The Asthma Action Plan

1. The Asthma Action Plan April 21, 2009 Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan

2. Why is the Asthma Action Plan Important? • Helps minimize or eliminate the need for trips to the ED and hospitalizations. • Allows the family and other caregivers to manage their asthma with the help of their provider. • Many school systems now require them.

3. A Successful Equation Patient Participation + Plan of Care = Asthma Control

4. The Plan of Care Includes: • Medical Management • Psychosocial Issues • Basic Asthma Education • Development of Skills • Asthma Action Plan

5. The Plan of Care • Begins at time of diagnosis • Includes other medical care • Reinforces important information • Includes skills demonstration and return demonstration • Incorporates/reflects a sensitivity to cultural factors

6. What is an Asthma Action Plan? • Self-management plan for managing asthma on a daily basis • Provider-directed • Written • Provides instructions for changes in asthma status • Based either on peak flow readings or symptoms (early warning signs)

7. What Does the Research Say? “Provide all patients with a written asthma action plan that includes two aspects: (1) daily management and (2) how to recognize and handle worsening asthma. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).” EPR-3: Guidelines for the Diagnosis and Management of Asthma—2007

8. What do Asthma Educators Say? It’s an effective tool! We love it!

9. What Does the Patient Say? Thank You! Now I know what I’m supposed to do!

10. Goals of Asthma Therapy… …are the foundation of an Asthma Action Plan

11. Goals of Asthma Therapy – Reducing Impairment • Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion) • Require infrequent use (≤2 days a week) of inhaled SABA for quick relief of symptoms • Maintain (near) “normal” pulmonary function • Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) • Meet patients’ and families’ expectations of and satisfaction with asthma care

12. Goals of Asthma Therapy – Reducing Risk • Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations • Prevent progressive loss of lung function; for children, prevent reduced lung growth • Provide optimal pharmacotherapy with minimal or no adverse effects

13. Developing the Asthma Action Plan • Use existing medications • Use the three zones • Include the patient in the development of the plan • Get provider’s signature and/or adjustments

14. Peak Flow Monitoring What you and your patient need to discuss: • Importance of peak flow monitoring • Benefits and limitations • When and how to monitor peak flow • Peak flow diary (focus on trends) • How to care for the device

15. Something to Remember... Peak flow results should be validated by spirometry annually: Spirometry will be in liters per second (6.0 l/sec) Peak Flow meter is in liters per minute (360 l/min)

16. What does the Research Say? “When self-management is the chosen method for maintaining asthma control, peak-flow-based self-management is equivalent to symptom-based self-management as long as either method also includes a written asthma action plan with instructions on how to recognize and handle worsening asthma, including self-adjustment of medications.” EPR-3: Guidelines for the Diagnosis and Management of Asthma—2007

17. Developing the Zones Green,Yellow and Red! Symptoms vs. Peak Flow

18. Zones Green Zone: (Goal: Stay in this zone.) • No Symptoms • PEFR >80% of Personal Best Yellow Zone: (Goal: Return to green zone.) • Symptoms/early warning signs • PEFR 50-80% of Personal Best with static or downward trend

19. Zones Red Zone: (Goal: Don’t go there!) • Danger Signs-worse symptoms (medical emergency) • PEFR: Continuing to fall while in yellow zone. Approaching 50% or less of Personal Best

20. First sign of URI Cough Itchy neck or chin Tight chest Stomach or headache Change in mood Change in activity level Dark circles under eyes (allergic shiners) Change in face color – flushed or pale Nose rubbing (allergic salute) Throat clearing Early Warning Signs

21. Asthma Danger Signs • Clipped speech • Retractions • Difficulty walking due to SOB • Nasal flaring • Cyanosis of lips or fingernails • Agitation • Wheezing stops (silent chest) • Rescue medicines are not helping • Peak flow (if used) is indicating red zone

22. Choose a Plan • The RIGHT format is the one that works! • May differ from patient to patient • May differ from clinician to clinician ***KEEP IT SIMPLE!***

26. Asthma Action Plan University of Michigan electronic asthma action plan: http://www.med.umich.edu/1info/fhp/practiceguides/asthma.html

28. Implementing the Plan • Get provider signature/approval • Provide several copies of plan • Establish follow-up plan for evaluation • Update as level of control or goals change (or child grows!) • Encourage patient to use this as a communication tool

29. The Plan as a Communication Tool Encourage and support the patient in: • Verbalizing his/her partnership in the self-management of his/her asthma • Incorporating the action plan into daily living—work place, day care, etc • Demonstrating asthma action skills

30. Evaluating the Asthma Action Plan • Is the patient attaining the goals of asthma management? • How is the plan working on a day to day basis?

31. Reworking the Plan(An Ongoing Process) • Before contacting the provider for possible medication changes…ask: • Are the meds being taken/delivered properly? • How can the patient make the “plan” more workable? • Have the patient’s goals changed? • If the “plan” is still not working, medication may need to be changed

32. And the Cycle Continues... • Ongoing evaluation of the plan • Tweak the plan as necessary • Reinforce key information and skills

33. Asthma Action Plan – Yellow Zone Medications Options • Bronchodilator Yellow zone: albuterol - 2 puffs every 4-6 hours as needed Alternative: - 2 to 8 puffs - every 20 minutes times 3 (first hour) - then every 1 to 4 hours

34. Asthma Action Plan – Yellow Zone Medications Options • Inhaled Steroid - many preparations • Increase sooner rather than later • Usually double the dose • New guidelines say consider quadrupling dose • Use higher dose for 1 to 2 weeks

35. Asthma Action Plan – Yellow Zone Medications Options • Oral Steroids Liquid preparations (15 mg / 5 mL) - 1-2 mg / kg per day for 3-10 days - 0-4 year olds (max 30 mg/day) - 5-11 years olds (may 60 mg/day) - usually 1 mg / kg once a day for 5 days - could use twice a day to start and taper to once a day when better - typical adult dose is 40 mg. X 5 days

36. Putting the Plan into Action:One Example • Green Zone - fluticasone (44) 2 puffs BID • Yellow Zone - albuterol - every 20 minutes X 3 then every 4 hours - fluticasone (44) 6 puffs BID X 1-2 weeks - oral steroids- 1 mg/kg daily or BID X 5 days • Red Zone - albuterol – 6-8 puffs - oral steroids - 2 mg/kg dose - call office or consider ER or call 911

37. Remember... The asthma educator practices health care at its best by Engaging the patient by accepting him/her where he/she is at the moment Empowering him/her with knowledge and skills needed to make choices and changes Supporting him/her as he/she works to make positive changes