Guided self management of asthma—how to do it

Introduction

Almost 75% of admissions for asthma are avoidable, and potentially preventable factors are common in deaths from asthma.¹,² At least 40% of people with asthma do not react appropriately when their symptoms worsen, and over 50% of patients admitted with acute asthma have had alarming symptoms for at least a week before admission.³,⁴ As many as 60% of asthmatic patients are poor at judging their dyspnoea.⁵ Self management of asthma involves the patient making therapeutic, behavioural, and environmental adjustments in accordance with advice from healthcare professionals.⁶ Guided self management of asthma is a treatment strategy in which patients are taught to act appropriately when the first signs of asthma exacerbations appear.

In a recent Cochrane review, self management of asthma in adults was compared with usual care in 22 studies.⁷ Self management education reduced hospital admissions (odds ratio 0.57, 95% confidence interval 0.38 to 0.88), emergency room visits (0.71, 0.57 to 0.90), unscheduled visits to the doctor (0.57, 0.40 to 0.82), days off work or off school (0.55, 0.38 to 0.79), and nocturnal asthma (0.53, 0.39 to 0.72). Self management programmes that contained a written action plan showing patients how to act in early exacerbations showed a greater reduction in admissions to hospital than did programmes without a plan (0.35, 0.18 to 0.68).

Cost effectiveness studies of self management programmes for asthma have shown positive results, with cost benefit ratios between 1:2.5 and 1:11.22⁸; the programme with the most favourable result saved $11.22 (£7) for every $1 (£1.60) spent.

Summary points

• Self management of asthma prevents exacerbations, improves care, and is a cost effective investment

• Patient education is crucial and should be given in a structured way

• Patients should be taught to understand their symptoms and to monitor peak expiratory flow at home

• Patients should know how to act when signs of asthma deterioriation first appear

• There should always be supervision of and continuity in asthma care

Methods

This article is based largely on my experience as a pulmonary specialist, in charge of organising asthma treatment in my hospital district, and on studies of self management of asthma. I have also included the views of several national and international working groups in which I have participated, and I have supplemented reviews and articles from high quality journals.

Setting up a self management programme for asthma

Although the reasons for starting a self management programme for asthma are obvious (box B1), it is not always an easy task to start this kind of programme. Giving asthmatic patients more responsibility and independence may be a cultural challenge for healthcare staff, and starting a new programme means additional workload. Patients’ willingness to make decisions in their own asthma care can also be poor.⁹ Educating and motivating both patients and healthcare teams are crucial for a successful self management programme. The good results achieved with self management programmes should be emphasised and shown, and information supplied should be kept as clear and simple as possible.

Box 1.

: Reasons for self management of asthma

• Insidious deterioration (common in asthma)²
• Three quarters of asthma exacerbations resulting in hospital care are preventable¹
• Nearly half of patients react inappropriately to asthma exacerbations³
• Poor perception of deteriorating dyspnoea⁵
• Proved value of patient education in the treatment of asthma¹⁰
• Poor compliance (30-40%) with asthma drugs¹¹

There is reasonable consensus on the self management skills that patients should possess as a result of education (box B2).¹² Although research evaluating education for asthma has been conducted in many settings—hospitals, emergency rooms, general practices, community organisations, hospital outpatient clinics—there have been no studies assessing the effect of the setting on education. It would seem reasonable to expect that education should be available at every patient contact for each setting and that the information should be given in a structured form. In my experience, group sessions plus personal counselling is the most effective method for educating asthmatic patients. Good audiovisual material can give help and increase interest. Although asthmatic patients have a strong desire to be informed about their illness,⁹ their individual backgrounds will influence the extent to which they utilise information. The patient’s own responsibility for treatment is crucial, and building a firm partnership with the patient is the key to success. The responsibility for treatment is borne by the patient and the primary healthcare system, supported by specialised medical care. In asthma self management the patients should not be seen as objects for treatment but rather as active participants in a treatment team.

Box 2.

: Self management skills

Patients should:

• Accept that asthma is a long term and treatable disease
• Be able to accurately describe asthma and its treatment
• Actively participate in the control and management of their asthma
• Identify factors that make their asthma worse
• Be able to describe strategies for avoidance or reduction of exacerbating factors
• Recognise the signs and symptoms of worsening asthma
• Follow a prescribed written treatment plan
• Use correct technique for taking drugs including inhalants by metered dose inhalers, dry powder inhalers,diskhalers, spacers, or nebulisers
• Take appropriate action to prevent and treat symptoms in different situations
• Use medical resources appropriately for routine and acute care
• Monitor symptoms and objective measures of asthma control
• Identify barriers to compliance (adherence) to the treatment plan
• Address specific problems that have an impact on their individual condition

Information alone is insufficient, and successful interventions combine the provision of information with individualised self treatment plans. Such action plans may be based on symptoms, peak expiratory flow values, or both.¹³ It is essential that patients notice exacerbations in their asthma (box B3) early enough and start appropriate interventions by themselves. Self management programmes for asthma have used different action limits or zones for peak expiratory flow or symptoms. Clear peak flow charts or pocket sized cards with colours to mark different action limits can be used. For example14:

Box 3.

: Warning signs of asthma exacerbation

• Increased dyspnoea
• A combination of increased wheeze, cough, or mucus secretion
• Nocturnal asthma
• Increased use of short acting sympathomimetics
• Increased exercise induced asthma
• Decreased morning peak expiratory flow values

• Asthma under control: peak expiratory flow values greater than 85% of personal best—use regular treatment

• Asthma getting worse: peak expiratory flow values less than 85% of personal best—double dose of inhaled steroids

• Asthma severe: peak expiratory flow values less than 70% of personal best—start course of oral prednisone

• Asthma emergency: peak expiratory flow values less than 50% of personal best—go to emergency room immediately.

Programmes for self management of asthma should be aimed primarily at those patients who probably will benefit the most (box B4), and programmes should be individualised to suit the patient.

Box 4.

: Patients suitable for guided self management

Patients with:

• Moderate or severe asthma
• Variable disease
• History of emergency room visits owing to asthma
• Bad perception of the severity of the disease
• Good cooperation

In Finland, regional asthma networks according to the Finnish national asthma programme¹⁵ have been built up between general practice and specialised care to enforce the quality and continuity of asthma care. The experiences of these networks are good and they help asthma self management to work.