ASTHMA ACTION PLAN

Presented by:RuthAnn Begay Goradia,

MSN, MPH, RN, AE-C

EPR-3 Clinical Practice Guidelines

1. Use inhaled corticosteroids to control asthma.2. Use written asthma action plans to guide

patient self-management3. Assess asthma severity 4. Assess and monitor asthma control 5. Schedule follow-up visits6. Control environmental exposures

Asthma patients who spend as little as 30 minutes with a health care professional to develop a personalized self-management plan show improved adherence to medications and better disease control.

Why Use Asthma Action Plans?

Study findings were published in the April 2009 issue of “The Journal of Allergy and Clinical Immunology.”

Co-authors of the study are Kelly Wong McGrath, BA; Jack K. Covington, BA; Su-Chun Cheng, DSc; and Homer A. Boushey, MD

• Recommended in EPR-3 as part of an Educational Program

• Studies have found:– Reduced urgent care visits, emergency department

visits, hospitalizations, work absences, and nocturnal asthma

– Improved control

Why Use Asthma Action Plans?

I. Reducing impairmentII. Reducing risk

Goal Of Therapy

Goal of Therapy: To Control Asthma

• Prevent symptoms• Infrequent use of reliever(s)• (Near) normal pulmonary function• Normal activity levels• Patients’ and families’ satisfaction with care

Goal Of Therapy

EPR 3 p. 277

Reducing Impairment

• Prevent recurrent exacerbations; minimize ED visits and hospitalizations

• Prevent progressive lung function or loss of lung growth

• Optimal pharmacotherapy with minimal or no adverse effects

Goal Of Therapy

EPR 3 p. 277

Reducing Risk

Four components of asthma management

Asthma Management

Measures of assessment

and monitoring

Education for a partnership

in asthma care

Control of environmental

conditions and comorbid

conditions

Pharmacologic therapy

A plan, or roadmap to implement the goals of asthma therapy that uses all four components of asthma management.

Asthma Action Plans

What Is An Asthma Action Plan?

EPR 3 p. 94

• Created in partnership with the patient for guided self-management

• Addresses daily management to maintain control

• Identifies what to do for exacerbations by recognizing and handling worsening asthma

A Written Plan

What Is An Asthma Action Plan?

• Empowers the user to manage their asthma

• Following a daily management plan should lead to control of asthma

• Used as an education and communication tool between the provider & patient, other caregivers (e.g., schools, childcare)

The Purpose

What Is An Asthma Action Plan?

Asthma Action Plans are patient-

centered

Meets patient’s

goals

Consider level of

control and severity

Understandable

Culturally appropriate

Affordable

Doable

What are the goals of the patient?

Created In Partnership With The Patient

Patient’s Goals

Play basketball

Not use inhaler at

work

Afford medications

Sleep through the

night

• What sports would you play if your asthma was in good control?

• What’s your biggest concern about using your inhaler?

• When do you feel the most asthma symptoms?

Motivational Interviewing

What’s important to the patient?

• Soccer• Working out

What would life look like if your asthma

was well controlled?

• Breathe better while exercising

• Take less medicine

Action steps to get there.

• Pre-medicate• Quit smoking

Level of control and severity

Created In Partnership With The Patient

What IS good control? What does good control feel like?

Recognize yellow-zone symptoms and act to avoid worsening of symptoms.

Understand the severity of red-zone symptoms and seek medical attention quickly.

Is it understandable and culturally appropriate?

Created In Partnership With The Patient

FORMAT• Can range from simple design to more

detailed design • Age appropriate, child/adult versions• Increased font size for elderly• Includes visual elements that are

LANGUAGE• Use language that is understandable to the

patient (i.e., Advair, “flat, purple inhaler”; Proventil, “yellow pump”)

• Use culturally appropriate imagery

SYMPTOM-BASED VS. PFM-BASED• Symptoms only• Symptoms + peak flow

ACCESSIBILITY• Consider who should have a copy, such as a

parents, caregivers, teachers, coaches, and other childcare providers

• Available in print format, triplicate form, web-based, or mobile-friendly

Tailor the plan to the patient

Work with the patient’s health insurance plan

• Health insurance plan may change over time• Consider options to lower costs

• Refer to formularies; may need to find the best medications at the lowest price/co-pay

• 90-day mail order• Prescription assistance programs

Created in Partnership with the Patient

Is it affordable?

Created In Partnership With The Patient

• Taking medications twice a day is doable, right?

Standard Question

• What are your work hours?• Where are you at 7 am and 7 pm? • What are you doing at 7 am and 7 pm?

Better Question

Is it doable/convenient/manageable?

Link To Understanding Asthma

Maintain Good Control

Understand the nature of

asthma

Inflammatory Chronic

Connect symptoms

with variability

Associate symptoms

with triggers

Recognize symptoms and

follow the plan

Asthma Action Plans

www.lung.org/asthma• Available in English & Spanish• Large or regular font

• NHLBI Asthma Action Plan:• http

://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/action-plans.htm

Asthma Action Plans

Asthma Action Plans

Asthma Action Plans

• CDC:• http://www.cdc.gov/asthma/tools_for_control.htm

• Print and Fill forms• Electronic forms• Computer-based, interactive plan

• New Mexico Asthma Action Plan for Schools• http://nmhealth.org/eheb/asthma_schoolhealth.shtml

Other Asthma Action Plans:

• Name, important contacts• Healthcare provider signature• Severity classification• Triggers• Premedication and exercise instructions

Asthma Zone – green means go! • Signs you are doing well• No symptoms• Peak flow meter reading of more than 80% of

personal best or number• Control medications – name, dosage, when to

take, descriptions • May include allergy medications

Asthma Zone Yellow: Caution! • Worsening symptoms• Peak Flow Meter reading between

50% - 80% of personal best, or number range• Quick-relief medications – name, dosage, when to

take

Asthma Zone Yellow: Caution! • What to do when symptoms and

peak flow meter reading improves • What to do if symptoms and peak flow meter

reading to do not improve

Asthma Zone Red: STOP!• Worsening symptoms• Peak Flow Meter less than 50% of personal best,

or number range• Quick-relief medications – name, dosage, when to

take

Asthma Zone Red: STOP!• What to do if symptoms and peak flow meter

reading does not improve in 15 minutes after using rescue medications

• When to call an ambulance immediately

• Meds, relaxation, breathing techniques for COPD

• Antihistamines, nasal steroids, hypertonic saline irrigation for rhinosinusitis

• Meds, dietary changes, elevation of bed for GERD

• Speech path, relaxation techniques for VCD

Include Treatment for Comorbid Conditions

If patients has other conditions, it’s also important to include. . .

Practical Tips for Medications: A

Emphasize difference between controllers and relievers at each encounter.

Success means control, especially of inflammation.

Relief also must be adequate.

Practical Tips for Medications: B

Repeat demonstration/counter-

demonstration of inhaler and peak flow

technique at each visit.

Keep regimen simple, affordable, doable.

• Patient and family• All caregivers – at school, after school, coaches• All professional caregivers – healthcare provider,

school nurse, etc.• Copies of Asthma Action Plan for all

Coordinate All the Players on the Team

Assess

Follow-Up

Reassess

Revise

Revising Asthma Action Plans

• Control – adjust until optimal

• Ongoing assessment, communication

• Trial and error, always subject to revision

• Frequency based on severity and acuity, how new

Follow-Up

Frequency of follow-upInitial, intermittent, final

Document in patient recordPaper Electronic charting

Type of follow-upPhone Face-to-face

Daily Self-Management Activities

Asthma diary

Symptom monitoring

To peak flow or not to peak flow?

Environmental control

• Use of controllers• Use of relievers• Daily symptoms• Peak flows • Nocturnal episodes• Triggers• Effects on activities

What Is an Asthma Diary?

A log to help a patient monitor their asthma

From: Seattle Children’s Hospital, http://www.seattlechildrens.org/kids-health/page.aspx?id=62128

Self-Monitoring: Asthma Diary

Controllers: AM PM

Puffs Albuterol last 24 hours:

Activities limited? Yes No

Nocturnal symptoms? Yes No

Triggers:

Peak flows:

Zone: Green Yellow Red

Notes:

Available in print, web-based, or mobile-friendly

• PEF provides a simple, quantitative and reproducible measure of the existence and severity of airflow obstruction.

• PEF can be measured with inexpensive, portable peak-flow meters.

• PEF is effort- and technique-dependent; patients need frequent instruction, demonstration and review of technique.

Peak Expiratory Flow Monitoring (PEF)

Peak Flow Monitoring

When To Use Peak-Flow Monitoring

EPR 3 p. 59

Discretion of patient and

provider

Evaluate responses to

treatment

Occupational or environmental

exposuresPoor perceivers

“When self-management is the chosen method for maintaining asthma control, peak-flow-based self-management is equivalent to symptom-based self-management as long as either method also includes a written asthma action plan with instructions on how to recognize and handle worsening asthma, including self-adjustment of medications.”

NAEPP-3 on Peak-Flow Monitoring

EPR 3 p. 60-61

Peak Flow vs. Signs & Symptoms

Peak Flow vs. Signs & Symptoms

Questions and Answers

Clicker Time!!!

Which of the following statements BEST describes the concept of an “active partnership in asthma care” between the health care provider and the person with asthma and/or the family?

A. The person with asthma and/or the family is fully compliant, carrying out all aspects of the plan of care on a regular basis.

B. All asthma management decisions must be approved by both the health care provider and the person with asthma and/or the family.

C. The health care provider designs an asthma care plan that is acceptable to and realistic for the person with asthma and/or the family

Best Answer:

C. The health care provider designs an asthma care plan that is acceptable to and realistic for the person with asthma and/or the family

True or False: An Asthma Action Plan should be written according to the judgment and experience of the provider and then carefully explained to the patient.

A. TrueB. False

Best Answer:

B. False

John’s peak flow reading in the office is between 50-80% of his personal best. This reading indicates:

A. An expected level for individuals with asthma.B. A need for observation but no increase in the level of

medication.C. A need for observation and an increase in the level of

medication.D. A severe asthma episode.

Best Answer:

C. A need for observation and an increase in the level of medication.

Which of the following signs/symptoms indicates a deteriorating or worsening asthma status that requires immediate medical intervention?

A. No improvement in asthma symptoms within 5 minutes of use of a quick relief inhaler.

B. Difficulty walking and talking due to shortness of breath.C. Inspiratory wheezing and persistent cough.D. A and B.E. B and C.

Best Answer:

D. A and B.– A. No improvement in asthma symptoms within 5

minutes of use of a quick relief inhaler.– B. Difficulty walking and talking due to shortness of

breath.

Peak flow monitoring can be used for all of the following EXCEPT:

A. Short term monitoring.B. Managing exacerbations.C. Daily long-term monitoring.D. Diagnosing asthma.

Best Answer:

D. Diagnosing asthma.

Asthma Action Plans should be revised:

A. Whenever therapy is stepped up or down on a long-term basis.

B. When a patient who has adhered well to the plan has an exacerbation requiring oral steroids.

C. When a patient’s PEF/Personal Best is re-established.D. When a patient has not needed to use a short-acting

beta agonist reliever for 2 consecutive months.E. Both A and C.

Best Answer:

E. Both A and C.– A. Whenever therapy is stepped up or down on a

long-term basis.– C. When a patient’s PEF/Personal Best is re-

established.

A person with asthma has a predicted peak flow reading of 400L/min. Today the peak flow reading is 450L/min. Based on the predicted reading, what is the BEST interpretation of today’s peak flow?

A. Red zone.B. Yellow zone.C. Green zone.D. Personal best zone.

Best Answer:

C. Green zone

Case Study: Pedro, 23 y.o. male1. Break into groups and discuss Pedro case

study 2. Think about the Asthma Action Plan for Pedro,

and discuss: Controllers Relievers Environmental changes Monitoring Other

Case Study

• RuthAnn Goradia, MSN, MPH, RN, AE-CAPS Chronic Health Needs Resource Nurse

• Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma – Pages 115-121– Pages 124-125– Pages 277-288

Acknowledgements

We will breathe easier when the air in everyAmerican community is clean and healthy.

 We will breathe easier when people are free from the addictivegrip of cigarettes and the debilitating effects of lung disease. 

We will breathe easier when the air in our public spaces andworkplaces is clear of secondhand smoke.

We will breathe easier when children no longerbattle airborne poisons or fear an asthma attack. 

Until then, we are fighting for air.