma control.26 Of the 3 questionnaires cited by the NAEPP, we recommend the Asthma Control Test (ACT) over the Asthma Control Questionnaire because it does not require arithmetic division by the patient.27 The Asthma Therapy and Assessment Questionnaire has not been as rigorously studied in terms of reliability, responsiveness, and reproducibility in adults. The ACT asks patients to assess their symptoms during the previous 4 weeks; the total score indicates whether asthma is controlled.27 The ACT can be incorporated into regular physician visits and can be used for long-term home monitoring. An example of an ACT can be found at www.asthmacontrol.com.
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FORMULATING A WRITTEN ASTHMA ACTION PLAN
FIGURE. Screenshot of a completed written asthma action plan. HFA = hydrofluoroalkane.
MONITORING OF PEF Peak expiratory flow is an objective assessment of airflow that has been used for self-management of asthma. Poor adherence to daily PEF monitoring suggests that this may not be a practical approach for most patients. However, a subset of “poor perceivers” who consistently underestiMayo Clin Proc.
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mate the worsening asthma symptoms and airflow obstruction may benefit from a PEF-based approach.25,28,29 A purely symptom-based management plan may result in overtreatment of some patients with anxiety who are panic prone and who perceive airflow obstruction when none exists.30 We recommend using a symptom-monitoring approach with the option of PEF to confirm obstruction when
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TABLE 1. Components of Poor and Good Written Asthma Action Plans Poor action plan Action points
Too many decision points for patients to navigate
Readability
Poor readability (ie, not tailored to patient population) No description of expected results from the interventions No mention of severe signs or symptoms that warrant immediate medical attention A static and generic plan not customized to patient’s specific situation. It rarely changes and is not addressed at most visits for chronic asthma care
Elements When to call for help Customization
Good action plan 2 to 4 clearly specific action points: when, what, how much and how long, and what to expect Clear, unequivocal, brief, appropriate language describing how to increase treatment Description of how long to increase treatment Clear instructions on when to obtain additional advice Contact information included; feedback incorporated on a regular basis
symptoms of worsening control are detected. Choosing which method (PEF monitoring or symptom monitoring or both) to anchor the WAAP is best made by a physician familiar with the patients’ preferences.31-33 If PEF monitoring is part of the WAAP, we suggest using a persistent decrease (2 readings, 24 hours apart) of 20% from a patient’s personal best PEF as an action point. In the FACET study, 69% of patients had a decrease in PEF of 20% or more in the 14 days before an asthma exacerbation.24
their physicians if they do not respond to the treatment outlined in their WAAP. Patients with these risk factors benefit not only from a detailed WAAP but also from close follow-up each time they activate their action plan. This may initially result in more frequent physician visits but will ultimately pay dividends in terms of better outcome for the patient.
RECOGNIZING THE RISK OF FATAL ASTHMA
Knowledge, self-efficacy, and attitude are important factors in self-management. It is important for patients to understand the purpose of the different medications involved in asthma. Ignacio-Garcia and Gonzalez-Santos34 provide information intended to help patients understand their asthma medications (Table 3). Information regarding some of the most common asthma exacerbation medications follows.
A physician caring for a patient with asthma should consider the patient’s risk of fatal asthma. Risk factors include previous severe exacerbation, 2 or more hospitalizations for asthma in the past year, 3 or more ED visits for asthma in the past year, a hospitalization or ED visit for asthma in the past month, use of more than 2 canisters of short-acting β-agonist (SABA) per month, poor perception of airflow obstruction, sensitivity to Alternaria species, lack of a WAAP, cardiovascular disease, other chronic lung disease, low socioeconomic status, illicit drug use, and major psychological problems.1 Patients should be instructed to call TABLE 2. Written Asthma Action Plan Checklists Physicians Follow up patients closely until asthma is well controlled Educate patients about asthma symptoms and peak flow readings that require action Educate patients about proper use of asthma medications, including when to use them Complete a written asthma action plan Establish a follow-up plan and review medications and action plan at each visit Patients Learn the basics about asthma Recognize your asthma triggers Learn how and when to use medications Understand and agree with your physician on a way to monitor your asthma (such as peak flow monitoring or use of the Asthma Control Test) Review your action plan with your physician regularly Know what to do if asthma is worsening and in an emergency
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EDUCATING PATIENTS WITH ASTHMA ABOUT THEIR MEDICATIONS
SHORT-ACTING BRONCHODILATORS Patient Instruction. Use your rescue medications when short of breath. When. Patients should be instructed to use their rescue medicines when they have symptoms of dyspnea at rest or during exertion, cough, chest tightness, wheezing, or a decrease in PEF from baseline of more than 10% to 20%. What. Short-acting bronchodilators include albuterol, pirbuterol, or levalbuterol metered-dose inhalers. Recently, the propellant for inhaled short-acting bronchodilators has been changed from chlorofluorocarbons to hydrofluoroalkane for environmental reasons. Nebulization (compression with a machine) is an alternative mechanism of delivery of SABAs that is less portable than metered-dose inhalers and that does not necessarily improve medication delivery. How Much and How Often. For mild baseline dyspnea, patients should use 2 to 4 puffs of albuterol every 4 hours. For severe dyspnea, patients should use 2 puffs of
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FORMULATING A WRITTEN ASTHMA ACTION PLAN
TABLE 3. Information Given to Patients Regarding Asthma Medicines Used in the Action Plana Short-acting β-agonists (rescue inhalers) Fast-acting inhalers that help alleviate immediate symptoms Not helpful as a scheduled, everyday inhaler to prevent asthma symptoms If you need more rescue inhaler, this might mean that your asthma is becoming worse and that your physician may need to adjust your medications ICS An inhaled medicine that cuts down on swelling and mucus in the airway Very useful for stabilizing your asthma Currently is considered the most important everyday asthma medication Does not relieve immediate symptoms of asthma and should not be used for this like the rescue inhaler It is important to take this medication every day for it to help prevent your asthma from interfering with your usual activities (job, school, sports) Inhaled long-acting bronchodilators Some drugs in this group do not act immediately Not to be used for immediate symptoms Only use these medicines if you are also using an ICS Using this medicine with an ICS may allow your asthma to be controlled with a lower dose of ICS Oral corticosteroids (prednisone) Oral medicines that are sometimes needed to help with asthma flares Help cut down on swelling and mucus in the airway Very important to follow the physician’s instructions on how to use these medicines Using these medicines may cause some adverse effects but you should not be afraid to take these medicines when they are needed for your asthma Antibiotics A treatment for bacterial infection Most asthma flares are unrelated to bacterial infections Asthma flares should be treated with medicines that reduce inflammation (airway swelling and mucus)
use of an ICS during exacerbation should be limited to patients with very mild asthma who have rare and mild exacerbations.35 What. Different ICSs have similar clinical efficacies but different potencies and bioavailabilities.1 This is especially important for patients requiring a high-dose ICS because they have to use more puffs to obtain the same effect with certain ICS preparations (beclomethasone, budesonide, triamcinolone, flunisolide).36 Knowledge about systemic bioavailability is important for patients taking a high-dose ICS because risk of adverse effects may be higher in preparations with higher oral availability.1 How Much and How Often. Treatment plans that double the dose of the patients’ baseline ICS do not effectively treat asthma exacerbations.37-39 Treatment plans using substantially higher ICS doses than the usual daily dose (eg, 2 mg/d of fluticasone) were effective in adult studies but ineffective in a pediatric study.40-43 Issues with using a high-dose ICS for exacerbations include cost, tolerability, and the difficulty in increasing ICS dose in patients who use a fixed ICS/LABA combination inhaler. How Long. The maintenance dose of ICS necessary to attain asthma control should be continued throughout the exacerbation. Why No Relief. Studies suggest that anti-inflammatory treatment should be started early.40 Poor technique and poor adherence are common reasons why ICSs are ineffective. Bottom Line. An ICS should be viewed as a daily controller medication rather than as a treatment for asthma exacerbations.
a
ICS = inhaled corticosteroid. Adapted from Am J Respir Crit Care Med,34 with permission.
albuterol every 5 minutes up to 20 puffs (if no response in 1 hour, seek immediate medical attention); nebulized (compressed) SABAs can also be used. Why No Relief. Increasing requirement for SABAs is a red flag that symptoms such as cough, dyspnea, or airway obstruction may be due to mucus or inflammation or are unrelated to asthma. Patients with poor improvement after SABA treatment should report this to the physician because it requires additional action. Comment. Assessing SABA response determines the next action point in a well-formulated WAAP. Anticholinergic medication should not be used for immediate relief. INHALED CORTICOSTEROIDS Patient Instruction. Do not forget that asthma is inflammation of the airways and that it is important to continue your controller medication(s). When. Patients should be instructed to continue their usual ICS doses during an exacerbation. The intermittent Mayo Clin Proc.
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LONG-ACTING β-AGONISTS Patient Instruction. This medication is not intended as a quick relief or rescue medication. When. Long-acting β-agonists (LABAs) are often part of patients’ long-term asthma plan and are particularly effective at decreasing ICS dose and reducing mild exacerbation rates.44,45 What. Unless accompanied by regular use of an ICS, LABAs such as salmeterol and formoterol should not be used for asthma unless accompanied by regular use of an ICS.46 The following caution should be noted: LABAs (salmeterol or formoterol) are not recommended for rescue use.47 Formoterol has an onset of action in minutes but is not currently approved by the Food and Drug Administration as a rescue medication. Short-acting anticholinergic medications have a role in ED management of asthma exacerbations but are not recommended for home management. Research. Treatment approaches using a combined ICS/LABA on an as-needed basis to effectively control
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asthma have been supported by recent studies.48,49 Additional studies are required to clarify the role of combined ICS/LABA in acute exacerbations. Bottom Line. Using as-needed ICS/LABA combination products has not been approved by the Food and Drug Administration for treatment of acute asthma exacerbations.
monitoring, the dosing and duration of increased treatment, and contact information to facilitate immediate medical attention if needed. Physicians should strongly consider formulating a personalized WAAP to help their patients with asthma recognize exacerbations early and treat them effectively.
SYSTEMIC CORTICOSTEROIDS Patient Instruction. It is important to start early to control an exacerbation; systemic corticosteroids are safe for short-term use. When. Initiation of systemic corticosteroid therapy is determined by an action point in the WAAP (ie, when symptoms are severe and/or when the PEF decreases 20% from the patient’s personal best on 2 readings taken 24 hours apart). What. By clinical consensus, systemic corticosteroids are the first line of treatment for severe exacerbations or for those that cannot be controlled by increasing the SABA dose.36,50,51 Oral and intravenous corticosteroids appear to have similar efficacy for asthma exacerbations. How Much and How Often. In the FACET study, a dose of 30 mg/d of prednisone was used to treat 425 episodes of severe exacerbation.24 Current guidelines suggest administering prednisone at 40 to 60 mg/d for adults and 2 mg/kg per day for children.1 How Long. A suggested duration of systemic corticosteroid therapy is 5 or 10 days.24,50 Longer duration or higher doses of systemic corticosteroid therapy have not been shown to be more effective.52,53 Tapering. Tapering is only necessary for patients who are receiving long-term systemic corticosteroid therapy or for patients who receive frequent systemic corticosteroid bursts. Studies have shown that adrenal function typically recovers quickly.54-57 Proponents of tapering suggest that it may prevent rebound exacerbation, maintain anti-inflammatory control, and prevent adrenal failure.1,54 If the patient is taking an ICS, it is unnecessary to use a systemic corticosteroid to extend anti-inflammatory therapy. Why No Relief. In a study by Levy et al,40 the high failure rate in the prednisone arm was attributed to delayed initiation. Patients should expect improvement in about 48 hours; however, for severe exacerbations, relief may take longer.52 Only a small proportion of patients with asthma are resistant to corticosteroids. Comment. Systemic corticosteroids are the preferred treatment for moderate to severe asthma exacerbations.
REFERENCES 1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3). www.nhlbi.nih.gov/guidelines /asthma/index.htm. Accessed September 28, 2008. 2. Peters SP, Jones CA, Haselkorn T, Mink DR, Valacer DJ, Weiss ST. Real-world Evaluation of Asthma Control and Treatment (REACT): findings from a national Web-based survey. J Allergy Clin Immunol. 2007 Jun;119 (6):1454-1461. Epub 2007 May 3. doi:10.1016/j.jaci.2007.03.022. 3. Beauchesne, MF, Levert V, El Tawil M, Labrecque M, Blais L. Action plans in asthma. Can Respir J. 2006;13(6):306-310. 4. Douglass J, Aroni R, Goeman D, et al. A qualitative study of action plans for asthma. BMJ. 2002;324(7344):1003-1005. doi:10.1136/bmj.324.7344 .1003. 5. Butz AM, Huss K, Mudd K, Donithan M, Rand C, Bollinger ME. Asthma management practices at home in young inner-city children. J Asthma. 2004;41(4):433-444. doi:10.1081/JAS-120033985. 6. Fernandes AK, Mallmann F, Steinhorst AM, et al. Characteristics of acute asthma patients attended frequently compared with those attended only occasionally in an emergency department. J Asthma. 2003;40(6):683-690. doi:10.1081/JAS-120023487. 7. Masoli M, Fabian D, Holt S, Beasley R; Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy. 2004;59(5):469-478. doi:10.1111/j.1398-9995.2004.00526.x. 8. Markson LE, Vollmer WM, Fitterman L, et al. Insight into patient dissatisfaction with asthma treatment. Arch Intern Med. 2001;161(3):379-384. doi:10.1001/archinte.161.3.379. 9. Hemp P. Presenteeism: at work—but out of it. Harv Bus Rev. 2004; 82(10):49-58, 155. 10. Williams SG, Schmidt DK, Redd SC, Storms W. Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program. MMWR Recomm Rep. 2003;52(RR-6):1-8. 11. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2003;1:CD001117. 12. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-1309. doi:10.1136/bmj.326.7402.1308. 13. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children’s use of acute care services: a meta-analysis. Pediatrics. 2008;121(3):575-586. doi:10.1542/peds.2007-0113. 14. Toelle BG, Ram FS. Written individualised management plans for asthma in children and adults. Cochrane Database Syst Rev. 2004;2: CD002171. 15. Scherer YK, Bruce S. Knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma. Heart Lung. 2001;30(4):250-257. doi:10.1067/mhl.2001.116013. 16. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364(9444):1523-1537. doi:10.1016/S01406736(04)17277-2. 17. Lahdensuo A, Haahtela T, Herrala J, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ. 1996;312(7033):748-752. 18. Fox P, Porter PG, Lob SH, Boer JH, Rocha DA, Adelson JW. Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies. Pediatrics. 2007; 120(4):e902-e911. doi:10.1542/peds.2006-1805. 19. Dinakar C, Van Osdol TJ, Wible K. How frequent are asthma exacerbations in a pediatric primary care setting and do written asthma action plans
CONCLUSION A WAAP is a useful asthma management tool that should include action points based on an agreed method of self1268
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help in their management? J Asthma. 2004;41(8):807-812. doi:10.1081/JAS -200038418. 20. Mangold RA, Salzman GA. Electronic asthma action plan database: asthma action plan development using Microsoft Access. J Asthma. 2005;42(3): 191-196. doi:10.1081/JAS-200054631. 21. D’Souza W, Crane J, Burgess C, et al. Community-based asthma care: trial of a “credit card” asthma self-management plan. Eur Respir J. 1994;7(7): 1260-1265. 22. McFadden ER Jr. Acute severe asthma. Am J Respir Crit Care Med. 2003;168(7):740-759. doi:10.1164/rccm.200208-902SO. 23. Roberts NJ. Development of a paper and electronic pictorial asthma selfmanagement plan [abstract]. Am J Respir Crit Care Med. 2007;A589. 24. Tattersfield AE, Postma DS, Barnes PJ, et al; FACET International Study Group. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. Am J Respir Crit Care Med. 1999;160(2):594-599. 25. Banzett RB, Dempsey JA, O’Donnell DE, Wamboldt MZ. Symptom perception and respiratory sensation in asthma. Am J Respir Crit Care Med. 2000;162(3, pt 1):1178-1182. 26. Wallenstein GV, Carranza-Rosenzweig J, Kosinski M, Blaisdell-Gross B, Gajria K, Jhingran P. A psychometric comparison of three patient-based measures of asthma control. Curr Med Res Opin. 2007;23(2):369-377. doi:10.1185/030079906X167426. 27. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113(1):59-65. doi:10.1016/j.jaci.2003.09.008. 28. Clark NM, Evans D, Mellins RB. Patient use of peak flow monitoring. Am Rev Respir Dis. 1992;145(3):722-725. 29. Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ. 1993;307(6901):422-424. 30. Chetta A, Gerra G, Foresi A, et al. Personality profiles and breathlessness perception in outpatients with different gradings of asthma. Am J Respir Crit Care Med. 1998;157(1):116-122. 31. Malo JL, L’Archevêque J, Trudeau C, d’Aquino C, Cartier A. Should we monitor peak expiratory flow rates or record symptoms with a simple diary in the management of asthma? J Allergy Clin Immunol. 1993;91(3):702-709. doi:10.1016/0091-6749(93)90189-M. 32. Clough JB, Sly PD. Association between lower respiratory tract symptoms and falls in peak expiratory flow in children. Eur Respir J. 1995;8(5):718722. 33. Chan-Yeung M, Chang JH, Manfreda J, Ferguson A, Becker A. Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma. Am J Respir Crit Care Med. 1996;154(4, pt 1): 889-893. 34. Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med. 1995;151(2, pt 1):353-359. 35. Boushey HA, Sorkness CA, King TS, et al; National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;352(15):15191528. doi:10.1056/NEJMoa042552. 36. Reddel HK, Barnes DJ; Exacerbation Advisory Panel. Pharmacological strategies for self-management of asthma exacerbations. Eur Respir J. 2006; 28(1):182-199. doi:10.1183/09031936.06.00105305. 37. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363(9405):271-275. doi:10.1016/S01406736(03)15384-6. 38. FitzGerald JM, Shragge D, Haddon J, et al. A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J. 2000;7(1):61-67. 39. Rice-McDonald G, Bowler S, Staines G, Mitchell C. Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults. Intern Med J. 2005;35(12):693-698. doi:10.1111/j.1445 -5994.2005.00972.x. 40. Levy ML, Stevenson C, Maslen T. Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care. Thorax. 1996;51(11):1087-1092. 41. Foresi A, Morelli MC, Catena E; Italian Study Group. Low-dose budesonide with the addition of an increased dose during exacerbation is effective in long-term asthma control. Chest. 2000;117(2):440-446. doi:10 .1378/chest.117.2.440.
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42. Rodrigo G, Rodrigo C. Inhaled flunisolide for acute severe asthma. Am J Respir Crit Care Med. 1998;157(3, pt 1):698-703. 43. Schuh S, Reisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med. 2000;343(10):689-694. doi:10.1056/NEJM200009073431003. 44. Pauwels RA, Löfdahl C-G, Postma DS, et al; Formoterol and Corticosteroids Establishing Therapy (FACET) International Study Group. Effect of inhaled formoterol and budesonide on exacerbations of asthma [published correction appears in N Engl J Med. 1998;338(2):139]. N Engl J Med. 1997; 337(20):1405-1411. doi:10.1056/NEJM199711133372001. 45. O’Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med. 2001.164(8, pt 1):1392-1397. 46. Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM; SMART Study Group. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol [published correction appears in Chest. 2006;129(5):1393]. Chest. 2006;129(1):15-26. doi:10.1378/chest.129.1.15. 47. Pauwels RA, Sears MR, Campbell M, et al; RELIEF Study Investigators. Formoterol as relief medication in asthma: a worldwide safety and effectiveness trial. Eur Respir J. 2003;22(5):787-794. doi:10.1183/09031936 .03.00055803. 48. Papi A, Canonica GW, Maestrelli P, et al; BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;356(20):2040-2052. doi:10.1056/NEJMoa063861. 49. O’Byrne PM, Bisgaard H, Godard PP, et al. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med. 2005 Jan 15;171(2):129-136. Epub 2004 Oct 22. doi:10.1164/rccm.200407-884OC. 50. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007;3:CD000195. 51. Manser R, Reid D, Abramson M. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database Syst Rev. 2001;1:CD001740. 52. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic corticosteroids in the treatment of asthma exacerbation: a randomized study. Intern Med. 2000;39(10):794-797. doi:10.2169/internalmedicine.39.794 53. O’Driscoll BR, Kalra S, Wilson M, Pickering CA, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993;341(8841):324-327. doi:10.1016/0140-6736(93)90134-3. 54. Webb J, Clark TJ. Recovery of plasma corticotrophin and cortisol levels after a three-week course of prednisolone. Thorax. 1981;36(1):22-24. 55. Hatton MQ, Vathenen AS, Allen MJ, Davies S, Cooke NJ. A comparison of ‘abruptly stopping’ with ‘tailing off’ oral corticosteroids in acute asthma. Respir Med. 1995;89(2):101-104. doi:10.1016/0954-6111(95)90191-4. 56. Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: is a taper needed? J Emerg Med. 1998;16(1):15-19. doi:10.1016/S0736-4679(97)00227-8. 57. Karan RS, Pandhi P, Behera D, Saily R, Bhargava VK. A comparison of non-tapering vs. tapering prednisolone in acute exacerbation of asthma involving use of the low-dose ACTH test. Int J Clin Pharmacol Ther. 2002;40(6): 256-262.
CME Questions About Formulating a Written Asthma Action Plan 1. Which one of the following would be considered a recommended rescue medication for a patient experiencing a moderate asthma exacerbation? a. b. c. d. e.
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Budesonide (double the usual dose) Albuterol Formoterol Salmeterol Ipratropium •
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2. Which one of the following should be included in a good written asthma action plan (WAAP)? a. Action points (6 to 8) b. A standardized list of medications used for all patients c. Clear, brief language appropriate to the patient’s level of education d. A rigid format that is not changed from visit to visit e. A detailed description about the pathophysiology of asthma 3. Which one of the following is considered the most effective therapy for a moderate to severe asthma exacerbation? a. Inhaled fluticasone b. Formoterol c. Loratadine d. Prednisone e. Montelukast 4. Which one of the following is the most accurate statement about patient monitoring in WAAPs? a. All patients should be monitored by peak expiratory flow (PEF) b. All patients should be monitored by symptoms
c. Physicians should consider monitoring by symptoms, PEF, or both depending on the patient’s particular situation d. Physicians should not specify how to monitor symptoms because patients develop their own method e. Infants and young children should be monitored by PEF because they often cannot effectively communicate their symptoms 5. Which one of the following approaches is best for treatment of acute asthma exacerbations, given the findings of recent studies? a. LABAs for mild asthma exacerbations b. Intermittent ICS use for patients with moderate to severe asthma c. Anticholinergics as part of an early home-based intervention in the WAAP d. Combined ICS/LABA use on an intermittent basis for patients with mild asthma e. Very high–dose ICS (eg, fluticasone, 2 mg/d) for children
This activity was designated for 1 AMA PRA Category 1 Credit(s).™
Because the Concise Review for Clinicians contributions are now a CME activity, the answers to the questions will no longer be published in the print journal. For CME credit and the answers, see the link on our Web site at mayoclinicproceedings.com.
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Formulating an Effective and Efficient Written Asthma Action Plan MATTHEW A. RANK, MD; GERALD W. VOLCHECK, MD; JAMES T. C. LI, MD, PHD; ASHOKAKUMAR M. PATEL, MD; AND KAISER G. LIM, MD On completion of this article, you should be able to: (1) create an effective and efficient written asthma action plan, (2) describe the options for monitoring asthma using a written asthma action plan, and (3) review the rationale for the medications used in asthma exacerbations and be able to explain the differences in medications to patients in a way that facilitates proper use and adherence.
Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician’s busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient selfmonitoring) and treatment.
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ACT = Asthma Control Test; ED = emergency department; FACET = Formoterol and Corticosteroids Establishing Therapy; ICS = inhaled corticosteroid; LABA = long-acting β-agonist; NAEPP = National Asthma Education and Prevention Program; PEF = peak expiratory flow; SABA = short-acting β-agonist; WAAP = written asthma action plan
T
he National Asthma Education and Prevention Program (NAEPP) recommends that all patients with asthma (regardless of severity) receive a written asthma action plan (WAAP).1 This is true especially for patients with a history of frequent and severe (near-fatal) asthma exacerbations.1 Unfortunately, only 25% to 56% of eligible patients receive a WAAP.2-6 We searched MEDLINE using the key words asthma, action plan, self care, patient care planning, anti-asthmatic agents, and patient education. On the basis of this review, we have synthesized practical suggestions for formulating an effective and efficient WAAP with the primary care physician as the intended audience. Asthma is a chronic disease with intermittent or episodic worsening of symptoms. Asthma exacerbations can lead to absenteeism, presenteeism, urgent care and emergency department (ED) visits, hospitalizations, discomfort, dissatisfaction with care, and death.7-9 The WAAP is a contingency plan to aid the patient in decreasing the severity and duration of an asthma exacerbation. A WAAP is only one part of asthma self-management; other compoMayo Clin Proc.
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nents include scheduled visits for asthma, monitoring of rescue medication use, and education in how to monitor symptoms and lung function and how to use medications. These and other features of high-quality asthma care are summarized in a Centers for Disease Control and Prevention review.10 A WAAP does not direct the patient to selfdiagnose asthma, and the symptoms listed in a WAAP can result from confounding or comorbid illness; therefore, the WAAP is optimal when accompanied by physician supervision and an ongoing educational program.11 When a WAAP is part of a comprehensive self-management program, studies report reductions in exacerbations in children and adults.11-13 The effect attributable to the WAAP alone is unknown.14 It is a misconception that a self-management program has to be complicated and personnel-intensive; rather, it can focus on educating the patient in how to use the WAAP. Self-management should be part of the treatment plan for any chronic disease because it empowers patients, reduces dependency, and minimizes the response time so that the morbidity and pain due to episodic exacerbations can be reduced. We agree with the NAEPP’s recommendation that WAAPs should be formulated for most if not all patients with asthma.1 As part of a comprehensive asthma management plan, the principal aim of a WAAP is to help patients recognize asthma exacerbations early and initiate prompt treatment. To facilitate issuance of a WAAP, an electronic version should be made available either in the electronic medical record or as a form with prefilled options (in portable document format [PDF]) for ease of customization to a patient’s condition.
From the Division of Allergic Diseases (M.A.R., G.W.V., J.T.C.L.) and Division of Pulmonary and Critical Care Medicine (A.M.P., K.G.L.), Mayo Clinic, Rochester, MN. Individual reprints of this article are not available. Address correspondence to Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
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THE ROLE OF SELF-MANAGEMENT IN ASTHMA Patients with chronic diseases need a positive attitude, selfefficacy (ie, the level of confidence a patient has in handling the disease), and knowledge. Self-efficacy and a positive attitude have been correlated with adherence (and also with a lower number of hospitalizations).15 A review of interventions targeted to effect behavioral changes found that 57% of the studies used a combination of education and a WAAP.16 One study found that appropriate oral corticosteroid therapy was initiated in 77% of patients with a WAAP.17 A study of children of low socioeconomic status found that medication adherence was improved in strategies that included a WAAP.18 The most common reason patients do not have a WAAP is that their physician did not give them one.4 One survey found that 90% of patients who used a WAAP found it to be helpful.4 Another study reported that patients who used their WAAP customized it according to their personal perception of disease severity.19 The patient must be actively involved in the formulation of a WAAP. This is an opportunity to encourage patient participation and buy-in, to solicit treatment preferences, and to discuss specific responses on the basis of the WAAP. ANATOMY OF A WAAP Although several versions of the WAAP exist,1,20,21 all share certain features. First, patients have to monitor their symptoms or peak expiratory flow (PEF) to detect deviations from the usual state of controlled asthma. Second, reminders of warning signs and symptoms as well as potential precipitating factors or personal triggers are included. Third, patient-initiated treatment options to restore control are explicitly provided in writing. Fourth, expected response time, danger signs, and contact information are included (Figure). Written asthma action plans must have clearly defined action points that teach the patient to recognize and respond to an exacerbation. These action points should be customized to the patient’s personal triggers (eg, seasonal allergies, viral infections) for buy-in and ease of teaching. Action points can be simplified using various forms, including a “traffic light” system of green, yellow, and red zones indicative of increasing severity of exacerbation (Figure). In general, action points help patients determine when to use a medication, what medication to use, how much of the medication to use and for how long, and what to expect of an asthma exacerbation.9 The patient should additionally be educated about signs of severe and life-threatening exacerbations.22 Table 1 summarizes the characteristics of poor and good WAAPs.11 Table 2 provides a checklist, 1264
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intended for physicians and patients, that summarizes key aspects of using a WAAP. Language and literacy level should be considered if a WAAP is to be successful. For children, alternative WAAP forms focusing on parent education and signs that a parent can visually recognize (such as intercostal retractions) are available.1 If the printed word is not the accustomed source of information, an alternative, such as a visual or pictorial version of an asthma action plan, should be considered.23 Another option would be to incorporate an early telephone call to a nurse or other health care professional for worsening asthma symptoms; the office or school nurse could then use the WAAP to give timely verbal advice. This is just one example of how a WAAP can facilitate dialogue between various caregivers and care sites. PATIENT MONITORING Although an action point can be based on monitoring of symptoms or PEF, the Formoterol and Corticosteroids Establishing Therapy (FACET) study clearly showed that patients primarily depend on symptoms to decide when to initiate prednisone therapy.24 The basic assumption of symptom-based monitoring is to detect any deviation from the normal state of good control. It is difficult to establish a WAAP when asthma is poorly controlled, adding to the patient’s confusion and the work for the physician and support staff. Frequent office visits may be necessary to establish asthma control before the WAAP can be optimally formulated. A WAAP is not a substitute for physician follow-up of patients with poorly controlled asthma. Asthma control questionnaires are convenient and may help overcome problems of variable symptom perception. The use of asthma control questionnaires also simplifies symptom monitoring for patients and for educators. They focus the patient instruction process and identify which symptoms to monitor very concretely.25 Several validated asthma questionnaires are available to help patients and physicians quickly quantify the degree of asthma control.26 Of the 3 questionnaires cited by the NAEPP, we recommend the Asthma Control Test (ACT) over the Asthma Control Questionnaire because it does not require arithmetic division by the patient.27 The Asthma Therapy and Assessment Questionnaire has not been as rigorously studied in terms of reliability, responsiveness, and reproducibility in adults. The ACT asks patients to assess their symptoms during the previous 4 weeks; the total score indicates whether asthma is controlled.27 The ACT can be incorporated into regular physician visits and can be used for long-term home monitoring. An example of an ACT can be found at www.asthmacontrol.com.
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FORMULATING A WRITTEN ASTHMA ACTION PLAN
FIGURE. Screenshot of a completed written asthma action plan. HFA = hydrofluoroalkane.
MONITORING OF PEF Peak expiratory flow is an objective assessment of airflow that has been used for self-management of asthma. Poor adherence to daily PEF monitoring suggests that this may not be a practical approach for most patients. However, a subset of “poor perceivers” who consistently underestiMayo Clin Proc.
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mate the worsening asthma symptoms and airflow obstruction may benefit from a PEF-based approach.25,28,29 A purely symptom-based management plan may result in overtreatment of some patients with anxiety who are panic prone and who perceive airflow obstruction when none exists.30 We recommend using a symptom-monitoring approach with the option of PEF to confirm obstruction when
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TABLE 1. Components of Poor and Good Written Asthma Action Plans Poor action plan Action points
Too many decision points for patients to navigate
Readability
Poor readability (ie, not tailored to patient population) No description of expected results from the interventions No mention of severe signs or symptoms that warrant immediate medical attention A static and generic plan not customized to patient’s specific situation. It rarely changes and is not addressed at most visits for chronic asthma care
Elements When to call for help Customization
Good action plan 2 to 4 clearly specific action points: when, what, how much and how long, and what to expect Clear, unequivocal, brief, appropriate language describing how to increase treatment Description of how long to increase treatment Clear instructions on when to obtain additional advice Contact information included; feedback incorporated on a regular basis
symptoms of worsening control are detected. Choosing which method (PEF monitoring or symptom monitoring or both) to anchor the WAAP is best made by a physician familiar with the patients’ preferences.31-33 If PEF monitoring is part of the WAAP, we suggest using a persistent decrease (2 readings, 24 hours apart) of 20% from a patient’s personal best PEF as an action point. In the FACET study, 69% of patients had a decrease in PEF of 20% or more in the 14 days before an asthma exacerbation.24
their physicians if they do not respond to the treatment outlined in their WAAP. Patients with these risk factors benefit not only from a detailed WAAP but also from close follow-up each time they activate their action plan. This may initially result in more frequent physician visits but will ultimately pay dividends in terms of better outcome for the patient.
RECOGNIZING THE RISK OF FATAL ASTHMA
Knowledge, self-efficacy, and attitude are important factors in self-management. It is important for patients to understand the purpose of the different medications involved in asthma. Ignacio-Garcia and Gonzalez-Santos34 provide information intended to help patients understand their asthma medications (Table 3). Information regarding some of the most common asthma exacerbation medications follows.
A physician caring for a patient with asthma should consider the patient’s risk of fatal asthma. Risk factors include previous severe exacerbation, 2 or more hospitalizations for asthma in the past year, 3 or more ED visits for asthma in the past year, a hospitalization or ED visit for asthma in the past month, use of more than 2 canisters of short-acting β-agonist (SABA) per month, poor perception of airflow obstruction, sensitivity to Alternaria species, lack of a WAAP, cardiovascular disease, other chronic lung disease, low socioeconomic status, illicit drug use, and major psychological problems.1 Patients should be instructed to call TABLE 2. Written Asthma Action Plan Checklists Physicians Follow up patients closely until asthma is well controlled Educate patients about asthma symptoms and peak flow readings that require action Educate patients about proper use of asthma medications, including when to use them Complete a written asthma action plan Establish a follow-up plan and review medications and action plan at each visit Patients Learn the basics about asthma Recognize your asthma triggers Learn how and when to use medications Understand and agree with your physician on a way to monitor your asthma (such as peak flow monitoring or use of the Asthma Control Test) Review your action plan with your physician regularly Know what to do if asthma is worsening and in an emergency
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EDUCATING PATIENTS WITH ASTHMA ABOUT THEIR MEDICATIONS
SHORT-ACTING BRONCHODILATORS Patient Instruction. Use your rescue medications when short of breath. When. Patients should be instructed to use their rescue medicines when they have symptoms of dyspnea at rest or during exertion, cough, chest tightness, wheezing, or a decrease in PEF from baseline of more than 10% to 20%. What. Short-acting bronchodilators include albuterol, pirbuterol, or levalbuterol metered-dose inhalers. Recently, the propellant for inhaled short-acting bronchodilators has been changed from chlorofluorocarbons to hydrofluoroalkane for environmental reasons. Nebulization (compression with a machine) is an alternative mechanism of delivery of SABAs that is less portable than metered-dose inhalers and that does not necessarily improve medication delivery. How Much and How Often. For mild baseline dyspnea, patients should use 2 to 4 puffs of albuterol every 4 hours. For severe dyspnea, patients should use 2 puffs of
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FORMULATING A WRITTEN ASTHMA ACTION PLAN
TABLE 3. Information Given to Patients Regarding Asthma Medicines Used in the Action Plana Short-acting β-agonists (rescue inhalers) Fast-acting inhalers that help alleviate immediate symptoms Not helpful as a scheduled, everyday inhaler to prevent asthma symptoms If you need more rescue inhaler, this might mean that your asthma is becoming worse and that your physician may need to adjust your medications ICS An inhaled medicine that cuts down on swelling and mucus in the airway Very useful for stabilizing your asthma Currently is considered the most important everyday asthma medication Does not relieve immediate symptoms of asthma and should not be used for this like the rescue inhaler It is important to take this medication every day for it to help prevent your asthma from interfering with your usual activities (job, school, sports) Inhaled long-acting bronchodilators Some drugs in this group do not act immediately Not to be used for immediate symptoms Only use these medicines if you are also using an ICS Using this medicine with an ICS may allow your asthma to be controlled with a lower dose of ICS Oral corticosteroids (prednisone) Oral medicines that are sometimes needed to help with asthma flares Help cut down on swelling and mucus in the airway Very important to follow the physician’s instructions on how to use these medicines Using these medicines may cause some adverse effects but you should not be afraid to take these medicines when they are needed for your asthma Antibiotics A treatment for bacterial infection Most asthma flares are unrelated to bacterial infections Asthma flares should be treated with medicines that reduce inflammation (airway swelling and mucus)
use of an ICS during exacerbation should be limited to patients with very mild asthma who have rare and mild exacerbations.35 What. Different ICSs have similar clinical efficacies but different potencies and bioavailabilities.1 This is especially important for patients requiring a high-dose ICS because they have to use more puffs to obtain the same effect with certain ICS preparations (beclomethasone, budesonide, triamcinolone, flunisolide).36 Knowledge about systemic bioavailability is important for patients taking a high-dose ICS because risk of adverse effects may be higher in preparations with higher oral availability.1 How Much and How Often. Treatment plans that double the dose of the patients’ baseline ICS do not effectively treat asthma exacerbations.37-39 Treatment plans using substantially higher ICS doses than the usual daily dose (eg, 2 mg/d of fluticasone) were effective in adult studies but ineffective in a pediatric study.40-43 Issues with using a high-dose ICS for exacerbations include cost, tolerability, and the difficulty in increasing ICS dose in patients who use a fixed ICS/LABA combination inhaler. How Long. The maintenance dose of ICS necessary to attain asthma control should be continued throughout the exacerbation. Why No Relief. Studies suggest that anti-inflammatory treatment should be started early.40 Poor technique and poor adherence are common reasons why ICSs are ineffective. Bottom Line. An ICS should be viewed as a daily controller medication rather than as a treatment for asthma exacerbations.
a
ICS = inhaled corticosteroid. Adapted from Am J Respir Crit Care Med,34 with permission.
albuterol every 5 minutes up to 20 puffs (if no response in 1 hour, seek immediate medical attention); nebulized (compressed) SABAs can also be used. Why No Relief. Increasing requirement for SABAs is a red flag that symptoms such as cough, dyspnea, or airway obstruction may be due to mucus or inflammation or are unrelated to asthma. Patients with poor improvement after SABA treatment should report this to the physician because it requires additional action. Comment. Assessing SABA response determines the next action point in a well-formulated WAAP. Anticholinergic medication should not be used for immediate relief. INHALED CORTICOSTEROIDS Patient Instruction. Do not forget that asthma is inflammation of the airways and that it is important to continue your controller medication(s). When. Patients should be instructed to continue their usual ICS doses during an exacerbation. The intermittent Mayo Clin Proc.
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LONG-ACTING β-AGONISTS Patient Instruction. This medication is not intended as a quick relief or rescue medication. When. Long-acting β-agonists (LABAs) are often part of patients’ long-term asthma plan and are particularly effective at decreasing ICS dose and reducing mild exacerbation rates.44,45 What. Unless accompanied by regular use of an ICS, LABAs such as salmeterol and formoterol should not be used for asthma unless accompanied by regular use of an ICS.46 The following caution should be noted: LABAs (salmeterol or formoterol) are not recommended for rescue use.47 Formoterol has an onset of action in minutes but is not currently approved by the Food and Drug Administration as a rescue medication. Short-acting anticholinergic medications have a role in ED management of asthma exacerbations but are not recommended for home management. Research. Treatment approaches using a combined ICS/LABA on an as-needed basis to effectively control
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asthma have been supported by recent studies.48,49 Additional studies are required to clarify the role of combined ICS/LABA in acute exacerbations. Bottom Line. Using as-needed ICS/LABA combination products has not been approved by the Food and Drug Administration for treatment of acute asthma exacerbations.
monitoring, the dosing and duration of increased treatment, and contact information to facilitate immediate medical attention if needed. Physicians should strongly consider formulating a personalized WAAP to help their patients with asthma recognize exacerbations early and treat them effectively.
SYSTEMIC CORTICOSTEROIDS Patient Instruction. It is important to start early to control an exacerbation; systemic corticosteroids are safe for short-term use. When. Initiation of systemic corticosteroid therapy is determined by an action point in the WAAP (ie, when symptoms are severe and/or when the PEF decreases 20% from the patient’s personal best on 2 readings taken 24 hours apart). What. By clinical consensus, systemic corticosteroids are the first line of treatment for severe exacerbations or for those that cannot be controlled by increasing the SABA dose.36,50,51 Oral and intravenous corticosteroids appear to have similar efficacy for asthma exacerbations. How Much and How Often. In the FACET study, a dose of 30 mg/d of prednisone was used to treat 425 episodes of severe exacerbation.24 Current guidelines suggest administering prednisone at 40 to 60 mg/d for adults and 2 mg/kg per day for children.1 How Long. A suggested duration of systemic corticosteroid therapy is 5 or 10 days.24,50 Longer duration or higher doses of systemic corticosteroid therapy have not been shown to be more effective.52,53 Tapering. Tapering is only necessary for patients who are receiving long-term systemic corticosteroid therapy or for patients who receive frequent systemic corticosteroid bursts. Studies have shown that adrenal function typically recovers quickly.54-57 Proponents of tapering suggest that it may prevent rebound exacerbation, maintain anti-inflammatory control, and prevent adrenal failure.1,54 If the patient is taking an ICS, it is unnecessary to use a systemic corticosteroid to extend anti-inflammatory therapy. Why No Relief. In a study by Levy et al,40 the high failure rate in the prednisone arm was attributed to delayed initiation. Patients should expect improvement in about 48 hours; however, for severe exacerbations, relief may take longer.52 Only a small proportion of patients with asthma are resistant to corticosteroids. Comment. Systemic corticosteroids are the preferred treatment for moderate to severe asthma exacerbations.
REFERENCES 1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3 Web site. Guidelines for the diagnosis and management of asthma (EPR-3). www.nhlbi.nih.gov/guidelines /asthma/index.htm. Accessed September 28, 2008. 2. Peters SP, Jones CA, Haselkorn T, Mink DR, Valacer DJ, Weiss ST. Real-world Evaluation of Asthma Control and Treatment (REACT): findings from a national Web-based survey. J Allergy Clin Immunol. 2007 Jun;119 (6):1454-1461. Epub 2007 May 3. doi:10.1016/j.jaci.2007.03.022. 3. Beauchesne, MF, Levert V, El Tawil M, Labrecque M, Blais L. Action plans in asthma. Can Respir J. 2006;13(6):306-310. 4. Douglass J, Aroni R, Goeman D, et al. A qualitative study of action plans for asthma. BMJ. 2002;324(7344):1003-1005. doi:10.1136/bmj.324.7344 .1003. 5. Butz AM, Huss K, Mudd K, Donithan M, Rand C, Bollinger ME. Asthma management practices at home in young inner-city children. J Asthma. 2004;41(4):433-444. doi:10.1081/JAS-120033985. 6. Fernandes AK, Mallmann F, Steinhorst AM, et al. Characteristics of acute asthma patients attended frequently compared with those attended only occasionally in an emergency department. J Asthma. 2003;40(6):683-690. doi:10.1081/JAS-120023487. 7. Masoli M, Fabian D, Holt S, Beasley R; Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy. 2004;59(5):469-478. doi:10.1111/j.1398-9995.2004.00526.x. 8. Markson LE, Vollmer WM, Fitterman L, et al. Insight into patient dissatisfaction with asthma treatment. Arch Intern Med. 2001;161(3):379-384. doi:10.1001/archinte.161.3.379. 9. Hemp P. Presenteeism: at work—but out of it. Harv Bus Rev. 2004; 82(10):49-58, 155. 10. Williams SG, Schmidt DK, Redd SC, Storms W. Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program. MMWR Recomm Rep. 2003;52(RR-6):1-8. 11. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2003;1:CD001117. 12. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-1309. doi:10.1136/bmj.326.7402.1308. 13. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children’s use of acute care services: a meta-analysis. Pediatrics. 2008;121(3):575-586. doi:10.1542/peds.2007-0113. 14. Toelle BG, Ram FS. Written individualised management plans for asthma in children and adults. Cochrane Database Syst Rev. 2004;2: CD002171. 15. Scherer YK, Bruce S. Knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma. Heart Lung. 2001;30(4):250-257. doi:10.1067/mhl.2001.116013. 16. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364(9444):1523-1537. doi:10.1016/S01406736(04)17277-2. 17. Lahdensuo A, Haahtela T, Herrala J, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ. 1996;312(7033):748-752. 18. Fox P, Porter PG, Lob SH, Boer JH, Rocha DA, Adelson JW. Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies. Pediatrics. 2007; 120(4):e902-e911. doi:10.1542/peds.2006-1805. 19. Dinakar C, Van Osdol TJ, Wible K. How frequent are asthma exacerbations in a pediatric primary care setting and do written asthma action plans
CONCLUSION A WAAP is a useful asthma management tool that should include action points based on an agreed method of self1268
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help in their management? J Asthma. 2004;41(8):807-812. doi:10.1081/JAS -200038418. 20. Mangold RA, Salzman GA. Electronic asthma action plan database: asthma action plan development using Microsoft Access. J Asthma. 2005;42(3): 191-196. doi:10.1081/JAS-200054631. 21. D’Souza W, Crane J, Burgess C, et al. Community-based asthma care: trial of a “credit card” asthma self-management plan. Eur Respir J. 1994;7(7): 1260-1265. 22. McFadden ER Jr. Acute severe asthma. Am J Respir Crit Care Med. 2003;168(7):740-759. doi:10.1164/rccm.200208-902SO. 23. Roberts NJ. Development of a paper and electronic pictorial asthma selfmanagement plan [abstract]. Am J Respir Crit Care Med. 2007;A589. 24. Tattersfield AE, Postma DS, Barnes PJ, et al; FACET International Study Group. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. Am J Respir Crit Care Med. 1999;160(2):594-599. 25. Banzett RB, Dempsey JA, O’Donnell DE, Wamboldt MZ. Symptom perception and respiratory sensation in asthma. Am J Respir Crit Care Med. 2000;162(3, pt 1):1178-1182. 26. Wallenstein GV, Carranza-Rosenzweig J, Kosinski M, Blaisdell-Gross B, Gajria K, Jhingran P. A psychometric comparison of three patient-based measures of asthma control. Curr Med Res Opin. 2007;23(2):369-377. doi:10.1185/030079906X167426. 27. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113(1):59-65. doi:10.1016/j.jaci.2003.09.008. 28. Clark NM, Evans D, Mellins RB. Patient use of peak flow monitoring. Am Rev Respir Dis. 1992;145(3):722-725. 29. Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ. 1993;307(6901):422-424. 30. Chetta A, Gerra G, Foresi A, et al. Personality profiles and breathlessness perception in outpatients with different gradings of asthma. Am J Respir Crit Care Med. 1998;157(1):116-122. 31. Malo JL, L’Archevêque J, Trudeau C, d’Aquino C, Cartier A. Should we monitor peak expiratory flow rates or record symptoms with a simple diary in the management of asthma? J Allergy Clin Immunol. 1993;91(3):702-709. doi:10.1016/0091-6749(93)90189-M. 32. Clough JB, Sly PD. Association between lower respiratory tract symptoms and falls in peak expiratory flow in children. Eur Respir J. 1995;8(5):718722. 33. Chan-Yeung M, Chang JH, Manfreda J, Ferguson A, Becker A. Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma. Am J Respir Crit Care Med. 1996;154(4, pt 1): 889-893. 34. Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med. 1995;151(2, pt 1):353-359. 35. Boushey HA, Sorkness CA, King TS, et al; National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;352(15):15191528. doi:10.1056/NEJMoa042552. 36. Reddel HK, Barnes DJ; Exacerbation Advisory Panel. Pharmacological strategies for self-management of asthma exacerbations. Eur Respir J. 2006; 28(1):182-199. doi:10.1183/09031936.06.00105305. 37. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363(9405):271-275. doi:10.1016/S01406736(03)15384-6. 38. FitzGerald JM, Shragge D, Haddon J, et al. A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J. 2000;7(1):61-67. 39. Rice-McDonald G, Bowler S, Staines G, Mitchell C. Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults. Intern Med J. 2005;35(12):693-698. doi:10.1111/j.1445 -5994.2005.00972.x. 40. Levy ML, Stevenson C, Maslen T. Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care. Thorax. 1996;51(11):1087-1092. 41. Foresi A, Morelli MC, Catena E; Italian Study Group. Low-dose budesonide with the addition of an increased dose during exacerbation is effective in long-term asthma control. Chest. 2000;117(2):440-446. doi:10 .1378/chest.117.2.440.
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42. Rodrigo G, Rodrigo C. Inhaled flunisolide for acute severe asthma. Am J Respir Crit Care Med. 1998;157(3, pt 1):698-703. 43. Schuh S, Reisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med. 2000;343(10):689-694. doi:10.1056/NEJM200009073431003. 44. Pauwels RA, Löfdahl C-G, Postma DS, et al; Formoterol and Corticosteroids Establishing Therapy (FACET) International Study Group. Effect of inhaled formoterol and budesonide on exacerbations of asthma [published correction appears in N Engl J Med. 1998;338(2):139]. N Engl J Med. 1997; 337(20):1405-1411. doi:10.1056/NEJM199711133372001. 45. O’Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med. 2001.164(8, pt 1):1392-1397. 46. Nelson HS, Weiss ST, Bleecker ER, Yancey SW, Dorinsky PM; SMART Study Group. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol [published correction appears in Chest. 2006;129(5):1393]. Chest. 2006;129(1):15-26. doi:10.1378/chest.129.1.15. 47. Pauwels RA, Sears MR, Campbell M, et al; RELIEF Study Investigators. Formoterol as relief medication in asthma: a worldwide safety and effectiveness trial. Eur Respir J. 2003;22(5):787-794. doi:10.1183/09031936 .03.00055803. 48. Papi A, Canonica GW, Maestrelli P, et al; BEST Study Group. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;356(20):2040-2052. doi:10.1056/NEJMoa063861. 49. O’Byrne PM, Bisgaard H, Godard PP, et al. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med. 2005 Jan 15;171(2):129-136. Epub 2004 Oct 22. doi:10.1164/rccm.200407-884OC. 50. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007;3:CD000195. 51. Manser R, Reid D, Abramson M. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database Syst Rev. 2001;1:CD001740. 52. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic corticosteroids in the treatment of asthma exacerbation: a randomized study. Intern Med. 2000;39(10):794-797. doi:10.2169/internalmedicine.39.794 53. O’Driscoll BR, Kalra S, Wilson M, Pickering CA, Carroll KB, Woodcock AA. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993;341(8841):324-327. doi:10.1016/0140-6736(93)90134-3. 54. Webb J, Clark TJ. Recovery of plasma corticotrophin and cortisol levels after a three-week course of prednisolone. Thorax. 1981;36(1):22-24. 55. Hatton MQ, Vathenen AS, Allen MJ, Davies S, Cooke NJ. A comparison of ‘abruptly stopping’ with ‘tailing off’ oral corticosteroids in acute asthma. Respir Med. 1995;89(2):101-104. doi:10.1016/0954-6111(95)90191-4. 56. Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: is a taper needed? J Emerg Med. 1998;16(1):15-19. doi:10.1016/S0736-4679(97)00227-8. 57. Karan RS, Pandhi P, Behera D, Saily R, Bhargava VK. A comparison of non-tapering vs. tapering prednisolone in acute exacerbation of asthma involving use of the low-dose ACTH test. Int J Clin Pharmacol Ther. 2002;40(6): 256-262.
CME Questions About Formulating a Written Asthma Action Plan 1. Which one of the following would be considered a recommended rescue medication for a patient experiencing a moderate asthma exacerbation? a. b. c. d. e.
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2. Which one of the following should be included in a good written asthma action plan (WAAP)? a. Action points (6 to 8) b. A standardized list of medications used for all patients c. Clear, brief language appropriate to the patient’s level of education d. A rigid format that is not changed from visit to visit e. A detailed description about the pathophysiology of asthma 3. Which one of the following is considered the most effective therapy for a moderate to severe asthma exacerbation? a. Inhaled fluticasone b. Formoterol c. Loratadine d. Prednisone e. Montelukast 4. Which one of the following is the most accurate statement about patient monitoring in WAAPs? a. All patients should be monitored by peak expiratory flow (PEF) b. All patients should be monitored by symptoms
c. Physicians should consider monitoring by symptoms, PEF, or both depending on the patient’s particular situation d. Physicians should not specify how to monitor symptoms because patients develop their own method e. Infants and young children should be monitored by PEF because they often cannot effectively communicate their symptoms 5. Which one of the following approaches is best for treatment of acute asthma exacerbations, given the findings of recent studies? a. LABAs for mild asthma exacerbations b. Intermittent ICS use for patients with moderate to severe asthma c. Anticholinergics as part of an early home-based intervention in the WAAP d. Combined ICS/LABA use on an intermittent basis for patients with mild asthma e. Very high–dose ICS (eg, fluticasone, 2 mg/d) for children
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November 2008;83(11):1263-1270
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www.mayoclinicproceedings.com
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