Personalised Asthma Action Plan Research Articles

Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland

ObjectiveRecovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe...

Medication Adherence in Children with Asthma.

Asthma is the most common chronic disease in childhood. If untreated, asthma can lead to debilitating daily symptoms which affect quality of life, but more importantly can lead to fatal asthma attacks which unfortunately still occur globally. The most effective treatment strategy for controlling asthma is for the patient to follow a personalised asthma action plan (PAAP) which will invariably include regular use of an inhaled corticosteroid. To examine medication adherence in children with asthma, we collated recent evidence from systematic reviews in this area to address the following 5 key questions; What is adherence? Is there evidence that children are not adhering to preventer medication? Why is adherence poor and what are the barriers to adherence? Does good adherence improve outcomes in asthma? And lastly, how can treatment adherence be improved?

Asthma in Pregnancy: A Critical Review of Impact, Management, and Outcomes.

Asthma is a common chronic respiratory condition that can significantly impact the health of pregnant women and their developing fetuses. This comprehensive review provides insights into the prevalence of asthma in pregnant women, the physiological changes during pregnancy, and the multifaceted impact of asthma on maternal and fetal health. It emphasizes the importance of proper asthma diagnosis, medication management, and the development of personalized asthma action plans during pregnancy. Lifestyle modifications, trigger avoidance, and stress reduction are essential to effective management. Healthcare providers are pivotal in educating, monitoring, and individualized care to ensure optimal asthma control. The review underscores the critical significance of managing asthma during pregnancy, as it improves maternal and fetal outcomes and potentially influences long-term health for both mother and child. Future directions in this field involve ongoing research, personalized treatment, early intervention, and precision medicine to enhance the understanding and care of asthma during pregnancy.

Regular (up to 10 puffs 4-hourly) inhaled salbutamol should be prescribed at discharge after an asthma attack: myth or maxim?

Over the past 20 years, the concept of asthma weaning plans on discharge after an attack has crept into common practice, although the precise origin of these plans is unclear. High use of short-acting β2-agonists (SABAs) may result in tolerance to their bronchodilator effects, thus diminishing their efficacy, particularly when they are most needed at the time of an acute attack. Furthermore, key warning signs of a deterioration in asthma control may be masked and the weaning plan may encourage the over-use and over-reliance on SABAs. Side-effects from over-use may also occur, including lactic acidosis, downregulation of the β2-adrenoreceptor, increased allergen response and pro-inflammatory effects. The need for asthma education at discharge, a personal asthma action plan and vigilance about prescribing and ensuring adherence to maintenance therapy are definitely important. However, the current authors conclude that the benefit of prescribing regular salbutamol (up to 10 puffs every 4 h) at discharge after an acute asthma attack is a myth, and a very dangerous one.

Factors Influencing Use of Personalized Asthma Action Plans among Adult Patients Aged 18-65 in Nyamira County Kenya

Introduction: Globally the World Health Organization (WHO) estimates that up to 334 million people suffer from asthma. In Kenya it is estimated that about 10% of the Kenyan population, or 4 million people, have asthma.
 Aim: The objective of this study was to assess factors influencing the use of personalized asthma action plans among patients aged 18-65 in Nyamira County.
 Methodology: Cross-sectional study design was employed in this research. Participants were selected using systematic sampling. Significant differences in categorical variables were found using the Chi-square and Fisher's Exact Test. The threshold for statistical significance was set at p<0.05.
 Results: The study sample size was 220 asthma patients. Findings showed that majority did not use PAAPs with a response of 168(76.4%) respondents while those who used were 52(23.6%). Knowledge on PAAPs was low at 160(72.7%) against, 60(27.3%) who were knowledgeable. There was poor attitude and practices on use of PAAPs. Statistically there were significant association between the various patients’ factors influencing use of asthma action plans among adult asthmatic patients with a p = 0. 021. Among the health care givers, on knowledge of PAAPs 3 had knowledge while 3 did not. Among those who had knowledge the practice on use was low in which majority indicated that they don’t discuss and prescribe PAAPs with a response of 5 while 1 do. Statistically there were significant association on the health care workers’ factors influencing use of PAAPs at p = 0.03. Lack of training was a key institutional factor hindering use in which 3 (60.0%) had received training in the last 6 months while 2(40.0%) had not received. Statistically there were significant association on the institutional factors influencing use of PAAPs at p = 0.004.
 Conclusion: From the respondent’s majority of the patients were found not to be using the personalized asthma action plan cards. Lack of knowledge was a leading factor among the patient’s respondents. There was also a poor attitude reported in the patients’ respondents in which majority felt that they were for very sick patients. Among the health care givers; only one out of the six had this template/card in their office. Although half of the health care givers had general knowledge but it was not demonstrated in the use of PAAPs hence showing a gap in some specific skills needed. More workload and lack of these templates in the clinics were the major institutional factors hindering use of these tools.

IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a cluster randomised controlled implementation trial

BackgroundAsthma is a common long-term condition and major public health problem. Supported self-management for asthma that includes a written personalised asthma action plan, supported by regular professional review, reduces unscheduled consultations and improves asthma outcomes and quality of life. However, despite unequivocal inter/national guideline recommendations, supported self-management is poorly implemented in practice. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) implementation strategy has been developed to address this challenge. The aim of this implementation trial is to determine whether facilitated delivery of the IMP2ART strategy increases the provision of asthma action plans and reduces unscheduled care in the context of routine UK primary care.MethodsIMP2ART is a parallel group, cluster randomised controlled hybrid II implementation trial. One hundred forty-four general practices will be randomly assigned to either the IMP2ART implementation strategy or control group. Following a facilitation workshop, implementation group practices will receive organisational resources to help them prioritise supported self-management (including audit and feedback; an IMP2ART asthma review template), training for professionals and resources to support patients to self-manage their asthma. The control group will continue with usual asthma care. The primary clinical outcome is the between-group difference in unscheduled care in the second year after randomisation (i.e. between 12 and 24 months post-randomisation) assessed from routine data. Additionally, a primary implementation outcome of asthma action plan ownership at 12 months will be assessed by questionnaire to a random sub-group of people with asthma. Secondary outcomes include the number of asthma reviews conducted, prescribing outcomes (reliever medication and oral steroids), asthma symptom control, patients’ confidence in self-management and professional support and resource use. A health economic analysis will assess cost-effectiveness, and a mixed methods process evaluation will explore implementation, fidelity and adaptation.DiscussionThe evidence for supported asthma self-management is overwhelming. This study will add to the literature regarding strategies that can effectively implement supported self-management in primary care to reduce unscheduled consultations and improve asthma outcomes and quality of life.Trial registrationISRCTN15448074. Registered on 2 December 2019.

Quality of primary care delivered to children with asthma in South London before the introduction of integrated child focused care model: a population cohort study of primary care records

BackgroundAsthma is one condition being evaluated in a randomised control trial (RCT) of the Children and Young People's Health Partnership (CYPHP) model of care across two boroughs in South London. The integrated, specialist nurse lead service aims to deliver focused, age appropriate, good quality care to improve child health, within an ethnically diverse and deprived population. Providing good quality, evidence-based care is vital to keep children with asthma healthy. This study aimed to determine the quality of asthma care provided to children in primary care before the introduction of CYPHP in May, 2018. MethodsWe examined primary care health records of children registered within GP practices in Southwark and Lambeth. We identified children aged 5–15 years between April 1, 2014, and March 31, 2018, with asthma by a coded asthma diagnosis or three or more asthma medications in a 12-month period, and with more than 400 days of continuous GP registration after their asthma was identified. Child asthma quality measures were determined from guidelines and published literature, as follows: children aged 5 years and older with asthma have a personalised action plan; an annual asthma review; asthma control monitored at review; documented height at review; and a prescribed spacer device (which optimises medication delivery). FindingsOf the 7995 children identified with asthma, 44% (n=3508) were from the most deprived fifth of the national population. 36% (n=2868) had a coded annual asthma review record, and 15% (n=1219) had a personalised asthma action plan. Of the 2868 children with a coded annual review, 98% (n=2806) had evidence of asthma control being monitored, while only 2% (n=70) had a coded height documented. 80% (n=6381) had ever been prescribed a spacer. InterpretationCoding of primary care quality measures for child asthma was poor before the CYPHP service. This finding does not mean that the care was not provided, because information could have been recorded as uncoded text. An audit of primary care records is needed to determine the uncoded care provided. Prescription data are complete for the period a child is registered at a given practice. The fact that 20% of children were never prescribed a spacer needs further investigation. FundingGuy's and St Thomas' Charity.

Understanding personal asthma action plans

Personal asthma action plans (PAAPs) are written plans that help people with asthma to self-care and keep themselves as well as possible. PAAPs are usually developed in partnership with the patient or carer in primary care. PAAPs aim to ensure that people with asthma know how to manage their asthma and when to seek help if their condition deteriorates. To manage their asthma adequately at home, patients will need regular education about what asthma is, an understanding of their triggers, how their medications work and managing their devices. The practice nurse can play a key role in developing the PAAP, monitoring asthma control, and subsequently modifying the PAAP if necessary to maintain control of the condition.

Understanding personal asthma action plans

Personal asthma action plans are an essential tool to keep people with asthma as well as possible. Heather Henry explains the role of the practice nurse in developing them Personal asthma action plans (PAAPs) are written plans that help people with asthma to self-care and keep themselves as well as possible. PAAPs are usually developed in partnership with the patient or carer in primary care. PAAPs aim to ensure that people with asthma know how to manage their asthma and when to seek help if their condition deteriorates. To manage their asthma adequately at home, patients will need regular education about what asthma is, an understanding of their triggers, how their medications work and managing their devices. The practice nurse can play a key role in developing the PAAP, monitoring asthma control, and subsequently modifying the PAAP if necessary to maintain control of the condition.

Acute asthma exacerbations: tips from the shop floor.

Asthma places a significant burden on acute and non-acute services and is frequently encountered in the emergency department and the medical take. The UK has one of the highest asthma mortality rates in Europe. The National Review of Asthma Deaths has identified multiple factors that have contributed to preventable asthma deaths and solutions to these factors, including a better understanding and implementation of asthma guidelines. The British Thoracic Society and Scottish Intercollegiate Guidelines Network have recently updated their guidance on the management of asthma. This article outlines the guidelines for junior doctors managing patients with acute exacerbations of asthma. It highlights key areas of the initial assessment, establishing severity and initiating and escalating treatment. Furthermore, the discharge process from discharge criteria to promoting patient safety, education and ongoing self-management is discussed. This process, in particular education and personalised asthma action plans, can make a significant difference to the patient's outcomes and day-to-day burden of symptoms.

Completing asthma action plans by screen-sharing in video-consultations: practical insights from a feasibility assessment

Supported self-management is a vital component of routine asthma care. Completion of an agreed personalised asthma action plan is integral to implementation of this care, and traditionally this requires a face-to-face consultation. We aimed to assess the practical feasibility and potential utility of using screen-sharing technologies to complete asthma action plans remotely. Assisted by people with diverse technological ability and using a range of devices, we tested the technological feasibility of completing action plans in remote consultations using two leading video-conference systems. We used a semi-structured topic guide to check functionality and lead feedback discussions. Themes were interpreted using the Model for ASsessment of Telemedicine applications (MAST). Discussions with ten participants (age 20–74 years) revealed that screen-sharing was practical on most devices. Joint editing of an action plan (as was possible with Zoom) was considered to encourage participation and improve communication. Attend Anywhere had less functionality than Zoom, but the NHS badging was reassuring. Most participants appreciated the screen-sharing and considered it enabled a meaningful discussion about their action plan. Online shared completion of action plans is feasible with only a few (potentially remediable) practical problems. These findings suggest this may be a fruitful approach for further study—made more urgent by the imperative to develop remote consultations in the face of a global pandemic.

Paediatric asthma deaths in Ireland: 2006-2016.

Asthma is the commonest chronic condition in childhood but mortality from asthma during childhood is a rare occurrence. No national review into asthma deaths in children in Ireland has been performed to date. The aim of this study was to review all cases of mortality from asthma in the paediatric population over a 10-year period in Ireland. The objective was to identify risk factors contributing to asthma deaths in children. A retrospective chart review was performed on cases reported to the National Paediatric Mortality Register (NPMR) with asthma as the primary cause of death. Eleven cases were reported. Consent was obtained for six cases. Median age at death was 11.8years. All patients presented to the Emergency Department (ED) in asystole. Fifty percent of patients had acute symptoms prior to the fatal episode. None of the patients was attending secondary services. Only 60% had a written personalised asthma action plan (PAAP). Our data suggests that most patients present in extremis and have little warning signs of severity of the attack. Better education on recognition of symptoms and initiation of action plans is required.

Paediatric asthma care in the UK: fragmented and fatally fallible.

The National Review of Asthma Deaths (NRAD) report entitled Why Asthma Still Kills ,1 published on World Asthma Day in May 2014, concluded that only one of the 28 children and young people (CYP) who died had been adequately managed by health professionals. Of the 19 NRAD recommendations only one has been initiated nationally in the UK, namely setting up a National Asthma Audit, which has yet to report after nearly 5 years. Care for children with asthma in the UK is mainly provided in primary care, and is often limited to the few tasks set out in the Quality and Outcomes Framework (QOF)2 to provide data to qualify for payments. Currently the QOF requires a recorded asthma diagnosis confirmed by measures of airflow reversibility, smoking status, and evidence of an asthma review in the preceding 12 months that includes an assessment of asthma control using the Royal College of Physicians’ three questions (RCP 3 Questions); the latter are not validated and nor are they recommended for children aged <16 years by the UK Asthma Guidelines.3 The aim of the NRAD was to identify potentially preventable factors related to care preceding these tragic (and often preventable) deaths. The confidential inquiry identified a number of key themes associated with potentially preventable asthma deaths, which included: lack of objective evidence for the diagnosis of asthma and certification of death due to asthma; excess prescriptions and overreliance on reliever medication; insufficient prescriptions (and collection) of preventer (controller) medications; lack of provision of education for patients (in the form of personal asthma action plans [PAAPs]); and, importantly, a marked failure by health professionals, patients, and their carers to recognise risk of poor outcome in those who have already had at least one asthma attack. All these factors were previously known from …

Creation of a primary care personal asthma action plan

National guidelines recommend that all asthmatics are offered a personal action plan, writes Rachel Looms

Creation of a primary care personal asthma action plan

National guidelines recommend that all patients with asthma are offered a personal asthma action plan (PAAP), which contains potentially lifesaving information should a patient experience a decline in symptoms. A PAAP was created for use within a primary care setting based on a review of currently available plans. It was based on a colour-coded system: green for when the patient feels well, amber for a decline in symptoms, and red for an asthma attack. It was designed to fit onto one side of A4 paper, with guidance for the patient to take a photograph of it with their mobile phone. The PAAP was only recently introduced into practice, so its impact on reducing asthma related complications or hospital admissions has not yet been reviewed.

Pilot Results from an Integrated Pediatric Pulmonary Clinic on Outcomes in Children with Sickle Cell Disease

Abstract Introduction In children with sickle cell disease (SCD), asthma is a common comorbidity and is associated with increased disease severity when compared to children with SCD without asthma. Other pulmonary conditions, such as obstructive sleep apnea (OSA), are also more common in SCD and adversely affect clinical outcomes. Despite the well-established burden of pulmonary disease in children with SCD, optimal treatment paradigms are not well defined. Methods An integrated pediatric SCD and pulmonary clinic guided by the chronic care model was implemented at the University of Florida in July 2017 with the goal of coordinating subspecialty care and improving the treatment of concomitant pulmonary conditions. Prior to the formation of this clinic (pre-intervention phase), patients were managed separately by pulmonologists and hematologists in a tertiary academic medical center. During the intervention phase, patients received care in an interdisciplinary clinic composed of a pediatric pulmonologist, a pediatric hematologist with expertise in SCD, a respiratory therapist with access to an onsite pulmonary function testing (PFT) laboratory, asthma educator, and a SCD nurse educator/clinic coordinator. The objective of this abstract is to evaluate preliminary clinical outcomes of the integrated SCD-pulmonary clinic during the intervention phase (July 2017-June 2018) compared to 24 months prior to implementation (July 2015-June 2017). We hypothesized an integrated clinic model would improve access to specialized pulmonary care for children with SCD and reduce hospitalizations for vaso-occlusive episodes (VOEs). The primary endpoints are adherence to pulmonary clinic appointments and unplanned acute healthcare utilization for SCD-related complications and/or asthma exacerbations. Secondary endpoints are the number of unplanned packed red blood cell (PRBC) transfusions, percentage of patients able to complete PFTs, and new diagnoses or prescribed treatments during the intervention phase. Results During the intervention phase, 24 unique patients accounted for 40 clinic visits. Reasons for referral to the integrated SCD-pulmonary clinic included asthma (16), a history of severe and/or recurrent acute chest syndrome (12), OSA (3), hypoxia (1), shortness of breath (1), and concern for pulmonary hypertension (1). The mean age of participants was 10 years (range 2-18 years); 79% were male, 22 had hemoglobin (Hb) SS disease, 16 (67%) were being treated with hydroxyurea, and 2 were on chronic transfusion therapy. Mean baseline Hb and reticulocyte count were 9.1 gm/dL (SD 1.2) and 8.5% (SD 4.5), respectively. PFTs were successfully completed in 21 (88%) patients and reported as pre-treatment percent predicted values after adjusting for age, gender, height, and race. Mean forced expiratory volume in 1 second (FEV1) was 90% (SD 12.5), forced vital capacity (FVC) 94% (SD 12), and diffusing capacity of the lungs for carbon monoxide (DLCO) corrected for Hb was 103% (SD 26, measured in 12 patients). Mean duration of follow-up was 8 months (range 1-12 months). During the pre-intervention phase, this cohort accounted for 76 hospitalizations, 42 emergency department (ED) visits, 31 transfusions, and 26 missed pulmonary appointments. During the intervention phase, there were 9 hospitalizations, 7 ED visits, 3 transfusions, and 5 missed appointments. This represents an 86% reduction in unplanned acute healthcare utilization (mean difference (MD) 2.8, 95% CI 1.8-3.7; p&lt;0.0001), a 90% reduction in PRBC transfusions (MD 1.9, 95% CI 0.96-2.78; p&lt;0.001), and an 81% increase in adherence to pulmonary appointments (MD 1.3, 95% CI 0.71-1.92; p&lt;0.001). Twenty-two patients had a confirmed asthma diagnosis, and 8 were diagnosed with OSA. Interventions included personalized asthma action plans (22 patients), inhaled corticosteroids (16), supplemental oxygen during sleep (5), tonsillectomy and adenoidectomy (2), and the initiation of hydroxyurea (1). Conclusions These results demonstrate that interdisciplinary clinics can improve access to subspecialty pulmonary care for children with SCD and support the continued development and implementation of integrated care models. With limited follow-up, the results also suggest integrated SCD and pulmonary care can reduce hospitalizations and ED visits for VOEs, though additional follow-up is required to determine the true treatment effect. Disclosures Black: Bioverativ: Membership on an entity's Board of Directors or advisory committees; NIH: Research Funding; Pfizer: Research Funding; Sancilio Pharmaceuticals: Research Funding; Prolong Pharmaceuticals: Consultancy.

"Being in Control of My Asthma Myself" Patient Experience of Asthma Management: A Qualitative Interpretive Description.

Asthma control can be achieved with effective and safe medication use; however, many patients are not controlled. Patients’ perceptions of asthma, asthma treatment, and pharmacist roles can impact patient outcomes. The purpose of this study was to explore patients’ experiences and patient–pharmacist relationships in asthma care. Qualitative Interpretive Description method guided the study. Semi-structured individual interviews were conducted with 11 patients recruited from personal contacts, pharmacies, and asthma clinics. Categories and themes were identified using inductive constant comparison. Themes indicated patients had a personalized common sense approach to asthma management, “go-to” health care provider, and prioritized patient–pharmacist relationships. Patients described their illness experiences and asthma control based on personal markers similar to the common sense model of self-regulation. Patients chose a family physician, asthma specialist, respiratory therapist, or pharmacist as an expert resource for asthma management. Patient perceived pharmacists’ roles as information provider, adviser, or care provider. Pharmacists who develop a collaborative relationship with their asthma patients are better positioned to provide tailored education and self-management support. Inviting patients to share their perspective could increase patient engagement and uptake of personalised asthma action plans to achieve asthma control.

A review of asthma care in 50 general practices in Bedfordshire, United Kingdom

The United Kingdom (UK) National Review of Asthma Deaths (NRAD) (2011–2014) identified a number of contributory risk factors which had not previously been recognized by those caring for people with asthma. Only one of the 19 NRAD recommendations has so far been implemented nationally, and that only partially, and as yet systems are not in place to identify patients at risk of attacks and dying from asthma. In 2015/2016 Bedfordshire Clinical Commissioning Group (CCG) in England, UK, initiated a quality asthma audit of people with asthma to identify some of the risk factors identified in the NRAD report with the aim of optimizing patient care. Fifty (89%) of the General Practices caring for 415,152 patients (27,587 diagnosed with asthma (prevalence 7%; range 4–12%)), participated and the results identified a wide variation in process of care and presence of risk factors including: excess short acting reliever and insufficient preventer prescriptions, failure to issue personal asthma action plans, and to perform annual reviews or check inhaler technique. Identification of these patients involved high-intensity input by trained asthma nurses using sophisticated data extraction software. GP computer systems used in primary care currently do not have the functionally, without the need for manual audit, to implement the NRAD recommendations, starting with the identification of patients at risk. Modifications to existing systems within both primary and secondary care are required in order to prevent unnecessary deaths related to asthma. There is a pressing need to move towards a more pro-active model of care.

Asthma action plan for proactive bronchial asthma self-management in adults: a randomized controlled trial.

Written personalized asthma action plans are recommended as part of patient education and self-management. To enable asthmatic adults to proactively self-manage bronchial asthma and sustain asthma quiescent status through utilization of the Asthma Action Plan (AAP), and to establish a feasible asthmatic/care taker-health care provider communication. Randomized controlled trial with cluster sampling by pulmonologists. The study comprised 320 chronic asthmatic patients attending the chest department at the main health insurance hospital in Alexandria that were randomly allocated as the intervention group (AAIG; n=160) that received standard care and intervention by the AAP and a control group (AACG; n=160) that received the routine standard of care. Data were collected through an interviewing questionnaire. The study continued over a 6-month period and passed into three phase stations. During the preparatory phase the health care provider managed to explain, fill and simplify the use of the Arabic version of the AAP, to explain the correct utilization of the weekly follow-up form and to emphasize the weekly communication/visit with the health care provider (HCP) to update their weekly follow-up records. Follow-up was done on the 90th and 180th days from the launch of the study, respectively. The study asthmatics were subjected to history-taking of their asthma symptoms, signs and triggers, and a review of their medical/peak expiratory flow records, as well as his/her daily activity and exercise. The AAIG experienced superiority of the average of the green zone days ('doing well') with significantly more episodes of early asthma flare-up self-management concomitant with prominent fewer emergency department visits, hospitalization, admission at the ICU, private health facility, and days of sickness leaves and absenteeism. A preponderance of the high and medium adherence levels to asthma medications, avoidance of asthma triggers and smoking was achieved by the AAIG. AAP was the basis for effective patient-health care provider communication and patient real time asthma flare-up self-management to achieve and sustain better asthma control in asthmatic adults.

Asthma in pregnancy: Physiology, management and recommendations for midwives

Asthma in pregnancy is a common respiratory co-morbidity, but if this serious condition is not addressed appropriately, acute exacerbations may contribute to maternal mortality and morbidity. Indeed, any acute episode of asthma can quickly become life-threatening, and midwives should be aware of the need for urgent referral. The importance of effectively managing asthma in pregnancy includes the immediate detection of a worsening condition, along with immediate referral to a physician in order to minimise the complications associated with acute exacerbations. In order to minimise poor outcomes for women, midwives should be aware of evidence-based practice guidelines for managing asthma and to avoid complacency, midwives must be aware of the most recent report, Why Asthma Still Kills. Furthermore, as part of their scope of practice, midwives should ensure that all women have access to personalised asthma action plans, and should work across the multidisciplinary team to promote smoking cessation, infection control and vaccination against influenza. Importantly, midwives should assess compliance with women's prescribed short- and long-acting asthma medication.