Clinical review

Guided self management of asthmahow to do it

Aarne Lahdensuo, head. 

Department of Pulmonary Diseases, Tampere University Hospital, 36280 Pikonlinna, Finland

aarne.lahdensuo{at}tays.fi

	Introduction

Top Introduction Methods Setting up a self... References

Almost 75% of admissions for asthma are avoidable, and potentially preventable factors are common in deaths from asthma. ^{1 2} At least 40% of people with asthma do not react appropriately when their symptoms worsen, and over 50% of patients admitted with acute asthma have had alarming symptoms for at least a week before admission. ^{3 4} As many as 60% of asthmatic patients are poor at judging their dyspnoea.⁵ Self management of asthma involves the patient making therapeutic, behavioural, and environmental adjustments in accordance with advice from healthcare professionals.⁶ Guided self management of asthma is a treatment strategy in which patients are taught to act appropriately when the first signs of asthma exacerbations appear.

In a recent Cochrane review, self management of asthma in adults was compared with usual care in 22 studies.⁷ Self management education reduced hospital admissions (odds ratio 0.57, 95% confidence interval 0.38 to 0.88), emergency room visits (0.71, 0.57 to 0.90), unscheduled visits to the doctor (0.57, 0.40 to 0.82), days off work or off school (0.55, 0.38 to 0.79), and nocturnal asthma (0.53, 0.39 to 0.72). Self management programmes that contained a written action plan showing patients how to act in early exacerbations showed a greater reduction in admissions to hospital than did programmes without a plan (0.35, 0.18 to 0.68).

Cost effectiveness studies of self management programmes for asthma have shown positive results, with cost benefit ratios between 1:2.5 and 1:11.22⁸; the programme with the most favourable result saved $11.22 (£7) for every $1 (£1.60) spent.

	Methods

Top Introduction Methods Setting up a self... References

This article is based largely on my experience as a pulmonary specialist, in charge of organising asthma treatment in my hospital district, and on studies of self management of asthma. I have also included the views of several national and international working groups in which I have participated, and I have supplemented reviews and articles from high quality journals.

	Setting up a self management programme for asthma

Top Introduction Methods Setting up a self... References

Although the reasons for starting a self management programme for asthma are obvious (box 1), it is not always an easy task to start this kind of programme. Giving asthmatic patients more responsibility and independence may be a cultural challenge for healthcare staff, and starting a new programme means additional workload. Patients' willingness to make decisions in their own asthma care can also be poor.⁹ Educating and motivating both patients and healthcare teams are crucial for a successful self management programme. The good results achieved with self management programmes should be emphasised and shown, and information supplied should be kept as clear and simple as possible.

There is reasonable consensus on the self management skills that patients should possess as a result of education (box 2).¹² Although research evaluating education for asthma has been conducted in many settingshospitals, emergency rooms, general practices, community organisations, hospital outpatient clinicsthere have been no studies assessing the effect of the setting on education. It would seem reasonable to expect that education should be available at every patient contact for each setting and that the information should be given in a structured form. In my experience, group sessions plus personal counselling is the most effective method for educating asthmatic patients. Good audiovisual material can give help and increase interest. Although asthmatic patients have a strong desire to be informed about their illness,⁹ their individual backgrounds will influence the extent to which they utilise information. The patient's own responsibility for treatment is crucial, and building a firm partnership with the patient is the key to success. The responsibility for treatment is borne by the patient and the primary healthcare system, supported by specialised medical care. In asthma self management the patients should not be seen as objects for treatment but rather as active participants in a treatment team.

Information alone is insufficient, and successful interventions combine the provision of information with individualised self treatment plans. Such action plans may be based on symptoms, peak expiratory flow values, or both.¹³ It is essential that patients notice exacerbations in their asthma (box 3) early enough and start appropriate interventions by themselves. Self management programmes for asthma have used different action limits or zones for peak expiratory flow or symptoms. Clear peak flow charts or pocket sized cards with colours to mark different action limits can be used. For example¹⁴:

• Asthma under control: peak expiratory flow values greater than 85% of personal bestuse regular treatment
• Asthma getting worse: peak expiratory flow values less than 85% of personal bestdouble dose of inhaled steroids
• Asthma severe: peak expiratory flow values less than 70% of personal beststart course of oral prednisone
• Asthma emergency: peak expiratory flow values less than 50% of personal bestgo to emergency room immediately.

Programmes for self management of asthma should be aimed primarily at those patients who probably will benefit the most (box 4), and programmes should be individualised to suit the patient.

In Finland, regional asthma networks according to the Finnish national asthma programme¹⁵ have been built up between general practice and specialised care to enforce the quality and continuity of asthma care. The experiences of these networks are good and they help asthma self management to work.

	Footnotes

   Competing interests: None declared.

	References

Top Introduction Methods Setting up a self... References

1.	Blainey D, Lomas D, Beale A, Partridge MR. The cost of acute asthmahow much is preventable? Health Trends 1991; 22: 151-153.
2.	Johnson AJ, Nunn AJ, Somner AR, Stableforth DE, Stewart CJ. Circumstances of death from asthma. BMJ 1984; 288: 1870-1875.
3.	Avery CH, March J, Brook RH. An assessment of the adequacy of self-care by adult asthmatics. J Community Health 1980; 5: 167-180[Medline].
4.	Partridge MR. Patients' self assessment and treatment strategies for acute asthma. Res Clin Forums 1993; 15: 65-73.
5.	Kendrick AH, Higgs CMB, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ 1993; 307: 422-424.
6.	Partridge MR. Self-management in adults with asthma. Patient Educ Counseling 1997; 32: 1-4[Medline].
7.	Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ, et al. Self-management education and regular practitioner review for adults with asthma. In: Cochrane Collaboration ed. Cochrane Library. Issue 2. Oxford: Update Software, 1999.
8.	Liljas B, Lahdensuo A. Is asthma self-management cost-effective? Patient Educ Counseling 1997; 32: 97-104.
9.	Gibson PG, Talbot PI, Toneguzzi RE, the Population Medicine Group. Self-management, autonomy and quality of life in asthma. Chest 1995; 107: 1003-1008[Abstract/Free Full Text].
10.	Osman LM, Abdalla MI, Beattle JAG, Ross SJ, Russell IT, Friend JA, et al. Reducing hospital admissions through computer supported education for asthma patients. BMJ 1994; 308: 568-571[Abstract/Free Full Text].
11.	Kleiger JH, Dirks JF. Medication compliance in chronic asthma patients. J Asthma Res 1979; 16: 93-96[Medline].
12.	American Lung Association Working Group. Standards for comprehensive asthma education programs. New York: ALA, 1998.
13.	Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice. BMJ 1990; 301: 1355-1359.
14.	Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996; 312: 748-752[Abstract/Free Full Text].
15.	Ministry of Social Affairs and Health. Asthma programme in Finland 1994-2004. Clin Exp Allergy 1996; 26(suppl1): 1-24.