Asthma Education Is a Joint Effort: Guidelines From the NIH

Primary Care Update
Brief Summaries for Clinical Practice

The cornerstone of asthma management is patient education—and an active partnership between patients and their health care teams. Guidelines from the Expert Panel of the National Asthma Education and Prevention Program emphasize that education for asthma self-management, which ideally is provided by each member of the health care team, should be tailored to each patient according to special needs as well as cultural beliefs and practices.¹ It is important to incorporate systemic instruction and frequent review of asthma management principles into every patient’s treatment plan. Education can occur at any point of care, including clinics, medical offices, emergency departments and hospitals, pharmacies, homes, and schools.

Highlights of the Expert Panel’s recommendations are presented here.

ESTABLISHING A PARTNERSHIP
Optimally, asthma education begins as soon as a diagnosis is made and is integrated—within the context of office visits, formal educational sessions, and other types of clinician-patient communication—into every step of the patient’s care. Building a partnership requires open communication between physicians, patients, and the patients’ families.

It is essential that patients have a basic understanding of the disease process and the treatment approach, as well as the skills necessary to monitor their condition and follow their treatment regimen. When you take the time to provide education, it becomes very clear to patients and their families that being knowledgeable about self-management of asthma is critical, and it underscores the importance of physician-patient collaboration.

Jointly develop treatment goals. Explain the general goals of asthma treatment. These include gaining freedom from severe symptoms, attaining the best possible lung function, being able to participate in activities, minimizing time lost from work or school, reducing or eliminating urgent-care visits, and achieving optimal drug therapy with minimal side effects.

Determine the patient’s personal treatment goals. Find out how asthma interferes in his or her life, and incorporate the responses into treatment goals. You and the patient should agree on both the general and the personal goals.

Teach asthma self-management. Provide information about the following essential areas:

•Basic facts about asthma and the role of each medication, so that patients and their families understand why certain steps need to be taken. Repeat important messages and review all medications at each visit.
•Necessary medication skills, such as correct techniques for using inhalation devices and spacers or valved holding chambers, and knowing when and how to take rescue medications. Review this information periodically.
•Essential self-monitoring skills, such as symptom monitoring, peak expiratory flow (PEF) assessment, and the ability to recognize the early signs of deterioration.
•Environmental control/avoidance strategies. Be sure the patient is aware of allergens and irritants that can precipitate exacerbations and is able to recognize both immediate and delayed reactions.²

Provide self-management tools. The Expert Panel recommends that you develop an individualized, written asthma action plan with the patient (Table). The plan includes instructions both for daily actions to keep asthma controlled and for actions to adjust treatment when symptoms or exacerbations occur.¹ The plan should include the details of the patient’s medication regimen, the agreed-upon goals, and the self-management actions needed to achieve those goals. Along with the daily self-management program, the plan should provide the patient with instructions on how to adjust medication in the event of an exacerbation. It should also list PEF levels and/or symptoms that indicate the need for acute care, and emergency telephone numbers.

Written asthma action plans can be based on either symptoms or peak flow measurements. The choice is based on your clinical judgment and the preference of the patient.

Although all patients with asthma can benefit from an action plan, it is particularly advisable for those who have moderate to severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma. Discuss the long-term benefits of plan adherence and the possibility of medication adjustment. At subsequent office visits, review and adjust the plan.

Encourage adherence. The Expert Panel recommends the following measures:
•Encourage open communication with the patient. Willingness to address all questions, active listening, and use of good communication techniques can improve patient adherence and satisfaction with care.
•At each office visit, try to elicit the patient’s concerns, perceptions, and unresolved questions. Reassure the patient and allay fears by providing specific information. Open-ended questions—such as “What worries you most about your asthma?”—encourage expression of issues, concerns, and personal beliefs. It is important to identify these potential barriers to adherence so that they can be addressed. Discussion of the patient’s concerns builds trust and a feeling of partnership, and increases the likelihood of adherence.
•Determine the patient’s and the family’s perceptions of disease severity. Such questions as “How severe do you think your asthma is?” and “How much danger do you think you are in from your asthma?” are useful in identifying patients who underestimate the severity of their asthma as well as those who are unduly fearful. The written asthma action plan, which explains appropriate responses to exacerbations, may help allay patient anxiety.
•Ask specifically about concerns the patient may have about medications, such as safety, effects, and cost.
•Assess the level of social support available to the patient. Advise patients to choose an asthma “partner”—a family member or friend—who is willing to learn about the patient’s condition and provide support. Include this person in subsequent office visits so that he or she knows about the patient’s action plan and is aware of what steps the patient is expected to take in different situations.
•Enlist or encourage family support. Have the patient list ways in which family members can help in following the action plan, and invite the family’s suggestions and involvement.
•Increase the likelihood of adherence to the action plan by ensuring that the plan is simple for the patient to follow and that the medication regimens are as streamlined as possible and can be incorporated into the patient’s daily routine.
•If stress seems to interfere unduly with asthma management, consider referral to a mental health worker, or to a support group. As with other chronic diseases, emotional and social stress may complicate life for a patient struggling with asthma control. It can also contribute to the precipitation of exacerbations.

Individualize patient instruction. Determine whether there are cultural variables that might affect the patient’s understanding of and adherence to treatment. Think of ways to include harmless or potentially beneficial ethnic remedies in the patient’s treatment plan. Discourage the use of harmful remedies by suggesting culturally acceptable alternatives or safer practices.

Language barriers affect compliance as well as the appropriate use of health care services. If the patient’s first language is not English, be sure that educational messages are completely understood. Communicate in the patient’s native language if possible.

MAINTAINING THE PARTNERSHIP
The Expert Panel stresses that educational efforts must be continual if they are to be effective, and that you can be most helpful if you assume the role of a sympathetic coach. Specifically, be sure that you take the time during each visit to demonstrate, review, evaluate, and correct the patient’s technique with the inhaler, spacer, or holding chamber. These skills deteriorate rapidly, and although written instructions are helpful, they are not sufficient to maintain correct technique. For example, patients make common errors in using inhalers. They especially need to be reminded to inhale slowly and to activate the inhaler only once for each breath.

To maintain open communication, the Expert Panel recommends that the following steps be taken during each visit:
•Early in the course of each visit, ask the patient what concerns he may have about asthma and which issues he would like to have addressed during the visit.
•Review the goals agreed on in the initial visit, evaluate how well they are being achieved, and revise if necessary. Acknowledge the patient’s achievement of goals and progress in asthma management.
•Review the written asthma action plan and make adjustments as needed.
•Confirm that the patient knows what to do in the event of an asthma exacerbation.
•Continue to teach and reinforce key educational messages.
•Provide patients with simple, concise written materials that reinforce the actions recommended and the skills taught. The Box lists organizations that offer patient education materials. ■