Why a written asthma action plan?
Healthcare professionals see their patients for a matter of minutes over the year. For the rest of the time people with asthma need to know what to do to stay well and crucially what to do when their asthma becomes uncontrolled. A personalised asthma action plan helps patients stay in control of their asthma.
The National Review of Asthma Deaths (NRAD) highlighted that there were many cases where lives could have been saved if only people had taken medicines regularly as prescribed, carried a reliever inhaler and sought help much earlier when their asthma got worse. A written asthma action plan is an important method of supporting people to take the right actions at the right time.
There is evidence that people who are given a written asthma action plan are four times less likely to need hospital care for their asthma.
The following guidance will help you fill out an action plan in the most effective way. It covers each area of the action plan:
- Asthma triggers
- My asthma review
- The green zone
- The yellow zone
- The red zone
- Calculating peak flow for all sections
Action plans are only effective if they’re used. Try to:
- Save the plan to the patient notes so you or other healthcare professionals can refer back to it – capture it electronically by either adding notes or scanning the filled-out plan onto the computer.
- Ask your patient to take a photo of the plan on their own phone/tablet so their asthma action plan will be with them whenever they need it.
- Encourage your patient to keep a hard copy on their fridge or somewhere obvious so it reminds them what they need to do to stay on top of their asthma.
- Suggest your patient share their asthma action plan with friends, family and colleagues. They could send them the photo on their phone or tell them where a paper version is kept. This could be life-saving if your patient experiences an asthma attack.
It is really important that a written asthma action plan is created together by the clinician and patient, and any carers. The plan is generally self-explanatory, with boxes for you to add information that’s personalised for each patient. The below briefly explains the different sections and the best way to fill them in.
There is a space on the Asthma UK action plan to highlight any triggers. Make sure you include any allergies that might put people at risk of anaphylaxis, as well as any troublesome triggers like pollen, dust or cold weather. You can signpost your patients to Asthma UK’s triggers pages for information on how to manage their triggers.
Consider your patient’s pattern of asthma symptoms (winter, spring, summer) and their own preferences (evenings, weekends, holidays) when looking at routine follow ups.
The green zone of the Asthma UK asthma action plan is all about keeping your patient well. When filling it in:
- Highlight the importance of remembering to take their preventer medication every day and with the correct technique.
- Make sure they’re aware of the importance of using a spacer.
- After you have demonstrated good inhaler technique, signpost your patient to the Asthma UK inhaler videos at regular intervals so they can refresh their technique.
You could also ask your local community pharmacists to reinforce these important messages.
Use the green box to mention any other medications and devices that impact asthma control, such as:
- oral asthma medications and other treatments
- medicines for hay fever, gastric reflux or related conditions
- nebulisers if they have one
If your patient’s asthma has been well controlled for at least 12 weeks, you might decide it’s appropriate for them to step down to a lower dose of preventative medication. The action plan suggests that they ask their healthcare professional about this. If you do step down their medication, remind them to come back if their symptoms flare up again.
The yellow zone is possibly the most crucial part of the action plan. Asthma is a variable condition, often with unpredictable triggers so recognising when symptoms have got out of control and knowing what to do is key to an early recovery.
It is important to explain to your patient the actions that they need to take depending on the severity of their symptoms. If they act during this window of opportunity (which usually lasts one to three days) to manage a flare up using flexible dosing of the preventer by dampening down the inflammation in the airways, then they’re less likely to end up having a life-threatening asthma attack.
While many patients will simply increase their dose of inhaled steroids when they start experiencing more symptoms, you might want to give more specific advice to others. There is space for this in a yellow box at the bottom of this section where you could cover:
Some patients will benefit from having access to a rescue pack of oral steroids at home. If you think they will, give them clear written instructions about when they should start taking the steroids, at what dose and for how long. The BTS/SIGN 2016 guidelines suggest 40-50mg daily of prednisolone for at least five days or until recovery.
Also highlight the need for them to be checked by their GP or asthma nurse once they’ve started the course or more urgently if the symptoms or peak flow are getting worse at any time. Emphasise that they should come back to see you if they don’t feel better before the end of the course of prednisolone.
For patients taking formoterol-containing combination inhalers – such as Symbicort, Fostair or DuoResp – it is appropriate for patients to use their combination inhaler as both a regular preventer and when required as a reliever.
Explain to your patients, that when they use their SMART/MART inhaler as a reliever, as well as stopping the symptoms now, they’re also building up their protection for later. And they are less likely to get worse and need oral steroids as a result.
It is crucial they know when to seek help if this isn’t working or their symptoms are getting worse.
It’s very important that they must take their inhaler as a preventer as prescribed, even when well, and not to use the inhaler just as a reliever. Patients should have their dose reduced to the minimum required to maintain control of their asthma.
You’ll see on the action plan that it says if a patient uses their reliever inhaler three or more times a week, then they’re in the yellow zone. If they’re on the SMART/MART regime then they’re in the yellow if they use their SMART/MART inhaler as a reliever three or more times a week. Bearing in mind, that some patients will also have a SABA reliever inhaler if they’re on SMART/MART.
The SMART and MART regimes are not suitable for everyone – our page on Maintenance and Reliever therapies explains more.
It is crucial that everyone who has asthma, or who has responsibility for looking after anyone with asthma, knows exactly what to do in an asthma attack. This section of the action plan explains what to do in four simple steps.
Some asthma experts start with the red zone when completing the written asthma action plan with their patients. For more information see our advice on asthma attacks.
After an asthma attack
After one asthma attack, it’s important patients take action to prevent another one. Explain to your patients that having one asthma attack makes a second more likely. Emphasise that they should book an appointment with you or another healthcare professional within a minimum of 48 hours of having an asthma attack and being started on oral steroids.
If your patient has had an acute flare up of their asthma, taken up to 10 puffs of their blue inhaler, but not needed to call 999 they should seek an urgent assessment. Talk to them about the best way to navigate the urgent appointment system at their GP practice, and suitable alternatives such as A&E or local walk-in centres.
When they do come and see you after having an asthma attack, take time to discuss:
- what triggered the asthma attack
- whether they’re taking their preventer medication
- whether their inhaler technique is correct
- whether they understand their self-management plan and how they can keep their asthma under control
- when they should ask for help and support.
You could consider referring your patient to Asthma UK’s 12 Week Asthma Support Programme. It’s designed to encourage better self-care behaviours and improve asthma symptom control.
What to do in asthma attack on SMART/MART plan
It is essential that you protect your patient by giving them adequate instructions about taking extra doses of their SMART/MART inhaler and when to seek urgent or emergency clinical help. It is also important to understand the license for each individual inhaler.
Make sure you write the clear instructions in the space at the bottom of this section. You might want to include the following (based on British National Formulary guidance):
- In an acute situation a patient may take up to six doses of their SMART/MART inhaler
- Seek emergency support if this isn’t helping or if a dose of their inhaler is not lasting for four hours.
- If someone has required eight doses of inhaler in 24 hours or if they’re regularly taking additional doses of their inhaler on top of their usual maintenance dose, they should seek an urgent appointment to consider oral corticosteroid therapy.
It is important they also know the following dosage limits for their particular SMART/MART plan (based on British National Formulary licensing).
DuoResp spiromax 160: Adults over 18 only. One additional inhalation as required for relief of symptoms. Total daily dose of up to 12 inhalations can be used for a limited time (including maintenance dosing) but medical assessment is recommended if more than eight inhalations daily are needed.
Symbicort 100/6: Adult and over 12’s only. One puff as required for relief of symptoms, max eight puffs per day (including maintenance dosing); up to 12 puffs daily can be used for a limited time but medical assessment should be considered.
Symbicort 200/6: Adults over 18 only. One puff as required for relief of symptoms, max eight puffs per day (including maintenance dosing); up to 12 puffs daily can be used for a limited time but medical assessment should be considered.
Fostair 100/6: Adults over 18 only. One inhalation as required for relief of symptoms. Maximum eight inhalations per day (including maintenance twice daily dosing).
For many people with asthma, peak flow is a very useful way of monitoring control and detecting the early stages of an exacerbation. It is also an important part of assessing the severity of an exacerbation and assuring recovery. Note that a few people find their peak flow doesn’t change even when they’re getting more asthma symptoms. Explain to your patients that if their asthma symptoms are changing they should take action – whether their peak flow changes or not.
For someone to be well controlled with their asthma, their peak flow should be at least 80% of their personal best score.
A peak flow below 80% should trigger yellow zone activity and will require optimisation of care and self-care if this persists.
A peak flow below 60% indicates that person might be having an asthma attack and they should take urgent action.
There isn’t space to write below 40% on the action plan, but you might want to flag to your patients that this is an indicator that they should call 999.
|-||Yellow zone||Red zone, urgent care||Red zone, emergency 999|
A written asthma action plan is only one piece of the jigsaw to help people maintain good control of their asthma. Pinnock and Taylor explain the application of PRISMS to people with asthma (PDF) which includes giving people information about their asthma – for example Asthma UK website – and giving people a supportive community, for example they could talk to other people with asthma on: