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. 2004 Feb;59(2):94–99. doi: 10.1136/thorax.2003.011858

Written action plans for asthma: an evidence-based review of the key components

P Gibson 1, H Powell 1
PMCID: PMC1746945  PMID: 14760143

Abstract

Background: Written action plans for asthma facilitate the early detection and treatment of an asthma exacerbation. Several versions of action plans have been published but the key components have not been determined. A study was undertaken to determine the impact of individual components of written action plans on asthma health outcomes.

Methods: Randomised controlled trials (n = 26) that evaluated asthma action plans as part of asthma self-management education were identified. Action plans were classified as being individualised and complete if they specified when and how to increase treatment (n = 17), and as incomplete (n = 4) or non-specific (n = 5) if they did not include these instructions.

Results: For individualised complete written action plans the use of 2–4 action points and the use of both inhaled (ICS) and oral (OCS) corticosteroid consistently improved asthma outcomes. Action points based on personal best peak expiratory flow (PEF) consistently improved health outcomes while those based on percentage predicted PEF did not. The efficacy of incomplete action plans was inconclusive because of insufficient data. Non-specific action plans led to improvements in knowledge and symptoms.

Conclusion: Individualised written action plans based on personal best PEF, using 2–4 action points, and recommending both ICS and OCS for treatment of exacerbations consistently improve asthma health outcomes. Other variations appear less beneficial or require further study. These observations provide a guide to the types of variations possible with written action plans, and strongly support the use of individualised complete written action plans.

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Selected References

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  1. Abdulwadud O., Abramson M., Forbes A., James A., Walters E. H. Evaluation of a randomised controlled trial of adult asthma education in a hospital setting. Thorax. 1999 Jun;54(6):493–500. doi: 10.1136/thx.54.6.493. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bailey W. C., Kohler C. L., Richards J. M., Jr, Windsor R. A., Brooks C. M., Gerald L. B., Martin B., Higgins D. M., Liu T. Asthma self-management: do patient education programs always have an impact? Arch Intern Med. 1999 Nov 8;159(20):2422–2428. doi: 10.1001/archinte.159.20.2422. [DOI] [PubMed] [Google Scholar]
  3. Bailey W. C., Richards J. M., Jr, Brooks C. M., Soong S. J., Windsor R. A., Manzella B. A. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med. 1990 Aug;150(8):1664–1668. [PubMed] [Google Scholar]
  4. Beasley R., Cushley M., Holgate S. T. A self management plan in the treatment of adult asthma. Thorax. 1989 Mar;44(3):200–204. doi: 10.1136/thx.44.3.200. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Chan-Yeung M., Chang J. H., 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 Oct;154(4 Pt 1):889–893. doi: 10.1164/ajrccm.154.4.8887581. [DOI] [PubMed] [Google Scholar]
  6. Charlton I., Antoniou A. G., Atkinson J., Campbell M. J., Chapman E., Mackintosh T., Schapira D. Asthma at the interface: bridging the gap between general practice and a district general hospital. Arch Dis Child. 1994 Apr;70(4):313–318. doi: 10.1136/adc.70.4.313. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Coté J., Cartier A., Robichaud P., Boutin H., Malo J. L., Rouleau M., Fillion A., Lavallée M., Krusky M., Boulet L. P. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med. 1997 May;155(5):1509–1514. doi: 10.1164/ajrccm.155.5.9154850. [DOI] [PubMed] [Google Scholar]
  8. D'Souza W., Crane J., Burgess C., Te Karu H., Fox C., Harper M., Robson B., Howden-Chapman P., Crossland L., Woodman K. Community-based asthma care: trial of a "credit card" asthma self-management plan. Eur Respir J. 1994 Jul;7(7):1260–1265. doi: 10.1183/09031936.94.07071260. [DOI] [PubMed] [Google Scholar]
  9. FitzGerald J. M., Shragge D., Haddon J., Jennings B., Lee J., Bai T., Pare P., Kassen D., Grunfeld A. 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 Jan-Feb;7(1):61–67. doi: 10.1155/2000/587957. [DOI] [PubMed] [Google Scholar]
  10. Gallefoss F., Bakke P. S. Cost-effectiveness of self-management in asthmatics: a 1-yr follow-up randomized, controlled trial. Eur Respir J. 2001 Feb;17(2):206–213. doi: 10.1183/09031936.01.17202060. [DOI] [PubMed] [Google Scholar]
  11. Gallefoss F., Bakke P. S. How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication? Am J Respir Crit Care Med. 1999 Dec;160(6):2000–2005. doi: 10.1164/ajrccm.160.6.9901028. [DOI] [PubMed] [Google Scholar]
  12. Gallefoss F., Bakke P. S. Impact of patient education and self-management on morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Respir Med. 2000 Mar;94(3):279–287. doi: 10.1053/rmed.1999.0749. [DOI] [PubMed] [Google Scholar]
  13. Gallefoss F., Bakke P. S. Patient satisfaction with healthcare in asthmatics and patients with COPD before and after patient education. Respir Med. 2000 Nov;94(11):1057–1064. doi: 10.1053/rmed.2000.0886. [DOI] [PubMed] [Google Scholar]
  14. Gallefoss F., Bakke P. S., Rsgaard P. K. Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999 Mar;159(3):812–817. doi: 10.1164/ajrccm.159.3.9804047. [DOI] [PubMed] [Google Scholar]
  15. George M. R., O'Dowd L. C., Martin I., Lindell K. O., Whitney F., Jones M., Ramondo T., Walsh L., Grissinger J., Hansen-Flaschen J. A comprehensive educational program improves clinical outcome measures in inner-city patients with asthma. Arch Intern Med. 1999 Aug 9;159(15):1710–1716. doi: 10.1001/archinte.159.15.1710. [DOI] [PubMed] [Google Scholar]
  16. Ghosh C. S., Ravindran P., Joshi M., Stearns S. C. Reductions in hospital use from self management training for chronic asthmatics. Soc Sci Med. 1998 Apr;46(8):1087–1093. doi: 10.1016/s0277-9536(97)10047-8. [DOI] [PubMed] [Google Scholar]
  17. Gibson P. G., Wong B. J., Hepperle M. J., Kline P. A., Girgis-Gabardo A., Guyatt G., Dolovich J., Denburg J. A., Ramsdale E. H., Hargreave F. E. A research method to induce and examine a mild exacerbation of asthma by withdrawal of inhaled corticosteroid. Clin Exp Allergy. 1992 May;22(5):525–532. doi: 10.1111/j.1365-2222.1992.tb00161.x. [DOI] [PubMed] [Google Scholar]
  18. Hargreave F. E., Dolovich J., Newhouse M. T. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol. 1990 Jun;85(6):1098–1111. doi: 10.1016/0091-6749(90)90056-a. [DOI] [PubMed] [Google Scholar]
  19. Hartert T. V., Windom H. H., Peebles R. S., Jr, Freidhoff L. R., Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996 Apr;100(4):386–394. doi: 10.1016/s0002-9343(97)89513-7. [DOI] [PubMed] [Google Scholar]
  20. Heard A. R., Richards I. J., Alpers J. H., Pilotto L. S., Smith B. J., Black J. A. Randomised controlled trial of general practice based asthma clinics. Med J Aust. 1999 Jul 19;171(2):68–71. doi: 10.5694/j.1326-5377.1999.tb123522.x. [DOI] [PubMed] [Google Scholar]
  21. Ignacio-Garcia J. M., Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med. 1995 Feb;151(2 Pt 1):353–359. doi: 10.1164/ajrccm.151.2.7842191. [DOI] [PubMed] [Google Scholar]
  22. Jones K. P., Mullee M. A., Middleton M., Chapman E., Holgate S. T. Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee. Thorax. 1995 Aug;50(8):851–857. doi: 10.1136/thx.50.8.851. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Knoell D. L., Pierson J. F., Marsh C. B., Allen J. N., Pathak D. S. Measurement of outcomes in adults receiving pharmaceutical care in a comprehensive asthma outpatient clinic. Pharmacotherapy. 1998 Nov-Dec;18(6):1365–1374. [PubMed] [Google Scholar]
  24. Kotses H., Bernstein I. L., Bernstein D. I., Reynolds R. V., Korbee L., Wigal J. K., Ganson E., Stout C., Creer T. L. A self-management program for adult asthma. Part I: Development and evaluation. J Allergy Clin Immunol. 1995 Feb;95(2):529–540. doi: 10.1016/s0091-6749(95)70315-2. [DOI] [PubMed] [Google Scholar]
  25. Kotses H., Stout C., McConnaughy K., Winder J. A., Creer T. L. Evaluation of individualized asthma self-management programs. J Asthma. 1996;33(2):113–118. doi: 10.3109/02770909609054539. [DOI] [PubMed] [Google Scholar]
  26. Lahdensuo A., Haahtela T., Herrala J., Kava T., Kiviranta K., Kuusisto P., Perämäki E., Poussa T., Saarelainen S., Svahn T. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ. 1996 Mar 23;312(7033):748–752. doi: 10.1136/bmj.312.7033.748. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Levy M. L., Robb M., Allen J., Doherty C., Bland J. M., Winter R. J. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med. 2000 Sep;94(9):900–908. doi: 10.1053/rmed.2000.0861. [DOI] [PubMed] [Google Scholar]
  28. Lewis C. E., Rachelefsky G., Lewis M. A., de la Sota A., Kaplan M. A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics. 1984 Oct;74(4):478–486. [PubMed] [Google Scholar]
  29. Marks G. B., Burney P. G., Premaratne U. N., Simpson J., Webb J. Asthma in Greenwich, UK: impact of the disease and current management practices. Eur Respir J. 1997 Jun;10(6):1224–1229. doi: 10.1183/09031936.97.10061224. [DOI] [PubMed] [Google Scholar]
  30. Matheson M., Wicking J., Raven J., Woods R., Thien F., Abramson M., Walters E. H. Asthma management: how effective is it in the community? Intern Med J. 2002 Sep-Oct;32(9-10):451–456. doi: 10.1046/j.1445-5994.2002.00273.x. [DOI] [PubMed] [Google Scholar]
  31. Moudgil H., Marshall T., Honeybourne D. Asthma education and quality of life in the community: a randomised controlled study to evaluate the impact on white European and Indian subcontinent ethnic groups from socioeconomically deprived areas in Birmingham, UK. Thorax. 2000 Mar;55(3):177–183. doi: 10.1136/thorax.55.3.177. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Mulloy E., Donaghy D., Quigley C., McNicholas W. T. A one-year prospective audit of an asthma education programme in an out-patient setting. Ir Med J. 1996 Nov-Dec;89(6):226–228. [PubMed] [Google Scholar]
  33. Oommen Abraham, Lambert Paul C., Grigg Jonathan. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003 Nov 1;362(9394):1433–1438. doi: 10.1016/S0140-6736(03)14685-5. [DOI] [PubMed] [Google Scholar]
  34. Perneger Thomas V., Sudre Philippe, Muntner Paul, Uldry Christophe, Courteheuse Christiane, Naef Anne-Françoise, Jacquemet Stéphane, Nicod Laurent, Rochat Thierry, Assal Jean-Philippe. Effect of patient education on self-management skills and health status in patients with asthma: a randomized trial. Am J Med. 2002 Jul;113(1):7–14. doi: 10.1016/s0002-9343(02)01136-1. [DOI] [PubMed] [Google Scholar]
  35. Pizzichini M. M., Pizzichini E., Efthimiadis A., Chauhan A. J., Johnston S. L., Hussack P., Mahony J., Dolovich J., Hargreave F. E. Asthma and natural colds. Inflammatory indices in induced sputum: a feasibility study. Am J Respir Crit Care Med. 1998 Oct;158(4):1178–1184. doi: 10.1164/ajrccm.158.4.9712082. [DOI] [PubMed] [Google Scholar]
  36. Rowe B. H., Keller J. L., Oxman A. D. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. 1992 Jul;10(4):301–310. doi: 10.1016/0735-6757(92)90007-k. [DOI] [PubMed] [Google Scholar]
  37. Schermer Tjard R., Thoonen Bart P., van den Boom Guido, Akkermans Reinier P., Grol Richard P., Folgering Hans T., van Weel Chris, van Schayck Constant P. Randomized controlled economic evaluation of asthma self-management in primary health care. Am J Respir Crit Care Med. 2002 Oct 15;166(8):1062–1072. doi: 10.1164/rccm.2105116. [DOI] [PubMed] [Google Scholar]
  38. Snyder S. E., Winder J. A., Creer T. J. Development and evaluation of an adult asthma self-management program: Wheezers Anonymous. J Asthma. 1987;24(3):153–158. doi: 10.3109/02770908709070931. [DOI] [PubMed] [Google Scholar]
  39. Sommaruga M., Spanevello A., Migliori G. B., Neri M., Callegari S., Majani G. The effects of a cognitive behavioural intervention in asthmatic patients. Monaldi Arch Chest Dis. 1995 Oct;50(5):398–402. [PubMed] [Google Scholar]
  40. Turner M. O., Hussack P., Sears M. R., Dolovich J., Hargreave F. E. Exacerbations of asthma without sputum eosinophilia. Thorax. 1995 Oct;50(10):1057–1061. doi: 10.1136/thx.50.10.1057. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Turner M. O., Noertjojo K., Vedal S., Bai T., Crump S., Fitzgerald J. M. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998 Jun;157(6 Pt 1):1804–1809. doi: 10.1164/ajrccm.157.6.9708092. [DOI] [PubMed] [Google Scholar]
  42. Woolcock A., Rubinfeld A. R., Seale J. P., Landau L. L., Antic R., Mitchell C., Rea H. H., Zimmerman P. Thoracic society of Australia and New Zealand. Asthma management plan, 1989. Med J Aust. 1989 Dec 4;151(11-12):650–653. [PubMed] [Google Scholar]
  43. Yoon R., McKenzie D. K., Bauman A., Miles D. A. Controlled trial evaluation of an asthma education programme for adults. Thorax. 1993 Nov;48(11):1110–1116. doi: 10.1136/thx.48.11.1110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Zeiger R. S., Heller S., Mellon M. H., Wald J., Falkoff R., Schatz M. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991 Jun;87(6):1160–1168. doi: 10.1016/0091-6749(91)92162-t. [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

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thorax_59_2_94__5.pdf (18.5KB, pdf)

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