MRCGP Exam Update - Self-management of asthma

Dr Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners' PasTest, 2006.

Current situation

  • The ultimate goal for the management of asthma is to help patients lead a normal life with no limitations on activities.
  • The British Thoracic Society guidelines indicate the importance of management plans in asthma control. A combination of education, review by health practitioners and a written self-management plan improve asthma outcomes.
  • Asthmatic patients should be trained to manage their own treatment using personal asthma action plans.

What is the evidence?

  • A recent study from Denmark showed that written action plans were provided for only 12 per cent of patients with asthma (Allergy Asthma Proc 2007; 28: 375-81).
  • A systematic review has recently concluded that symptom-based action plans are superior to peak flow action plans for preventing acute care visits for children with asthma (Cochrane Database Syst Rev 2006; 4: CD005306).
  • One trial showed that children receiving an individualised written home-management plan had fewer asthma events, lower symptom score and less nocturnal awakening (Acta Paediatr 2005; 94: 1,742-6).
  • A systematic review has shown that primary care professionals should encourage the ownership and use of action plans through the implementation of proactive practice-based organisational systems (Prim Care Respir J 2007; 16: 271-83).

Implications for practice

  • Asthma reviews should be viewed as an opportunity to give patients a written asthma action plan.
  • Further advances in monitoring may come through technology. Portable digital assistants can prompt assessment such as peak flow and administration of routine therapy as well as storing and supplying management plans (BMJ 2006; 332: 767-71).
  • The Gaining Optimal Asthma controL study (GOAL) confirmed that patients who achieve high levels of asthma control tended to maintain them (Eur Respir J 2007; 29: 56-62). This suggests doctors should aim for guideline-recommended levels of control that will help offer freedom from the intrusion of asthma.

An asthma action plan

  • Peak expiratory flow, based on personal best values and not predicted values.
  • Two to four levels of intervention in terms of symptoms or lung function.
  • Advice as to when to use oral corticosteroids.

Key points
- Many asthmatic patients are still not adequately controlled.
- Written action plans can improve health outcomes.
- Patients should be central to their management.
- Action plans are also beneficial for children.

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