Asthma Management Plan and Prognosis

ASTHMA MANAGEMENT PLAN
· A written asthma action plan detailing for the individual patient the daily management (medications and environmental control strategies) and how to recognize and handle worsening asthma

· Particularly recommended for patients who have moderate or severe asthma, a history of severe exacerbations, or poorly controlled asthma

· The written asthma action plan can be either symptom or peak-flow based; evidence shows similar benefits for each

· Developed jointly between the healthcare advisor and the patient

· There are many different asthma management plan formats. However, all action plans must have the following components:
o Recommended doses and frequencies of daily medications
o How to adjust medicines at home in response to particular signs, symptoms and peak flow measurements
o Listing of the patient’s peak expiratory flow (PEF) levels, including personal best PEF and calculated PEF zones based on personal best. PEF monitoring recommended for moderate and severe asthma only
o Symptoms indicating the need for closer monitoring or acute care
o Emergency telephone doctor, emergency department, rapid transportation and family/friends for support
o A list of triggers that may cause an asthma attack to inform the patient and others on what triggers to avoid

· A copy of patient’s asthma action plan should be:
o Carried with the patient
o Kept in the patient’s medical chart
o Provided to the patient’s day care, school or worksite
o Provided to the patient’s coach/physical education teacher
o Provided to other contacts of the patient as needed



Symptom-Based Plan
Ø Band 1
o Taking reliever medications not more than 3-4 times a week
o Free of regular night-time wheeze, cough or chest tightness
o Able to take part in normal physical activity without getting asthma symptoms
o Means there is no need to adjust medication

Ø Band 2
o Require reliever medication more than once a day
o Asthma status is deteriorating
o Amount of medication should be doubled

Ø Band 3
o Need short-acting reliever medication every 3-4 days
o Dangerous situation and need medical attention urgently
o Need to start or resume oral steroid treatment and contact doctor ASAP

Ø Band 4
o No relief with bronchodilators
o Emergency situation where situation gets worse very quickly
o Need an ambulance and continue use of bronchodilators



Peak-Flow Based Plan
Ø Objective measure of asthma severity in people with moderate to chronic asthma

Ø Little evidence showing that it is better than a symptom based plan

Ø Peak flows are not 100% accurate

Ø Sometimes, they overestimate the need for drugs, while in other cases they fail to diagnose an asthma attack

Ø Readings can be incorrect because of wrong technique

Ø Technique of using a peak flow meter:
o Sit upright/stand up straight.
o Slide a marker to the end.
o Hold the meter horizontal.
o Keep your fingers away from the marker. Take a deep breath.
o Put the meter in your mouth. Close your lips around the mouthpiece and blow out as hard and as fast as you can.
o Repeat the entire routine three times.
o Take note of your highest reading.
o Keep a chart of your peak flow rate – upon rising in the morning and early in the evening.
o Important to use the peak flow meter at the same time everyday

Ø A personal best peak flow is obtained by keeping the records for a few days and determining what is normal for you.




Management of Catastrophic Sudden Severe (Brittle) Asthma
ª Unusual variant of asthma in which patients are at risk from sudden death despite the fact that their asthma may be well-controlled between attacks

ª Severe life-threatening attacks may occur within hours or even minutes

ª These patients require:
§ Emergency supplies of medications at home, in the car and at work
§ Oxygen and resuscitation equipment at home and at work
§ Nebulized β agonists at home and at work
§ Self-injectable epinephrine (adrenaline): 2 Epipens of 0.3 mg epinephrine at home, at work and to be carried by the patients at all times
§ Prednisolone 60 mg
§ Medic Alert bracelet

ª On developing wheeze, patient should attend the nearest hospital immediately



Prognosis for Asthma

v Is chronic, although may go into long periods of remission

v In mild to moderate cases, asthma can improve over time and many adults even become symptom-free

v Even in some severe cases, adults may experience improvement depending on the degree of obstruction in the lungs and the timeliness and effectiveness of the treatment

v However, although asthma often improves in children as they reach their teens, it is now realized that the disease frequently returns in the second, third and fourth decades

v In about 10% of the severe persistent cases, airways remodelling lead to progressive and irreversible problems in lung function, even in aggressively treated patients

v Led to reappraisal of the treatment strategy for asthma, mandating the early use of controller drugs and environmental measures from the time asthma is first diagnosed

v Death from asthma is a relatively uncommon event especially for a person receiving proper treatment