Asthma is a major source of ongoing morbidity and mortality in Ireland. It affects about 890,000 patients in Ireland at some stage and costs the state €472 million per year.¹ The UK review of asthma deaths brought home some stark realities for those of us involved in asthma care, including continued over-reliance on ‘blue’ inhalers, failure to recognise the severity of the situation and lack of self-management instructions.²

One aspect of care that stands out is the use of personal asthma action plans (PAAPs) and the fact that they remain underutilised as a strategy to improved asthma outcomes. PAAPs have been shown to reduce hospitalisations by 15-54% and ED visits by 18-46%,³ improve quality of life and asthma control and reduce absenteeism from work or school by 21%. Despite the large body of evidence in favour of PAAPs and consistent recommendations by all guidelines, studies show that only 4% of GPs reported consistently providing a PAAP and only 2%-30% of patients actually receive one. It is projected that widespread introduction of PAAPs in Ireland would result in a reduction of between 24,000 and 61,000 ED visits and a potential saving of €27-€54 million per year in healthcare costs and up to €48 million in indirect costs dues to absenteeism.^1,4

Self-management has been defined as the tasks that individuals must undertake to live with chronic conditions, including “having the confidence to deal with medical management, role management and emotional management of their conditions”. The literature suggests that an optimal self-management strategy includes education about the condition, self-monitoring and a written PAAP.

The barriers to the introduction of PAAPs include lack of time and experience in their use and delegating the job to equally inexperienced healthcare professionals who may not have received training in how to instruct patients in using PAAPs. In one study, only 30% of GPs attending an asthma workshop were able to prepare an adequate PAAP.⁵

The new Chronic Disease Management Programme in general practice is an opportunity to introduce a PAAP to patients with asthma and it can be included in the care plan for these patients. There is some ambiguity about PAAPs and many healthcare professionals are unsure about what and how to advise patients with asthma. A large review of the various PAAPs around the world showed large variability in both content and format, as well as poor usability. Most plans were developed ad hoc and by content experts exclusively. Most doctors do consider PAAPs to be important but often cite a lack of time as a major barrier to their implementation. The Irish PAAP can be downloaded from www.asthma.ie and is also in the new ICGP asthma guidelines (on www.icgp.ie) (see Figure 1).

The PAAP is based on a traffic light system:

• Green: good control. Minimal symptoms and PEF > 80%
• Amber: control suboptimal and need to alter asthma treatment
• Red: serious deterioration in asthma control and need to seek urgent medical care. The red zone is where the inhalers are not giving relief; there is difficulty in talking and breathing with a tight chest. The PEF is less than 60%.

The green and red zones are easy to understand and are relatively easy to put into action. The amber zone is where the ambiguity arises, as it involves upping the dose of inhaled steroids and/or using oral steroids to prevent further deterioration. There is much ambiguity about how to actually increase the ICS dose and this is further complicated with patients on fixed dose (ICS /LABA) regimes. There is a lack of clarity about what practical steps to take in the amber zone. The basic premise is to quadruple the dose of ICS despite where this temporarily exceeds the maximum dose of ICS. Doubling ICS has not proved to be effective.

Some patients need to be given a course of oral steroids to be used when their symptoms deteriorate. These patients are advised to seek medical attention when they start oral steroids. Patients who may need oral steroids include those who historically have not responded to increasing ICS and those with a history or severe or sudden deterioration in asthma.

A recent review in the European Respiratory Journal gives an excellent easy-to-use guideline to assist healthcare professionals when putting PAAPs into action (see Table 1).⁶

 (click to enlarge)

Introduction of PAAPs is time-consuming initially but has been shown to reduce exacerbations and improve control, which in turn reduce GP attendances. Further innovations such as apps and phone-based technology are in development, which will further assist in the wider use of PAAPs in Ireland.

Case study 1

John Murphy is a 42-year-old builder. He has had asthma for many years and is a non-smoker. He takes beclomethasone 200mcg BD and uses salbutamol PRN. He presents to the surgery for a repeat of his medications.

What should you do?

• Check control quickly – day/time symptoms, how often he is using blue inhaler, any recent exacerbations
• Check inhaler technique
• Check any comorbidities – rhinitis, reflux, smoker/work irritants.
• He has never been given a PAAP
• A PAAP can be printed out for him. He should be encouraged to get a PEF meter
• Give him good advice about asthma
• The PAAP involves him in his asthma care and promotes self-monitoring
• Green zone – continue medications
• Amber zone – take four puffs of beclomethasone BD for 7-10 days until symptoms improve.
• Red zone – take blue inhaler (2-4 puffs every 10-30 minutes). Seek medical attention as soon as possible
• This plan can be reviewed every year.

Case study 2

Johanna Murphy is a 21-year-old student who had severe asthma as a child with multiple admissions. She has not been in hospital for more than 10 years. She gets one to two ‘flare ups’ per year, which usually require oral steroids. She takes Singulair 10mg per day, Seretide 250/50 Diskus BD and salbutamol PRN.

What should you do?

• Check control
• Check inhaler technique and adherence
• Ask about comorbidities
• She should be offered a PAAP
• She has a PEF meter at home but rarely uses it. Advise her that PEF may fall before symptoms are experienced and this may be an opportunity to alter medications to avoid a full-blown exacerbation
• Green zone – keep with Seretide BD and Singulair
• Amber zone – we need to up her to the maximum Fluticasone dose (2,000mcg). We can’t up her Seretide as this will increase her LABA too much, which may be unsafe, so she could be given a separate Fluticasone Diskus 250. Ask her to continue taking Seretide BD along with Flixotide Diskus 250mcg – 3 puffs BD for 7-10 days
• Red Zone – take 30mg of Deltacortril immediately and seek urgent medical care. 

References

1. Easing the economic burden of asthma. Asthma Society of Ireland, June 2019. Report.
2. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. Royal College of Physicians. London; 2014.
3. Gibson PG, Powell H, Coughlan J, Haywood P et al. Self management education and regular practitioner reviews for patients with asthma. Cochrane Database Syst Rev 2003;(1):CD 001117
4. Levy ML, Garnett F, kuku S et al. A review of asthma care in 50 general practices in Bedfordshire, UK. NPJ Prim Care Resp Med 2018;28(1):29
5. Daines L, Morrow S, Wiener-Ogilvie S, et al. Understanding how patients establish strategies for living with asthma: a qualitative study in UK primary care as part of IMPART. Br j Gen Pract 2020. DOI https://doi.org/10.3399;/bjgp20X708869
6. Kouri A, Louis-Philippe, Gupta S. An evidence based, point of care tool to guide completion of asthma action plans in practice. European Resp. Journal 2017 49:1602238