What is the best approach to counsel a pediatric patient for an asthma action plan?

Counseling a Pediatric Patient for an Asthma Action Plan

Provide every child with asthma a written asthma action plan that uses simple language (5th grade reading level or below), is symptom-based rather than peak-flow based, and includes specific medication doses with clear instructions for three zones: green (doing well), yellow (getting worse), and red (medical emergency). 1, 2

Initial Counseling Session Structure

Start with Core Asthma Education

Explain asthma in simple terms: Tell the child and parents that asthma is a chronic lung disease where the airways become very sensitive, inflamed, and narrow, making breathing difficult. 1

Address their primary concerns first by asking: 1

• "What worries you most about your child's asthma?"
• "What do you want your child to be able to do that they can't do now because of asthma?"
• "What do you expect from treatment?"

This approach builds trust and ensures the education addresses their actual fears and goals, which is critical for adherence. 3

Teach the Two Types of Medications

Clearly distinguish between "preventers" and "relievers": 1

• Controller medications (preventers): Must be given every day, even when the child feels well, to prevent inflammation and symptoms. Inhaled corticosteroids are the most effective long-term control medication. 1, 4
• Quick-relief medications (relievers): Used only when symptoms occur for immediate relief of wheezing, coughing, or difficulty breathing. 1

Common pitfall to avoid: Many families stop controller medications when the child feels better, leading to loss of control and exacerbations. Emphasize that daily controller medication prevents attacks better than waiting to step up therapy during worsening symptoms. 2

The Written Action Plan Components

Green Zone (Child is Well)

Daily prevention instructions: 1

• List the specific long-term control medicines with exact doses and frequency (e.g., "Give fluticasone 2 puffs twice daily, every morning and evening")
• Include environmental control measures specific to the child's triggers (e.g., "Avoid tobacco smoke; ask people to smoke outside")
• State activity goals the child should be able to do

Yellow Zone (Getting Worse - Warning Signs)

Teach recognition of early warning signs: 1

• Increased coughing, especially at night
• Wheezing or chest tightness
• Difficulty walking, talking, eating, or playing
• Needing quick-relief medicine more than twice per week
• Waking at night due to asthma

Specific medication adjustments with doses: 1

• Increase quick-relief medication (specify exact dose and frequency)
• May add or increase inhaled corticosteroid dose
• For children with recurrent exacerbations, include instructions to start oral corticosteroids at home when symptoms reach a predetermined threshold 1

Red Zone (Medical Emergency)

Clear criteria for seeking immediate help - call 9-1-1 or go to hospital if: 1

• Breathing is so hard the child has trouble walking, talking, eating, or playing
• Wheezing, coughing, or difficulty breathing continues or worsens even after giving yellow zone medicines
• Child is drowsy or less alert than normal
• Lips or fingernails turn blue

Essential Skills Training

Demonstrate Proper Inhaler Technique

Show the technique, then have the child/parent demonstrate it back to you. 1, 4 This is critical because inadequate inhaler technique is a common cause of poor control and must be verified at every visit. 5, 4

For young children: Teach proper use of valved holding chambers or spacers with the inhaler. 1

Self-Monitoring Skills

Teach symptom-based monitoring rather than peak flow monitoring - symptom-based action plans are superior to peak-flow based plans for preventing exacerbations in children. 2

Instruct families to monitor: 1

• Frequency of daytime symptoms
• Nighttime awakenings
• Activity limitations
• How often quick-relief medicine is needed

Environmental Trigger Control

Identify and teach avoidance of specific triggers: 1, 6

• Tobacco smoke exposure (most critical modifiable factor)
• Indoor allergens if sensitized (dust mites, mold, cockroach, pet dander)
• Outdoor pollutants and irritants

Emphasize that environmental control can reduce medication requirements and is particularly important for children with frequent exacerbations. 6 Single interventions rarely work; multiple approaches to limit exposure are needed. 6

Adherence Strategies

Address Common Barriers

Financial barriers: Ensure families can afford medications and have filled prescriptions before leaving. 7

Misconceptions and health beliefs: Directly address fears about medication side effects, particularly growth concerns with inhaled corticosteroids. 7

Cultural influences: Use communication skills appropriate for multicultural populations and provide materials in the family's primary language. 1

Promote Adherence Through Partnership

Choose treatments that address what matters to the patient/family and remind them that adherence helps achieve their goals. 1

Provide easy access: Ensure families know how to reach you by phone and can get prompt attention during exacerbations. 7

Follow-Up Plan

Schedule specific follow-up: 4

• First visit in 2-4 weeks after starting therapy
• Every 1-6 months when control is achieved
• Every 3 months when stepping down therapy

At each follow-up visit, review: 1, 4

• Success of the treatment plan in achieving control
• Any difficulties adhering to the written action plan
• Inhaler technique (verify again)
• Environmental exposures
• Need to adjust medications based on current control level

Tell families what will be discussed at the next visit to set expectations and maintain engagement. 3

Key Educational Strategies

Use multiple teaching methods to accommodate different learning styles: individual instruction, written materials at 5th grade reading level or below, demonstration, and return demonstration. 1

Involve the entire healthcare team - nurses, pharmacists, and respiratory therapists should reinforce the same messages. 1, 4

Evidence strongly supports that written action plans coupled with prescriptions significantly improve adherence to inhaled and oral corticosteroids, increase asthma control, and reduce acute-care visits. 8 The independent value of the written action plan itself, even in busy emergency settings without extensive self-management education programs, has been proven effective. 8