ABIM • PCCULesson 6, Volume 15—Self-Management of AsthmaBy Susan Janson, DNSc, RN, ANP Objectives
Key wordsadherence; asthma; communication; education; peak flow monitoring; self-management AbbreviationsCI = confidence interval; OR = odds ratio Background and RationaleAsthma affects approximately 15% of the US population and can be a troublesome disease. Prevalence, morbidity, and mortality associated with asthma have been rising over the last 15 years.1 Office visits for asthma more than doubled from 1975 to 19951 and much of asthma is seen in primary care practice. Although many patients have mild disease, any person with asthma can develop a severe exacerbation. The complexity of managing asthma at home and at work or school can be overwhelming for many patients and their families and is generally underestimated by health-care providers. Treatment, education, and self-management training often must be individualized for each patient, and this can be a time-consuming process for clinicians. Asthma management can be a difficult and time-consuming process for patients as well. People with asthma are expected to carry out complex treatment regimens, monitor their clinical status at home, detect and self-treat exacerbations, take medications correctly and at appropriate intervals, institute home environmental control strategies, and communicate effectively with clinicians providing care. It is unrealistic to think that patients can do all of this without specific information, guidance, and training in the necessary skills. Most clinicians do not disagree, but finding the time and the best method of teaching this knowledge is a challenge in clinical settings. Yet, asthma is a disease in which the involvement of patients in their own care produces positive outcomes. The benefits of educating patients about asthma have been shown in both adults2-15 and children.16-26 These benefits include a reduction in asthma-related costs.4,27-28 Studies of asthma education and self-management training are so consistent in showing benefit that both are recommended in the 1997 revision of the National Guidelines for the Diagnosis and Management of Asthma.29 Asthma Self-Management EducationAsthma self-management may be defined as the direct involvement of patients in strategies to control their disease. Most clinicians have encountered patients with asthma who report harrowing episodes of symptoms about which they did nothing but wait. The reasons for this often relate to the patient's inability to determine what to do and failure to understand that escalating symptoms may be life-threatening. Asthma education is recommended for all persons with asthma. Some knowledge and specific skills are essential before a patient is able to learn to self-manage a chronic condition such as asthma. The asthma guidelines specify the essential information that all people with asthma need to know. Patients and their families need to understand the basic facts about asthma and what changes in the airway lead to acute attacks and chronic symptoms. A brief verbal description of asthma by the clinician, emphasizing the role of airway inflammation and intermittent bronchoconstriction in causing chronic problems, is an important starting place. The intended role of each medication prescribed should be explained, emphasizing the two basic components of pharmacotherapy: anti-inflammatory medicine to control airway inflammation and rescue bronchodilator to treat intermittent bronchoconstriction. The medication plan makes more sense to patients if they understand that airway inflammation is a chronic condition that requires chronic anti-inflammatory treatment and that quick-relief drugs are for short-term relief of bronchoconstriction. Medications that are added to achieve optimal asthma control, such as long-acting inhaled b-agonists and theophylline, must be explained carefully and reviewed often. The role of chronic exposure to environmental allergens and irritants should be explained as factors that make asthma worse and more difficult to control. If patients understand the impact of concentrated allergen exposure, they may be more willing to comply with recommended control strategies. All patients need to know how to detect and respond promptly to an episode of worsening asthma. They must be cautioned not to delay treatment but to seek prompt relief. A recent study of 95 adults with asthma reported that 86% of these adults delayed seeking treatment for acute asthma for reasons that included uncertainty about what to do, fear of steroids and emergency departments, the need to manage alone, minimization of symptoms, family disruption, and economic barriers to health-care resources.30 An additional 12% of these 95 patients had experienced a near-fatal asthma attack and no longer delayed treatment. Key essential information should be given to patients and families in brief and specific educational messages:
Self-management education has recently been examined in a meta-analysis to determine the strength of evidence behind this recommendation and to determine whether health outcomes are influenced by education and self-management interventions.31 Twenty-five trials were included and in 22 studies, self-management education was compared with usual care. Self-management education reduced hospitalizations (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.38–0.88); emergency department visits (OR, 0.71; 95% CI, 0.57–0.90); unscheduled urgent-care visits to doctors (OR, 0.57; 95% CI, 0.40–0.82); days off work or school (OR, 0.55; 95% CI, 0.38–0.79); and nocturnal asthma (OR, 0.55, 95% CI; 0.39–0.72). Self-management education that included providing patients with a written action plan showed greater reduction in hospitalizations than those who did not (OR, 0.35; 95% CI, 0.18–0.68). Pulmonary function did not change significantly as a result of self-management but those who adjusted their medication at home according to a written plan had better lung function than those whose medication was adjusted by a doctor. There is some evidence that self-management skills develop slowly over time,15,32,33 and the duration of improvement in symptoms and health care use has been variable. Although both group and individual educational formats for teaching asthma skills have been tested, the most effective programs are those that focus on teaching self-management skills as well as providing information about asthma.31 Teaching Asthma Self-ManagementSelf-management education programs that use a combination of methods, adapting them to the developmental needs of patients in different age groups, are among the options available. Videos and interactive programs are effective in teaching parents to assess and respond to signs of wheezing in very young children.34 Even young children can be taught illness self-management and can make important daily decisions to manage their illness.26 Well-designed, validated, and evaluated programs for school-age children are published and available for dissemination and use in children and school settings.18,25 Newsletters, learning games, and support groups designed for teenagers are being tested for effectiveness in helping adolescents assume responsibility for managing their own asthma.35 Many programs for adults have been developed using a variety of learning techniques including workbooks, problem-solving exercises, and computer-assisted instruction. Individualized educational approaches were more powerful in changing self-management behavior in adults36,37 and in recently hospitalized children.38 It should be noted that these individualized approaches are distinct from simply teaching one-on-one; at least one study, conducted in a closed HMO setting, showed no difference in the effects of an individually taught education program compared with small-group education for adults.15 Important limitations of nearly all asthma education programs are their reliance on written materials and their dependence on the English language. One recent survey of 273 patients visiting an emergency department for an acute asthma exacerbation showed that only 27% read at the high-school level and only 33% read at the seventh- to eighth-grade level.39 Poor metered-dose inhaler technique was found to correlate with low reading levels. Clearly, literacy is an important factor in a patient's ability to comprehend and apply information and skills required for asthma self-management, and can become a significant barrier to achieving asthma control. Self-Monitoring to Enhance Self-ManagementSelf-monitoring by the patient with asthma is useful to evaluate clinical asthma control over time and is essential to detect exacerbations and institute early rescue treatment. To accomplish this, people with asthma and their families can be taught to watch for the warning signs of worsening asthma: waking at night with asthma symptoms, increased need for rescue inhaled bronchodilator medication, shortened duration of medication, escalating symptoms of dyspnea, wheezing, chest tightness, and in children, progressive coughing. Patients can also learn to assess the changing impact on their daily activities by evaluating what they are able to do or are prevented from doing because of symptoms. Peak flow monitoring is recommended for those whose asthma is not yet under control, those who need help in identifying environmental or occupational triggers, and for evaluating response to new or changed therapy.29 For peak flow monitoring to be reliable, patients must be trained in the correct exhalation technique and review it often with the clinician. Accurate peak flow measurements depend on maximal expiratory effort after a deep and full inhalation. Patients who are relying on peak flow measurements to monitor their asthma should be asked to demonstrate the peak flow maneuver at each clinic/office visit, preferably on their own peak flow meter. Many asthma self-management programs include peak flow and/or symptom monitoring and suggest that patients be taught to adjust treatment at home using a written asthma action (self-management) plan. Monitoring peak flow or signs and symptoms can be integrated into self-management plans as a guide to the need to adjust therapy. There are eight published studies, seven of them randomized clinical trials, of the efficacy of such monitoring.40-48 Four studies compared peak flow monitoring with usual care, defined as periodic physician evaluation.40-43 While two studies of patients with relatively mild asthma found no effects from peak flow monitoring,40,41 the other two found significant decreases in emergency urgent-care visits and lost work days,42,43 and decreased need for steroids and increased quality of life.43 Five studies (three randomized clinical trials) compared peak flow–directed action plans with symptom-directed action plans as a basis for guiding self-management.44-48 All five studies showed decreased asthma morbidity in all groups and three44,46,48 showed no difference between the two types of monitoring. One study showed emergency-room visits to decrease markedly in the peak flow monitoring group47 and one showed significant improvement in lung function, symptoms, and quality of life.48 The level of therapy is an important confounder of these results. In two of the recent studies,46,48 when medical therapy was optimized before patients were randomized to educational/monitoring treatment groups, short-term compliance and knowledge of asthma improved and morbidity decreased in all groups, but there were no differences between groups in outcomes achieved. To detect and self-treat asthma exacerbations, patients need a detailed, written action plan with a written set of specific actions to follow when asthma worsens. The steps in the plan can be directed by changes in peak flow or by signs and symptoms. For children with asthma, an asthma action plan should also be sent to the school with specific instructions about whom to call and what to do for an acute asthma exacerbation. Peak flow–directed action plans are based on the patient's predicted or best peak flow and rely on the patient's ability to perform peak flow correctly and match the numbers to the green, yellow, or red zone where specific instructions are written about what to do. Action plans can also be based on symptoms or observable signs, such as waking at night with asthma symptoms, using rescue bronchodilator more frequently with decreased duration of effect, and decreased activity tolerance. Symptom-based action plans are useful and effective in those patients who can perceive subtle increases in dyspnea, wheezing, chest tightness, and cough, and are preferred by some patients. However, some patients are not able to detect increasing airflow obstruction by symptoms alone. Currently, there is no readily available, reliable method for identifying patients who are poor perceivers of symptoms until a severe exacerbation occurs. Therefore, peak flow–directed self-management is recommended in any patient who has suffered a near-fatal attack or severe exacerbation requiring hospitalization or has moderate or severe persistent asthma so that exacerbations can be detected and treated promptly. The National Asthma Education Program published an easy-to-use asthma action plan that contains prompts to remind both the clinician and the patient which medications to use at each step.29 A pocket version is provided in Figure 1.
Action plans provide simple guided steps to follow for initial self-treatment of asthma flares and cues for seeking acute medical treatment. Periodic review of the plan's appropriateness is essential and success is more likely if the patient can verbally describe how he or she will use it. Asthma self-management, where patients are involved directly in their care, appears to improve asthma control and clinical outcomes. This positive treatment effect is most apparent in self-management that includes written action plans, self-monitoring, and regular review by a knowledgeable clinician. The Role of the Clinician in Asthma Self-ManagementThe quality of the doctor-patient relationship may be one of the strongest influences on patient adherence to a treatment plan. The specific means by which influence is exerted is not clear, but there are new findings about the impact clinicians have in their approach to patient self-management education. These findings suggest that greater emphasis should be placed on teaching patients to manage and control asthma. Specific techniques of effective communication were identified and then incorporated into an educational program for general-practice pediatricians treating children with asthma.49 These specific communication strategies designed to build trust and a partnership between the clinician and the patient include the following:
In a randomized study49 of teaching these communication techniques to physicians, the investigators found that physicians in the intervention group were more likely to address patients' fears about medicines, provide a sequence of educational messages, and write down how to adjust the medicines when symptoms change, but spent no more time with their patients than did the control group of physicians. Parents of the children treated by intervention-group physicians were significantly more likely to report that the physician was reassuring, stated the child should be fully active, and gave information to alleviate concerns. Additionally, these parents were also more likely to report that they knew how to make management decisions at home. Effective communication is clearly necessary to teach patients asthma self-management but the best method of preparing clinicians to do this is not clear. Future research is needed to give direction to the development of an effective patient-clinician alliance for asthma control. References
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