Chapter 12 - part 3
Illustrative patient pathway to self care: asthma

Box 12.3:

Action plan you can suggest to patients to optimise control of their asthma

Management may be based on symptoms and/or peak flow readings completed in each box at the asthma review

Zone one/green zone (good control)

You do not have, or only have very slight, symptoms in the day, or at night

You can do all your normal activities without asthma symptoms

• Symptoms include: wheezing, coughing, shortness of breath, tightness of the chest
  
• Your best peak flow is ___
  
• Your peak flow is at or above (85% of your best) ___

Action plan

• Continue to take your usual asthma treatment
• Take your preventer medication every day even if you have no symptoms
• Take your reliever medication if you have symptoms

If you are always at this level, discuss stepping down your medication at your next asthma clinic review.

Zone two/yellow zone (moderately worse)

Your asthma is worse and not well controlled if:

• you need to use your reliever inhaler more than once a day
  
• you have difficulty sleeping because of asthma
  
• your peak flow reading has fallen to between 70% to 80% of your best ___

Action plan

• Increase preventer 1 to: Number of puffs/doses/day ___
• Increase preventer 2 to: Number of puffs/doses/day ___
• Stay on this dose until you have had no symptoms for: Number of days: ___
  
• Then reduce your dose of preventer to that in Level one
• Continue to take your reliever as needed all the time
  
• Contact your doctor or nurse for advice if you do not improve in Number of days: ___

Your doctor or nurse will discuss your inhaler with you and perhaps check your technique.Youmaybe started on a different medicine to control your symptoms.

If you are often at Level two, but do not need to contact your doctor or nurse each time, let them know at the next asthma review. You may need your medication increased or changed.

Zone three/yellow zone (much more severe)

Your asthma is much worse and poorly controlled if:

• you need to take your inhaler every four hours or even more often
• your symptoms are there all the time
• your peak flow reading is between 50% and 75% of your best

Action plan

• Take your preventer medication at the higher dose as listed in Level two
  
• Continue to take your reliever when you need it
• If you have been prescribed steroid tablets, take 5mg prednisolone tablets (number) . . . . . . . . . . immediately and repeat each day for . . . . . . . . . . days or until your symptoms have improved or your peak flow has been at . . . . . . . . . . for two days
  
• Let your doctor or nurse know within 24 to 36 hours if you start a course of steroids (delete if not required)
  
• Let your doctor or nurse know within 36 to 48 hours if you are not improving
  after starting a course of steroids

If you are often at Level three but have not needed to contact the doctor or nurse, let themknowat your next asthma review so that your usual medication can be adjusted.

Zone four/red zone (emergency)

Symptoms indicating an emergency are:

• your reliever is not helping
  
• your symptoms are getting worse (wheeze, cough, breathlessness, tightchest)
  
• you are too breathless to speak a sentence
  
• your peak flow reading is below

Action plan

• Sit up and loosen any tight clothing
• Take one puff/dose of your reliever every minute for five minutes or until symptoms improve
• If symptoms do not improve after five minutes, call 999

Box 12.4:

A structured asthma care programme

1 Find the resources for written action plans and information leaflets. Nonpromotional material is available from Asthma UK.5

2 Everyone on the team should give consistent advice.

3 Discuss how to deliver the programme, e.g. target those with most severe symptoms or everyone, integration of advice into usual care or into asthma clinics (or both), one-to-one consultations and/or in groups.

4 Tailor the education and advice to the individual needs of the patient. Some will want greater autonomy than others; and levels of ability to understand or to self care will vary.

5 Ensure that individuals know where to obtain further advice if the action plan does not provide the answer (a safety net).

Box 12.5:

Possible content of an educational programme

1 The nature of the disease

2 What triggers exist for that patient and how they can be avoided or reduced

3 How asthma can be treated

4 Which effects of asthma the patient wants to control most

5 How to use the treatment

6 How to recognise the zones of deterioration

7 What barriers the patient has against recognising when the asthma is affecting them or against using treatment

8 Co-operation in designing the action plan to suit the needs of the patient

9 How to recognise the need for urgent help and how to obtain it

Tailor the information you give to the individual. Take into account the patient’s educational level, reading ability, understanding, social and emotional factors, as well as their physical health. Take a look at the Joining Up Self Care initiative online.19