VOL: 97, ISSUE: 12, PAGE NO: 8
Teresa Burgoyne, RN, is respiratory nurse, Queen’s Medical Centre, Nottingham
Teresa Burgoyne, RN, is respiratory nurse, Queen’s Medical Centre, Nottingham
It is vital that people with asthma understand their disease and how to control it. A management plan gives them the knowledge and confidence to do so. Involving patients in the day-to-day management of their asthma enhances their control and reduces admission to hospital (Osman, 1996).
A management plan is an agreement between the health professional and the patient. It provides the following:
- Information on how to deal with an episode of asthma;
- Information on using drug therapy to control symptoms;
- Advice on making therapeutic changes - for instance, either increasing use of inhaled steroids or starting oral steroids based on peak flow measurements and symptoms;
- Written instructions from a health care professional.
Management plans allow patients to monitor their asthma and respond according to the individual criteria given for both long-term and acute attack management.
Liljas and Lahdensuo (1996) affirmed that self-management of asthma is cost-effective and thus a sensible investment, as supported by the National Asthma Society, which has evidence to suggest that self-management plans can reduce asthma attacks (Asthma News, 1999).
Fishwick et al (1997) categorised patients suitable to work with a management plan as those on regular inhaled corticosteroids and beta agonists as required, with the greatest benefit for patients with chronic severe asthma. The present British Thoracic Society guidelines (1997) suggest that management plans should be given to everyone admitted to hospital and those at step three of the guidelines and above.
Individualised management plans
Educating patients about their asthma and the use of treatment is an integral part of management (Rees and Kanabar, 2000) and it should be given in a way that is individual to each patient. For example, a teenager will have different concerns than a younger child or an older person. Information should be clear, simple and in a language that the patient understands and, more importantly, backed up in the form of leaflets and booklets to support the verbal information.
Wherever possible, a team approach in both hospital and general practice should be taken to establish a partnership with the patient, preferably early, following diagnosis. This reinforces and expands patient education, improves adherence to the negotiated plan’s actions and leads to the formation of an effective management plan that is reviewed on a regular basis.
The basis of the management plan is developed from the patient’s peak flow readings. Although peak flow measurement forms the basic assessment of our management plans, the literature suggests that there is no definitive method; an assessment can include symptoms, peak flow measurements or a combination of the two. Symptom control may be used - it is perhaps more subjective but can be more meaningful to the patient. Symptoms have been shown to be as good an indicator of deterioration as peak flow readings (Charlton et al, 1990; Osman, 1996). However, 35% of patients in a prospective trial of home monitoring found it difficult to assess the severity of airway obstruction in relation to clinical symptoms (Ignacio-Garcia and Gonzales-Santos, 1995).
Key symptoms and objective measures of airflow obstruction is the method adopted by the National Asthma Campaign for management plans (D’Souza et al, 1994).
Having reviewed the literature, there seems to be a wide and varied range of intervention (zone) levels.
The patient’s asthma is well controlled - peak flow is anything above 75% of their best.
The next intervention level is when a patient’s asthma is less controlled and peak flow drops below a certain percentage (on two consecutive occasions). Patients are then asked to double inhaled steroids. The lowest reading indicating intervention is 70%. Charlton et al (1990) found that a figure of 75 or 80% might be a more appropriate criterion for doubling up. The study, which used 85% as an intervention level for doubling up, seemed to work well because the patients were taking higher doses more quickly. However, the danger is that higher doses of inhaled steroid are given unnecessarily (Liljas and Lahdensuo, 1996).
The third intervention level is when a patient’s asthma is becoming severe.The patient is asked to start taking oral steroids. Liljas and Lahdensuo’s (1996) high threshold of intervention starts oral steroids at 70%, compared with the majority of studies, which start at 60%. This raises the issue of patients potentially receiving oral steroids earlier, which consequently subjects them to a higher risk of side-effects.
At this level the patient’s asthma is severe and emergency help needs to be sought. Again, the threshold varies from 40-50%. The level set as life-threatening is 33%, so there is a small safety margin, but the speed at which patients enter these intervention levels varies, so much so that this should be a consideration when a lower level is set for going to hospital.
Having identified intervention levels, other issues come to light, such as how long, once patients have doubled inhaled steroids, they should continue to take the higher dose. The evidence from the majority of experts suggests that they count how many days it took to drop to the intervention threshold to the day they return to their best, and they then carry on with the double dose for that amount of time.
We try and make it simple for patients and tell them to continue for one week and then reduce. It is more straightforward for the dose of oral steroid - this is usually 30-40mg of prednisilone and fairly standardised. Patients are told to go to their GP once they have started a course of steroids, and the GP will then advise them on how long they should continue the treatment, which is usually between one and two weeks.
Management plan maintenance
Sufficient time must be allocated for the management plan to be successful. It has to be explained and supported with written information, and the patient needs time to ask questions and voice concerns. Whether at the GP surgery or in an out-patient department, the consultation must be long enough to negotiate the management plan with the patient.
It is important to stress to patients that the completed management plan needs reviewing and is not written in stone. Patients are asked to see their GP or asthma nurse at least every six months to review therapy. Patients also need written guidelines on how to measure their symptoms so that they can recognise when their condition is worsening. This information is included in the management plan to alert the patient to seek help.
Management plans may not be suitable for every patient with asthma. Some do not agree or comply with their prescribed regimen or health care advice. Becker et al (1977) highlighted the notions of health motivation and efficacy of treatments and suggested that not all patients behave in a way that improves their condition or makes them better. Some have no wish to take control of their condition and should not be forced to do so.
For patients at very high risk or those where symptoms occur very quickly, added measures need to be employed. In some areas arrangements are made so that a patient can go straight to hospital and the ambulance service operates a fast-track system for these patients, giving them high priority.
An area that has not been thoroughly studied is the adherence of patients to the self-management instructions. Some of the reasons for this are lack of understanding: patients may not have been given enough information or they may have difficulty interpreting the instructions. Some management plans can be extremely complex and others as simple as an appointment to go back to the respiratory nurse. Lack of regular review may also be a factor.
Further work needs to be done to standardise ideal intervention levels. Management plans should be considered essential for the long-term treatment of adult asthma. It improves the patient’s autonomy and compliance, conveys control, reduces exacerbations and is therefore very cost-effective.
It is important that we motivate and educate patients by helping them understand the benefits of adhering to the plan and the advantages for each individual in improving the quality of their lives.
Asthma Information Centre: http://www.mdnet.de/asthma/
British Lng foundation: http://www.lunguk.org
Asthma web; http://www.asthmaweb.net
National Asthma Campaign; http://www.asthmas.org.uk/
British guidelines for the management of asthma: http://www.tecc.co.uk