Asthma education and self-management

INTRODUCTION — Asthma education and self-management are essential components of successful asthma management. Several helpful documents have been published on what to include in an asthma education program, including the National Asthma Education and Prevention Program (NAEPP): Expert Panel Report 3, the 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, the Global Initiative for Asthma guidelines, and the National Asthma Council Australia: Australian Asthma Handbook [1-6].

A comprehensive asthma education program covering all asthma education topics in depth may not be possible in all clinical settings. Based on a series of focus group interviews, the "core elements" necessary in an asthma education program have been identified [7,8]. The three topics of primary importance for patient education are the following:

●Function and appropriate use of medication

●Pathophysiology of asthma

●Issues in the prevention and treatment of symptoms

The NAEPP has emphasized that clinician care is necessary, but not sufficient to achieve asthma control. In addition, the patient must be taught to perform effective self-management [1,6,9,10]. The essential components of effective asthma self-management include [6]:

●Self-monitoring of symptoms with or without peak flow

●A written asthma action plan that guides patients to recognize and respond to worsening asthma

●Regular review of asthma control, treatments, and skills by a health care provider

The essentials of what patients need to know about their asthma will be reviewed here. An overview of asthma management, the use of peak-flow monitoring in asthma, and the techniques of using inhaler devices are discussed separately.

●(See "An overview of asthma management".)

●(See "Peak expiratory flow monitoring in asthma".)

●(See "The use of inhaler devices in adults".)

●(See "The use of inhaler devices in children".)

EFFECTIVENESS OF EDUCATION — There is ample evidence that asthma education results in a variety of patient- and society-important outcomes, including the following [9,11-23]:

●Improved quality of life

●Improvement in symptoms

●Fewer limitations in activity

●Improved medication adherence

●Fewer urgent care visits and hospitalizations

●Reduction in asthma-related costs

ESTABLISHING A PARTNERSHIP — The clinician should make efforts to establish open communication and a sense of shared responsibility and decision-making [24,25] by doing the following at every asthma visit:

●Involve the patient and caregivers in decision making. For school-age children, the partnership also should involve the school.

●Encourage the patient and family in their self-management efforts

●Ask openly about patient preferences and goals and incorporate these into treatment when possible

●Enquire about patient and family concerns and fears about chronic illness, medication use, nebulizer use, dependency, health beliefs, and cost

●Foster a trusting relationship that allows patients to express the barriers they face that impede successful self-management

●Identify relevant indoor allergens for mitigation, as advised by the NAEPP 2020 Focused Update. Patient and clinician should partner in exploring which, if any, are important and feasible to address.

●Consider implementation of Single Maintenance And Reliever Therapy (SMART) protocols in steps 3 and 4 of recommended asthma management, as advised by the NAEPP 2020 Focused Update. Like any new schedules of medications, these should be discussed between patients and clinicians for benefit and feasibility and any changes should be reflected in the action plan.

Studies have shown that a partnership between clinicians and patients that establishes a rapport, provides educational information, teaches skills, and provides a written asthma action plan improves treatment adherence and clinical outcomes compared with less patient-centered care [24,26].

ASTHMA ACTION PLANS — An "asthma action plan" is a written document that provides instructions for the patient to follow at home. Conflicting evidence has been reported about whether action plans have a meaningful benefit in the management of asthma. A systematic review and meta-analysis did not find evidence that action plans reduce exacerbations or improve quality of life or lung function for adults with asthma [27]. However, the evidence was felt to be of low quality and many asthma specialists, including ourselves, believe that written action plans are useful in clarifying the medication plan and providing guidance for adjusting treatment in response to changes in asthma symptoms [6]. Written asthma action plans are especially useful for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma [1].

Action plans should include directions about daily self-assessment and baseline medications, as well as a plan for managing exacerbations, including peak expiratory flow (PEF) levels and symptoms for which acute care is needed (form 1 and form 2 and algorithm 1) [1]. The action plan should be simple and formatted for ease of reading and the possibility that a patient's literacy level is low [28]. The School-Based Asthma Action Plan proposes a plan that coordinates the partnership of family, school, and clinician and includes an online action plan toolkit [29].

If newer daily regimens such as SMART are agreed upon, the regimen should be detailed in the action plan [30].

The plan should be individualized during initial visits in consultation with the patient [31]. During a patient's first visit, information regarding medications, treatment goals, how following the plan will help the patient reach these goals, and when to seek urgent care can be incorporated into the plan.

For those patients who have or will be provided with a peak flow meter, the concepts of personal best peak flow rate and how this measurement is used should be discussed. The patient should receive a chart to record peak flow rates. At a subsequent visit, the patient's personal best peak flow can be added to the plan. Specific instructions for including peak flow in an individualized asthma action plan, as well as the needed charts for recording peak flows, are reviewed separately. (See "Peak expiratory flow monitoring in asthma".)

The plan should be reviewed and refined at subsequent follow-up visits. Emphasizing the patient's personal goals is essential to enhancing adherence. For example, ask, "Have you had any problems taking your bronchodilator immediately before playing basketball? Has it helped you stay in the game?". Question the patient about any aspects of the plan that were confusing or unhelpful.

The action plan should also include relevant allergen mitigation activities if any are identified.

Daily asthma care — Patients may monitor the status of their asthma based upon symptoms alone, or by additionally monitoring daily peak flow readings. Peak flow monitoring has not been shown to be superior to symptom-based monitoring, so either approach or a combined approach is acceptable. Making sure the patient has optimal peak flow technique is essential. Peak flow monitoring may be useful after careful instruction for any change in therapy such as going to a SMART protocol.

In summary, the patient’s action plan should stipulate the patient's daily medications, including doses and frequencies. It should be at the patient’s literacy level and in their primary language. When patients are instructed to use inhaled medicines "as needed," the maximum number of "puffs" per day should be specifically stated. Environmental recommendations should be included.

Attack management — Patients should understand how to recognize early symptoms and begin therapy [32]. They should understand the signs that are indications for emergency care and they should be encouraged to stay calm during severe exacerbations. (See "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment" and "Acute exacerbations of asthma in adults: Home and office management".)

Detecting symptoms and initiating treatment — Stress the importance of recognizing and immediately treating early warning signs and symptoms. These include a drop in peak expiratory flow rate (despite optimal technique), an increase in asthma symptoms, awakening at night or early in the morning with asthma symptoms, or other individual patterns related to shortness of breath or tightness in the chest. Give patients written instructions about when to take extra doses of quick-acting reliever medications and when to initiate a course of oral glucocorticoids [1,32].

Indications for emergency care — Describe signs that require immediate emergency medical attention, such as cyanosis, failure of medications to control symptoms, or a significant drop in peak flow rate. Stress the importance of understanding the difference between attacks they can manage on their own and those that require a patient to seek medical attention without delay. Emphasize the benefits of staying calm during a severe exacerbation.

The asthma action plan should include emergency telephone numbers for the clinician, emergency department, rapid transportation, and family/friends for aid and support.

PATIENT EDUCATION — Important self-management knowledge and skills can be categorized into four broad areas [33]:

●Understanding asthma

●Attack management

●Attack prevention

●Communication

The table shows the patient education topics outlined by the National Asthma Education and Prevention Program (NAEPP) and its 2020 Update (table 1) [1,5].

Understanding asthma — The patient and family should understand the characteristics of asthma, the principles of effective treatment, the effects of various medications, and the resources available. It is recommended that the clinician provide information in the following manner (table 2A):

What is asthma? — Explain the three characteristics of asthma:

●Airway inflammation

●Increased airway sensitivity to a number of triggers

●Temporary airflow obstruction leading to breathing difficulty

Characteristic airway changes — Describe the principal variations in airways that cause an asthma exacerbation: inflammation, bronchospasm, and excess mucus; and explain how different medications target these causes.

Treatment — Review the five principles of effective asthma treatment:

●The need for individualized, continuing care

●The way medications work to prevent and/or relieve symptoms

●Medication side effects and how to manage them

●Preventive treatment to reduce inflammation when symptoms are not present

●Early treatment of symptoms when present

Patient fears concerning medication — Discuss and try to alleviate patients' fears about medication. These are generally related to such concerns as long-term adverse effects, toxicity, addiction, and tolerance.

Proper health care resource utilization — Discuss when it is appropriate to call or visit the clinic, as opposed to the emergency department.

Attack prevention — Important issues include understanding the use of medications, avoidance of triggers, proper inhalation technique, the role of monitoring, and the use of premedication in specific situations.

Signs and symptoms of asthma — Instruct how to recognize all possible symptoms of a potential asthma episode, such as shortness of breath, wheezing, chest tightness, and recurrent coughing. Explain how symptoms may be subtle and how using a peak flow meter can help detect changes before symptoms are present. (See "Peak expiratory flow monitoring in asthma" and "Patient education: How to use a peak flow meter (Beyond the Basics)".)

Role of medications — Describe differences in bronchodilators and anti-inflammatory medications and the proper use of each. If different options for anti-inflammatory medications are available (for example pressurized metered dose inhaler [pMDI] versus dry powder inhaler [DPI], or daily versus as-needed medications), encourage the patient and caregivers to participate in the choice. A shared decision-making approach that solicits participation of patients and caregivers can lead to improvement in quality of life, asthma control, and adherence [24,34]. (See "An overview of asthma management".)

Factors that make asthma worse — Explain how to identify, avoid, eliminate, or control asthma "triggers." Stress that treatment measures without environmental control are ineffective. (See "Trigger control to enhance asthma management" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)

Correct inhaler use — Provide skills training in using each type of inhaler prescribed (picture 1 and picture 2 and table 3 and table 4 and table 5). It may be helpful to have pictures of commonly used inhalers to confirm which inhaler the patient is using [35]. Also discuss spacer devices (picture 3) and nebulizers if used. Clinicians should review and teach correct inhaler technique at each visit as these skills frequently worsen over time [1]. (See "The use of inhaler devices in adults" and "The use of inhaler devices in children" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Delivery of inhaled medication in adults", section on 'Nebulizers'.)

Monitoring — Describe the advantages of keeping diaries of medication use, peak flow rates, environmental exposures, symptoms, and actions taken. These data provide a valuable resource to both the clinician and patient in planning attack prevention and management strategies. The difficulty of monitoring must be discussed with the patient. For example, monitoring with a peak flow meter requires appropriate technique while keeping a symptom diary requires persistence. The patient and health care provider should come to an agreement about the monitoring method and frequency that would be optimal for the individual patient. The success of this monitoring plan should be discussed at subsequent visits. (See "Peak expiratory flow monitoring in asthma" and "Patient education: How to use a peak flow meter (Beyond the Basics)".)

Premedicating to prevent onset of symptoms — Tell patients what medication measures to take when triggers cannot be avoided. For example, premedication with beta-agonist agents prior to exercise or exposure to known allergens or irritants may prevent onset of symptoms. (See "Exercise-induced bronchoconstriction" and "Patient education: Exercise-induced asthma (Beyond the Basics)".)

Evaluation of results of treatment plan — Periodic clinical evaluation is necessary to assess adherence to the management plan and status of therapy goals. Discuss areas where desired outcomes are not being achieved, and change the therapy as necessary.

Communication — Alleviating fears and misconceptions, encouraging family understanding and support, and developing open communication among the patient, school, family, and health care team are critical to optimal management and attainment of as normal a lifestyle as possible.  

The patient’s access to medication, concerns about asthma or asthma treatments, and adherence to their medical regimen should be explored tactfully to avoid embarrassing or shaming the patient. Expressing concern and caring, providing reassurance, and establishing a partnership can help to improve communication. (See "The patient’s culture and effective communication" and "Enhancing patient adherence to asthma therapy".)

Fears and misconceptions — Identify and help alleviate patient and family fears and misconceptions about asthma. They may need to be told that asthma is not caused by psychological factors; most asthma fatalities are due to under-treatment; asthma does not have to limit physical activity; and asthma does not necessarily lead to lung disability.

Family support — Encourage patients to inform family members, friends, and co-workers about their asthma, at least to the extent that help can be provided if needed. Educational information that can help patients and their families may be found on the American College of Asthma Allergy & Immunology web site (acaai.org/asthma/) and the American Academy of Allergy Asthma & Immunology web site (aaaai.org/Conditions-Treatments/asthma).

Feelings about asthma — Patients may have difficulty accepting that they have a chronic condition that can be treated but not cured. Help patients acknowledge and openly discuss their feelings, and take responsibility for managing their asthma.

Communication with the health care team — Stress that patient input into the treatment plan is essential, and that open, honest communication among those involved will ensure better asthma management.

Communication with the child's school — Encourage caregivers to inform relevant school personnel about regular and emergency care procedures. Use of a school action plan is advised (student asthma action plan).

Health promotion behaviors — Encourage patients to practice general preventive health practices that can affect physical and mental health [36].

INCORPORATING ASTHMA EDUCATION INTO PATIENT VISITS — It can be challenging to incorporate patient-focused asthma education into patient care visits. To help individualize asthma education, a short questionnaire has been developed to determine a patient's strengths and weaknesses in asthma self-management knowledge and skills (table 6) [37]. By using an instrument like this, busy clinicians can identify the most important points to discuss with each patient. The National Asthma Education and Prevention Program Expert Panel also has developed a strategy for building self-management education into patient care visits (table 2A-D) [1].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Asthma in adolescents and adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Asthma in adults (The Basics)" and "Patient education: Asthma in children (The Basics)" and "Patient education: How to use your metered dose inhaler (adults) (The Basics)" and "Patient education: How to use your dry powder inhaler (adults) (The Basics)" and "Patient education: How to use your soft mist inhaler (adults) (The Basics)" and "Patient education: Avoiding asthma triggers (The Basics)" and "Patient education: Medicines for asthma (The Basics)")

●Beyond the Basics topics (see "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●The three topics of primary importance for patient education are the function and appropriate use of medication, the pathophysiology of asthma, and the prevention and treatment of symptoms. A comprehensive list of asthma education topics outlined by the National Asthma Education and Prevention Program is provided in the table (table 1). (See 'Introduction' above.)

●The three characteristics of asthma for patients and families to understand are that airway inflammation, sensitivity to triggers, and the temporary occurrence of airflow obstruction leading to shortness of breath are all components of asthma. Understanding these characteristics provides the foundation for an understanding of asthma medications and trigger avoidance. (See 'What is asthma?' above.)

●An "asthma action plan" is developed based on the collaboration between the patient (and family) and asthma care provider and includes information and guidance on routine daily care and management of exacerbations. Examples of action plans are provided in the figures (form 1 and form 2). A school asthma action plan is also useful (student asthma action plan). A written action plan is especially important for patients with moderate-to-severe persistent asthma and patients with a history of severe exacerbations. (See 'Asthma action plans' above.)

●Inhaled medications are a key component of asthma management and correct inhaler use is essential. Patients and their families need clear instructions and demonstration of the correct use of each type of inhaler and spacer or chamber device prescribed (figure 1 and picture 3 and picture 2 and table 7 and table 3 and table 4 and table 5). (See 'Correct inhaler use' above and "The use of inhaler devices in adults" and "The use of inhaler devices in children" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)

●Asthma education also includes instruction on recognizing the various symptoms of a potential asthma episode, such as shortness of breath, wheezing, chest tightness, and coughing. (See 'Signs and symptoms of asthma' above.)

●Explaining how to use a peak flow meter can help patients detect changes in airflow before symptoms are present and obtain objective confirmation of changes in airflow when symptoms develop. (See 'Monitoring' above.)

●The patient’s access to medication, concerns about asthma or asthma treatments, and adherence to their medical regimen should be explored tactfully to avoid embarrassing or shaming the patient. Expressing concern and caring, providing reassurance, and establishing a partnership can help to improve communication.

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge William Bailey, MD, who contributed to earlier versions of this topic review.