Asthma Education and Action Plans

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Asthma Education and Action Plans

• LCDR L. H. Potter
• MC, FS, USN
• Pediatrics NH Jacksonville

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Asthma Education

• FOCUS ON HOME ASTHMA MANAGEMENT
• Challenges
• Patient population dependent who are you
  teaching child or adult?
• Which medium/method? Video, Internet, small
  group?
• Who teaches? Provider, Nurse, RT, HN
• Resourcesvideos, computer access, dedicated
  educator?

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• Provider-patient partnerships are required for
  effective outpatient asthma management.
• Asthma self-management education improves all
  outcome measures
• ER visits and hospitalizations (new meta-analysis
  MAR 2008 Pediatrics, Coffman et al.)
• Improved ADLs and quality of life
• Perceived asthma control

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• Active and effective therapeutic relationships
• Establish dialogues that are ethnically and
  culturally sensitive!
• Identify specific patient and parental concerns!
• Jointly develop treatment goals and medical
  management!
• Encourage self-monitoring and management!
• Partnership culminates in the ACTION PLAN!

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• Emphasize self management of asthma at each and
  every visit!
• Begin at diagnosis and all follow-up appts with
  the ACTION PLAN.
• Involve all members of the pts health care team
  MD, RN, RT, Pharmacist, Educator.
• Clinic settings for education have been proven
  most effective but
• Provide an environment of care involving home,
  community and school based programs.
• Determine best instructional method with each
  patient written, video, web-based or internet,
  one on one or group instruction.

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Rx for Success!

• Develop an ACTION PLAN for every patient with
  asthma to promote self-management.
• Address controller medications (asthma and
  allergies) and rescue medications
• Allergy avoidance mechanisms
• Identify actions to manage worsening asthma
• ER indications

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Symptom-Based Asthma Action Plan vs. Peak-Flow
Based Plan in Children and Adolescents
Outcome Number of patients requiring one or more
acute care visits for asthma
Favors Symptom-Based
Favors Peak Flow-Based
Zemek RL Bhogal SK Ducharme FM. Systematic
Review of Randomized Controlled Trials Examining
Written Action Plans in Children. What Is the
Plan? Arch Pediatr Adolesc Med.
2008162(2)157-163
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Rx for success!

• Peak Flow based Action plans
• Appropriate patient adult, poor perceivers or
  extremely compliant
• Can be manipulated by technique
• No evidence of superiority
• Symptom based action plans
• Proven effective
• Excellent teaching tool especially in
  conjunction with ACT

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Rx for Success!

• Encourage adherence to the action plan!
• Patient based treatment and outcome goals
• Review treatment and goals at every visit.
• Identify any problems in understanding or
  implementing the plan.
• Ensure adequate social support.
• Tailor all plans to the needs and literacy level
  of the patient and address specific ethnic or
  cultural concerns.

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Asthma Control Test

• Tool to measure Asthma Control
• Validated down to 4 years of age
• Recommended by NHLBI
• Aids provider in eliminating under-reporting of
  symptoms
• Excellent teaching tool especially if combined
  with symptom based AAT
• Consider reviewing once spirometry performed
• www.asthmacontroltest.com

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• Compliance Techniques
• Encourage family involvement.
• Review performance of agreed upon actions at
  follow-up visit.
• Assess influences of cultural beliefs and
  practices that might affect asthma care and
  attempt to resolve conflicts.
• Provide a clinic POC for questions and concerns.

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Provider Recommendations

• Ensure provider and health care team support of
  the therapeutic partnership by
• Providing clinician education strategies.
• Ensuring clinicians have effective communication
  skills.
• Use system based approaches such as clinical
  pathways to improve asthma care.
• What are the resources?

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Current InitiativesDisease Management
Teamswww-nmcphc.med.navy.mil/prevmed/asthma
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Asthma Toolkit Contents

• Admin Policy
• CPGs
• Critical Concepts
• Healthcare Team Materials
• Patient Education
• Practice Reengineering
• Spirometry Materials
• Treatment Treatment Devices
• Archived

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Provider Resources

• NHLBI/EPR 3 2007
• Diagnosis and Management of Asthma, Executive
  Summary NHLBI
• BUMED ASTHMA TOOLKIT
• VA/DOD Guidelines updating from 2002

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Education Resources

• Allergy and Asthma Network 1-800-878-4403
• Mothers of Asthmatics
• 2751 Prosperity Ave., Suite 150
• Fairfax, VA 22030
• www.breatherville.org

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Education Resources

• American Academy of Allergy, Asthma and
  Immunology 555 East Wells St, Suite 1100,
  Milwaukee, WI 53202-3823 www.aaaai.org
• American Association for Respiratory Care 9125
  North MacArthur Boulevard, Suite 100, Irving, TX
  75063 www.aarc.org

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Education Resources

• American College of Allergy, Asthma, and
  Immunology 85 W. Algonquin Rd, Suite 500,
  Arlington, IL 60005 www.acaai.org
• American Lung Association 61 Broadway, New York,
  NY 10006 www.lungsusa.org
• Association of Asthma Educators 1215 Anthony
  Ave., Columbia, SC 29201 www. Asthmaeducators.org
  

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Education Resources

• Asthma and Allergy Foundation of America 1233
  20th St., NW, Suite 402, Washington, DC 20036
  www.aafa.org
• Centers for Disease Control and Prevention 1600
  Clifton Rd., Atlanta, GA 30333
  http//www.cdc.gov
• Food Allergy and Anaphylaxis Network 11781 Lee
  Jackson Highway, Suite 160, Fairfax, VA 22033
  http//www.foodallergy.org

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Education Resources

• National Heart, Lung, Blood Institute Health
  Information Center PO Box 30105, Bethesda, MD
  20824-0105 www.nhlbi.nih.gov
• National Jewish Medical and Research Center
  1400 Jackson Street, Denver, CO 80206
  www.njc.org
• U.S. Environmental Protection Agency PO Box
  42419, Cincinnatti, OH 45242-0419 www.airnow.gov

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Recommendations for Patient Education
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• Assessment Questions Information Skills Initial
  Visit
• Focus on
• - Expectations of visit
• - Asthma control
• - Patients goals of treatment
• - Medications
• Quality of life
• Ask relevant questions
• What worries you most about your asthma?
• What do you want to accomplish at this visit?
• What do you want to be able to do that you cant
  do
• now because of your asthma?
• What do you expect from treatment?
• What medicines have you tried?
• What other questions do you have for me today?
• Are there things in your environment that make
  your asthma worse?

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• Teach in simple language Initial Visit
• What is asthma?
• Asthma is a chronic lung disease. The airways are
  very sensitive. They become inflamed and narrow
  breathing becomes difficult.
• The definition of asthma control
• - few daytime symptoms,no nighttime awakenings
  due to asthma, able to engage in normal
  activities, normal lung function.

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Medication Review for Patients

• Long-term control medications that prevent
  symptoms, often by reducing inflammation.
• Consider use of visual aids models, posters,
  etc
• Quick relief/Rescue short-acting bronchodilator
  relaxes muscles around airways.
• Bring all medications to every appointment.
• When to seek medical advice if medications not
  working or device concerns.
• Provide appropriate telephone number for
  questions.

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Teach or review and demonstrate Initial
Visits Inhaler and spacer or valved holding
chamber (VHC) use. Check performance. Ensure
appropriate technique and use of devices at every
visit.
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Action Plan Review initial visit.

• Self-monitoring skills that are tied to a written
  asthma action plan.
• Recognize intensity and frequency of asthma
  symptoms.
• Review the signs of deterioration and the need to
  reevaluate therapy
• - Waking at night or early morning with asthma
• - Increased medication use
• - Decreased activity tolerance
• - Use of a written asthma action plan that
  includes instructions for daily management and
  for recognizing and handling worsening asthma.

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• 2- 4 week Follow up - Focus on
• - Expectations of visit
• - Asthma control
• - Patients goals of treatment
• - Medications
• - Patients treatment preferences
• Quality of life
• Ask relevant questions from previous visit and
  also ask
• What medications are you taking?
• How and when are you taking them?
• What problems have you had using your
• medications?
• Please show me how you use your inhaled
• medications.

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• 2-4 week follow up - Teach in simple language
• Review the two types of medications.
• Remind patient to bring all medications and the
  peak flow meter, if using, to every appointment
  for review.
• - Self assessment of asthma control using
  symptoms
• and/or peak flow as a guide. May consider use of
  items such as the Asthma Control Test patient
  questionnaire as well.

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• 2-4 week Follow up - Teach or review and
  demonstrate
• - Use of written asthma action plan. Review and
• adjust as needed.
• Peak flow monitoring if indicated.
• Correct inhaler and spacer or VHC technique.

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• Focus on at second follow up visit
• - Expectations of visit
• - Asthma control
• - Patients goals of treatment
• - Medications
• Quality of life
• Ask relevant questions from previous visits and
• also ask
• Have you noticed anything in your home, work, or
  school that makes your asthma worse?
• Describe for me how you know when to call your
  doctor or go to the hospital for asthma care.
• What questions do you have about the asthma
  action plan?
• Can we make it easier?
• Are your medications causing you any problems?
• Have you noticed anything in your environment
  that makes your asthma worse?
• Have you missed any of your medications?

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Teach in simple language at second follow up
visit - Self-assessment of asthma control,
using symptoms and/or peak flow as a
guide. Relevant environmental control/avoidance
strategies How to identify home, work, or
school exposures that can cause or worsen
asthma How to control house-dust mites,
animal exposures if applicable How to avoid
cigarette smoke (active and passive) - Review all
medications
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• Teach or review and demonstrate at second follow
  up visit
• Inhaler/spacer or VHC technique.
• Peak flow monitoring technique.
• - Use of written asthma action plan. Review and
• adjust as needed.
• - Confirm that patient knows what to do if
• asthma gets worse

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• Focus on at all subsequent follow up visits
• - Expectations of visit
• - Asthma control
• - Patients goals of treatment
• - Medications
• Quality of life
• Ask relevant questions from previous visits and
  also ask
• How have you tried to control things that make
  your asthma worse?
• Please show me how you use your inhaled
  medication.

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Teach in simple language at all subsequent follow
up visits Review and reinforce all
Educational messages Environmental control
strategies at home, work, or school
Medications Self-assessment of asthma control,
using symptoms and/or peak flow as a guide OR
questionaires
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• Teach or review and demonstrate at all subsequent
  visits
• Inhaler/spacer or VHC technique.
• Peak flow monitoring technique, if appropriate.
• Use of written asthma action plan. Review and
  adjust as needed.
• - Confirm that patient knows what to do if asthma
  gets worse.

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Allergen Avoidance Education

• Tobacco Smoke
• If you smoke, ask your doctor for ways to help
  you quit. Ask family members to quit smoking,
  too.
• Do not allow smoking in your home, car or around
  you.
• Be sure no one smokes at a childs daycare center
  or school.
• NO RECOMMENDATIONS EXIST TO ALLOW SMOKING ONLY
  OUTSIDE! INFORM YOUR PATIENTS AND PARENTS!

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• Dust Mites
• Many people who have asthma are allergic to dust
  mites. Dust mites are like tiny bugs you cannot
  see that live in cloth or carpet.
• Things that will help the most
• Encase your mattress in a special dust-mite proof
  cover.
• - Encase your pillow in a special dust-mite proof
  cover or wash the pillow each week in hot water.
  Water must be hotter than 130 F to kill the
• mites. Cooler water used with detergent and
  bleach can also be effective.
• - Wash the sheets and blankets on your bed each
  week in hot water.

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• DUST MITE AVOIDANCE
• - Reduce indoor humidity to or below 60 percent,
  ideally 3050 percent. Dehumidifiers or central
  airconditioners can do this.
• Try not to sleep or lie on cloth-covered cushions
  or furniture.
• Remove carpets from your bedroom and those laid
  on concrete, if you can.
• Keep stuffed toys out of the bed, or wash the
  toys weekly in hot water or in cooler water with
  detergent and bleach.
• Placing toys weekly in a dryer or freezer may
  help.
• Prolonged exposure to dry heat or freezing can
  kill mites but does not
• remove allergen.

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• Animal Dander
• Some people are allergic to the flakes of skin or
  dried saliva
• from animals.
• The best thing to do
• Keep pets with fur or hair out of your home.
• If you cant keep the pet outdoors, then Keep
  the pet out of your bedroom, and keep the bedroom
  door closed.
• Remove carpets and furniture covered with cloth
  from your home. If that is not possible, keep the
  pet out of the rooms where these are.

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• Cockroach
• Many people with asthma are allergic to the dried
  droppings and remains of cockroaches.
• Keep all food out of your bedroom.
• Keep food and garbage in closed containers
  (Never leave food out).
• Use poison baits, powders, gels, or paste (for
  example, boric acid). You can also use traps.
• - If a spray is used to kill roaches, stay out of
  the room
• until the odor goes away.

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• Vacuum Cleaning
• Try to get someone else to vacuum for you once
  or twice a week, if you can. Stay out of rooms
  while they are being vacuumed and for a short
  while afterward.
• - If you vacuum, use a dust mask (from a hardware
  store), a central cleaner with the collecting bag
  outside the home, or a vacuum cleaner with a HEPA
  filter or a double-layered bag.
• Indoor Mold
• Fix leaking faucets, pipes, or other sources of
  water.
• - Clean moldy surfaces.
• - Dehumidify basements if possible.

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• Pollen and Outdoor Mold
• During your allergy season (when pollen or mold
  spore counts are high)
• Try to keep your windows closed.
• If possible, stay indoors with windows closed
  during the midday and afternoon, if you can.
  Pollen and some mold spore counts are highest at
  that time.
• - Ask your doctor whether you need to take or
  increase anti-inflammatory medicine before your
  allergy season starts.

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• Smoke, Strong Odors, and Sprays
• If possible, do not use a wood-burning stove,
  kerosene heater, fireplace, unvented gas stove,
  or heater.
• - Try to stay away from strong odors and sprays,
  such as perfume, talcum powder, hair spray,
  paints, new carpet, or particle board.
• Exercise or Sports
• You should be able to be active without symptoms.
  See your doctor if you have asthma symptoms when
  you are activesuch as when you exercise, do
  sports, play, or work hard.
• Ask your doctor about taking medicine before you
  exercise to prevent symptoms.
• Warm up for a period before you exercise.
• - Check the air quality index and try not to work
  or play hard outside when the air pollution or
  pollen levels (if you are allergic to the pollen)
  are high.

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Other Things That Can Make Asthma Worse -
Sulfites in foods Do not drink beer or wine or
eat shrimp, dried fruit, or processed potatoes if
they cause asthma symptoms. - Cold air Cover
your nose and mouth with a scarf on cold or windy
days. - Other medicines Tell your doctor about
all the medicines you may take. Include cold
medicines, aspirin, and even eye drops.
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The End!

• Establish a Partnership to improve Patient Asthma
  Management
• Role of patient education Action Plans both
  symptom based and peak flow
• Demonstrate, review, evaluate and correct
  skills at each visit Action plan, Peak Flow
  use (if indicated), MDI use, VHC use, Allergen
  Avoidance
• Provider Education
• Communication skills, Clinical pathways,
  Documentation (spirometry, AHLTA)

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References

• NHLBI Asthma Guidelines and Executive Summary
  2007.
• CDR R. Lee Understanding and Teaching Asthma
  Devices, SEP 2008.