What should be included in an evidence-based asthma action plan?

Evidence-Based Asthma Action Plan Components

Every patient with asthma should have a written asthma action plan that includes instructions for both daily management and actions to manage worsening symptoms, as this is crucial for reducing morbidity and mortality. 1

Core Components of an Effective Asthma Action Plan

1. Zone-Based Structure

• Green Zone (Well-Controlled)

  • Peak flow: 80-100% of personal best
  • No symptoms, normal activities
  • Action: Continue taking controller medications as prescribed 1

• Yellow Zone (Caution/Worsening)

  • Peak flow: 60-80% of personal best
  • Presence of symptoms (cough, wheeze, chest tightness)
  • Action: Increase inhaled corticosteroids and add short-acting beta-agonist (SABA) treatment 1

• Red Zone (Medical Alert)

  • Peak flow: below 60% of personal best
  • Severe symptoms
  • Action: Take prescribed oral corticosteroids and seek emergency care 1

2. Medication Instructions

• Clear distinction between:

  • "Reliever" medications (short-acting bronchodilators)
  • "Preventer" medications (anti-inflammatory treatments) 1

• Detailed information on:

  • Daily controller medications with specific doses
  • Step-up therapy instructions during exacerbations
  • Clear dosing instructions for all medications 2

3. Exacerbation Management

• Specific criteria for when to:
  • Start oral corticosteroids (prednisolone 30-40 mg daily until lung function returns to previous best) 2
  • Contact healthcare provider
  • Seek emergency care
  • Warning signs: day-by-day worsening of symptoms and peak flow to below 60% of patient's best; sleep disturbance; diminishing response to inhaled bronchodilators 2

4. Environmental Control Strategies

• Allergen avoidance instructions for relevant triggers:

  • House dust mite
  • Domestic pets
  • Pollens 2

• Smoking cessation guidance:

  • Current smoking status should be documented
  • Advice to stop smoking
  • Strategies tailored to individual circumstances
  • Avoidance of passive smoking 2

Implementation Considerations

1. Readability and Format

• Written at a 5th grade reading level or below
• Simple language and visual aids to enhance understanding 1
• Tailored to the individual patient's specific needs and triggers 2

2. Education and Follow-up

• Plan should be reviewed and updated at each visit
• Patients should demonstrate understanding of when and how to use the plan 1
• Planned asthma-care visits are essential for adequate teaching and control:
  • Patients with intermittent asthma: evaluated at least once yearly
  • Those on controller agents: seen at least twice yearly, and as often as every four months 2

3. Special Populations

• School-aged children:
  • Plan should be provided to school nurse or designee
  • Include plans to ensure reliable, prompt access to medications at school 2
  • Adolescents should be directly involved in establishing goals for therapy 2

Evidence of Effectiveness

Written asthma action plans have been shown to:

• Reduce emergency department visits and hospitalizations 1
• Improve asthma control and quality of life 1
• Enhance patient self-management skills 2

Common Pitfalls to Avoid

1. Overreliance on symptoms alone: Include objective measures like peak flow monitoring, particularly for patients with moderate or severe persistent asthma who may be "poor perceivers" of their symptoms 2

2. Inadequate education: Ensure patients understand how to use their action plan and can demonstrate proper inhaler technique 2

3. Outdated recommendations: No longer recommend doubling the dose of inhaled corticosteroids for home management of acute exacerbations 2

4. Complexity: Overly complicated plans reduce adherence; keep instructions clear and simple 1

5. Failure to update: Action plans should be reviewed and updated at each visit to reflect current best practices and the patient's changing needs 2

By implementing comprehensive, personalized asthma action plans that follow these evidence-based guidelines, healthcare providers can significantly improve asthma control and reduce morbidity and mortality in patients with asthma.