Vol. 10 •Issue 10 • Page 14
Implementing Asthma Action Plans as Education and Communication Tools * Implementing Asthma Action Plans as Education and Communication Tools
By Marianna M. Sockrider, MD, DrPH, Julie S. McGuire, MSN, RN, CPNP, Danita Czyzewski, PhD, and John Pella, RCP, CCRC
Allergy & Asthma
Optimal asthma control will occur only if families take an active daily role in using preventive medications, monitoring symptoms and responding to exacerbations in symptoms. An asthma action plan is a written guide to facilitate this self-management of asthma.
While there are guidelines for the structure of an action plan, there is not one action plan for all patients. Action plans are individualized based on disease severity, treatment and sophistication of the family, and the plans are refined as the disease, treatment or asthma self-management ability changes.
Used to its fullest, the asthma action plan facilitates communication between the patient, family and the medical team, by providing a tool from which to teach, collaborate and gather and use information about the patient’s asthma. The National Asthma Education Program Expert Panel (NAEPP) Guideline Report states, “Patients should be provided with and taught to use a written daily self-management plan and an action plan for exacerbations.”1
Limited research on written action plans and their role in asthma care has been performed. However, several clinical studies suggest that having a written action plan has a positive effect on self-management behavior in adults2,3 and children and their families.4,5
Many plans define three zones to link severity of symptoms with actions to take: well (green zone), symptoms (yellow zone) and emergency (red zone). Simpler plans, for less sophisticated patients, designate only “sick” and “well” zones. In practice, some families may be given a two-zone plan and then move to a three-zone plan as their self-management skills improve.
The asthma action plan should be easy to comprehend. The various components should be titled and organized so that the patient/family can follow the plan. All medication doses should be written in lay language. Reminders such as to use a spacer with metered dose inhalers and to gargle after using inhaled corticosteroids should be included.
Low literacy patients may require a picture format showing the color of inhalers and using images to illustrate symptoms. No matter what format is used, it should be reviewed with the patient/family to assure adequate comprehension and confidence in use.
THE DAILY MANAGEMENT PLAN
This section of the asthma action plan describes what to do even when the child is symptom free in order to stay in good control. Patients who have persistent asthma should receive daily controller therapy including anti-inflammatory medication, which is described in the green zone. Patients need clear directions regarding this maintenance “preventive” therapy to ensure proper benefit and compliance.
For plans including peak flow levels, personal best or the predicted normal range would be included in this section. Also included are any guidelines for exercise pretreatment. Environmental control strategies and recommendation for influenza vaccine might also be included. Some maintenance plans have included projected plans for weaning to lower doses or less medication with improved control.
THE RESCUE PLAN
Families need to know when a change in symptoms or peak flow requires a response from the family. The rescue plan or yellow zone describes the child’s symptoms and peak flow levels, and it outlines the prescribed response to symptoms. The plan helps families determine when to use rescue medication, how to evaluate how well it’s working, and decide when and how to communicate with the doctor. It’s important to be clear about how long to watch for a response and provide guidance on how long one can continue to treat within the “yellow” zone or use the “sick” plan before checking in.
In this section, families are reminded to continue to use preventive medications while treating exacerbations. They also are reminded that frequent use of rescue bronchodilators indicates that control is not optimal and the family should prompt the health care provider to re-evaluate the patient’s maintenance program and environment.
RECOGNIZING AND ADDRESSING EMERGENCIES
The NAEPP guidelines state that patients and families should be educated to seek medical help early if an asthma exacerbation is severe, therapy does not give rapid, sustained improvement, or there is further deterioration.1 This can be clearly communicated using the written action plan.
The emergency section or red zone should specify not only what symptoms or peak flow level indicate that an emergency response is necessary, but it also should state how to summon help and the physician’s contact number. When patients present for emergency care, they should be asked about the written action plan and what actions they have taken at home.
COMMUNICATION WITH THE ASTHMA TEAM
The action plan should be available for everyone on the asthma team. The patient/family should be advised to keep it in a convenient place, such as on the refrigerator, so it can be referred to easily. Some clinics offer pocket or wallet versions as well.
All members of a patient’s home asthma team who may participate in the care of the patient–including other family members, babysitters, and friends–should have access to and review the asthma action plan. Copies of the plan should be provided to the child’s school and/or day care. Simplified versions for the child helps him or her decide when to talk with a grown-up about asthma symptoms and how to use rescue medicine if alone.
Review and reinforcement of the action plan will help the family view the plan as an invaluable guide to treatment. Conversely, giving the family the action plan and never mentioning it again may render the action plan as useless as any other throwaway brochure. The action plan should be reviewed at each clinic visit and modified as necessary. The medical asthma team should ensure that the patient/family understand all parts of the plan and inquire about its effectiveness. Open discussion with the family will strengthen the idea that they are at the center of the team and that their concerns and input are essential.
Dr. Sockrider is a pediatric pulmonologist and behavioral scientist on the faculty at Baylor College of Medicine and the University of Texas Health Sciences Center-Houston School of Public Health. Dr. Czyzewski is a child psychologist on the faculty at Baylor. McGuire is a pediatric nurse practitioner specializing in asthma care. Pella is a respiratory care practitioner and clinical research coordinator in pediatric pulmonology. All the authors are members of the multi-disciplinary team at the Texas Children’s Hospital Children’s Asthma Center in Houston.
For a list of references, please call Sharlene Sephton at (610) 278-1400, ext. 1324, or visit Respiratory-care-sleep-medicine.advanceweb.com/reflist.html.