Personal asthma action plans (PAAPs) are written plans that explain to the patient the actions to take to manage their asthma. They are an essential tool to keep children, young people and adults with asthma as well as possible. They enable self-care and help parents of younger children to support their child at home. It is also useful for PAAPs to be shared with schools and other family members who may share childcare responsibilities, so they are aware of how to support a child.
PAAPs are normally developed in partnership with the patient or carer in primary care or, occasionally, in the case of more severe asthma, in partnership with a specialist asthma team. It is important that general practice nurses value PAAPs and use them as a tool within consultations to help with education and understanding.
Rationale
The National Review of Asthma Deaths (NRAD) (Royal College of Physicians, 2014) investigated the clinical records of 195 adults and children who died of asthma between February 2012 and January 2013. One of the many findings was that the patients' understanding of how to manage their asthma and when to seek help was extremely poor. For example, 45% of patients died without seeking medical assistance or before emergency assistance arrived. The knowledge and expertise of health professionals was also poor, with only 23% of the people who died having been given a PAAP.
Royal College of Physicians (2014) recommended that:
‘All people with asthma should be provided with written guidance in the form of a personal asthma action plan (PAAP) that details their own triggers and current treatment and specifies how to prevent relapse and when and how to seek help in an emergency.’
Encouragingly, Asthma UK found that the proportion of people with asthma who have a written asthma action plan is now over half (52.3%) for the first time – an increase of 29% on their findings in 2013 (Asthma UK, 2019).
The core elements of a PAAP
There are 3 core elements to a PAAP:
- A plan of the routine medication that the patient should take, and when, to stay well
- What to do if asthma symptoms worsen
- What to do in the case of an asthma attack and when to call 999.
These three stages are traffic lighted green (routine), yellow (warning that control is starting to go off track) and red (emergency). It is important that general practice nurses stress the importance of staying in the green zone and avoiding the yellow, which puts them at risk of an asthma attack.
Local asthma networks may design their own versions that map to their clinical pathways and prescribing guidelines. Therefore, it is important that nurses use the locally approved plan. In the absence of local plans, nurses can easily download and use template plans, the most common being the adult and child PAAP from Asthma UK (www.asthma.org.uk), which can also be downloaded in Welsh and in common South Asian languages. It is important to check for literacy issues and inquire whether immigrants and asylum seekers can read in their own language. Those on maintenance and reliever therapy (S/MART) regimes may have specific PAAPs. Some clinical IT systems also have template PAAPs. In any case, it is important to keep an electronic copy on the clinical system so the team can view and amend it.
Box 1.Pandemic measuresDuring the current pandemic, most routine asthma consultations are being performed remotely. Discussions with general practice nurses by the author in a closed Facebook forum revealed the sharing of personal asthma action plans (PAAPs) occurred in the following ways:
- Some clinical systems have editable PAAP templates
- Using Asthma UK templates and saving on their clinical system desktops
- PAAPs can then be saved and either emailed or texted to patients as an attachment
- Some sent hard copies through the post for those without internet or printers
- Inviting the patient to download the PAAP from Asthma UK's website and talk it though.
There are spaces to complete on a standard PAAP template. These are there to guide and personalise, so nurses should not hesitate to scribble out and write notes on it that best fit the patient's own situation.
Green zone
The green zone is where nurses will write down the patient's routine medications and dosages in the PAAP template. Nurses should explain the importance of remembering to take preventer medications and have the patient/carer repeat it back to ensure understanding. Talking to the patient about any relevant health issues such as their weight or smoking is also important.
Write down the patient's best peak expiratory flow rate (PEFR) score: this is the score they reach when their treatment has been established. The best PEFR should be a recent one – at least recorded in the last 2 years for an adult and yearly for a growing child. Check the patient's inhaler technique and point them towards inhaler technique videos (such as those on the Asthma UK website) so they can check back at intervals to make sure their technique is good. If the patient's asthma has been stable then consider whether their treatment could be stepped down.
Often there is a space for other medicines and devices to be recorded. This is where to add:
- Spacer devices or nebulisers
- Oral asthma medications
- Related medications, such as for gastric reflux.
Yellow zone
The yellow zone lists signs that indicate to the patient that their asthma is getting worse:
- Wheeze, tightness, breathlessness, cough
- Nocturnal wakening
- Interference in daily activities
- Using their reliever more than 3 times a week
- A PEFR that drops below around 60–80% of their best score (Primary Care Respiratory Society, 2019) – the nurse should write in the score chosen as a threshold, bearing in mind the patient's history. Check here that the patient wants to monitor their peak flow and has a meter at home.
Next, the nurse would indicate the actions the patient would take. This is the most critical part of the plan, as there is a window of 1–3 days to take action to reduce the inflammation in the lungs (Primary Care Respiratory Society, 2019). Actions may include:
- Increasing the number of doses of steroid inhaler
- SMART/MART therapy – those on combination therapy need instruction on how to use these treatments as a reliever. Generally, doses can increase to around 8–12 puffs a day depending on the drug. Drug manufacturers often supply PAAPs for those on S/MART regimes
- Start a course of rescue steroids that the patient keeps at home (following which they must contact the practice straight away for review).
Red zone
The red zone lists signs that indicate to the patient that they are having an asthma attack:
- Reliever inhaler or S/MART inhaler not helping/needing it more than every 4 hours
- Increasing difficulty breathing
- Difficult to talk and walk
- Worsening wheeze/cough
- PEFR of 40–60% or below – however, do stress that it is more important that the patient takes action depending on how they feel rather than relying on numbers.
Actions to take:
- Sit up straight
- Take 1 puff of reliever inhaler every minute for 10 mins
- If not improving or feeling worse, dial 999
- Repeat step 2 until the ambulance arrives
There is a balance to strike here between not frightening the patient (or parents) but explaining the severity of being in the red zone and that an asthma attack is a potentially life-threatening emergency.
PAAPs then advise the patient to make an appointment with the nurse within 48 hours for a review.
PAAPs in the Quality and Outcomes Framework
The Quality and Outcomes Framework (QOF) in primary care is a voluntary annual reward and incentive programme for GP practices in England, Wales and Northern Ireland. In 2016, QOF was abolished in Scotland and replaced by a requirement for GPs to take part in local peer-led quality improvement activities (GP Quality Clusters). The QOF requires that for every patient aged 6 years and over coded as having asthma on the clinical system that all the following are completed during an annual asthma review in order to trigger the incentive payment (NHS England, 2020):
- A valid and reliable Asthma Control Test (ACT)
- Number of exacerbations recorded in past year
- Asthma annual review
- Asthma action plan.
Asthma control and education are considered in more detail below.
Asthma control
The PAAP will be reviewed in the light of how well asthma is controlled. This is done by asking/looking back at the number of exacerbations (if any) recorded in the clinical system and the administration of an ACT. It is also good practice to review the number of repeat prescriptions issued. This will allow an assessment of whether the patient is requesting sufficient preventer inhalers or over-ordering reliever inhalers (this will not apply to those on MART regimes unless they have been supplied with a separate reliever inhaler).
If the asthma appears to be uncontrolled, nurses should consider the possible reasons below before adjusting medicines and making changes to the PAAP (NHS England, 2020):
- Alternative diagnoses
- Smoking (active or passive)
- Poor inhaler technique
- Lack of adherence
- Occupation exposures
- Psychosocial factors
- Seasonal or environmental factors.
Education
To manage their asthma adequately at home, patients will need regular education about what asthma is, an understanding of their triggers, how their medications work and managing their devices (British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2019. Since it is hard for patients/families to digest a lot of information during a single consultation and consultation times are short, education should be an ongoing process. Every consultation offers the opportunity to review, reinforce and extend knowledge, with a written asthma action plan as a central organising document (Lennon, J undated).
Understanding the difference between adherence and concordance
It is estimated that between two-thirds to one-half of all medications prescribed for long-term conditions are not taken as recommended (National Institute for Health and Care Excellence [NICE], 2009). There is widespread non-adherence to taking preventer medications regularly (NICE, 2009).
Adherence signifies the objective measurement of prescribed medication or monitoring of control. Concordance indicates that the patient/family and the health professional has come to a negotiated agreement about management and self-care. To facilitate adherence, the relationship between the nurse and the patient/family is crucial. This requires nurses to listen and form a close working relationship with the patient/family to develop an asthma action plan that is not only clinically effective, but also one that the patient/family understands and fits with their lifestyle and beliefs.
General practice nurses should ensure that they discuss the balance between the potential benefits and necessity of taking prescribed treatment and the perceived disadvantages or concerns of the patient or family about taking medication (Foot et al, 2016). The relative weight of these opposing arguments influences the decision to take medication or not.
Summary
- PAAPs are personalised documents that should be a central feature of a consultation
- They act as an essential self-management tool to help patients recognise and react when their asthma is suboptimal
- Valid and reliable ACTs enable a measurable assessment of control
- One of the main reasons for poor control is poor concordance with treatment. Understanding patients' concerns and beliefs is important
- PAAPs generally have three sections covering routine care, deteriorating asthma and emergency care
- Asthma education is an ongoing process at each consultation.
KEY POINTS:
- Personal asthma action plans (PAAPs) are written plans that explain to the patient the actions to take to manage their asthma
- There are three stages to a PAAP. These three stages are traffic lighted green (routine), yellow (warning that control is starting to go off track) and red (emergency)
- It is important that general practice nurses stress the importance of staying in the green zone and avoiding the yellow, which puts them at risk of an asthma attack
- The PAAP should be reviewed in the light of how well asthma is controlled. Asthma education is an ongoing process at each consultation
CPD reflective practice:
- Why are personal asthma action plans (PAAPs) important?
- How could you determine whether a patient's asthma is well-controlled?
- Can you describe the difference between adherence and concordance?
- Reflecting on your practice, could you increase the number of patients who have a PAAP?
Useful resources
- Asthma UK. Downloadable personal asthma action plan. 2021 https://www.asthma.org.uk/ccb4c070/globalassets/health-advice/resources/adults/asthmaactionplanadult-2021-final-editable.pdf
- Asthma UK. Inhaler technique videos: short videos for patients to learn how to use their inhaler properly and better manage their respiratory symptoms. How to use your inhaler: https://www.asthma.org.uk/advice/inhaler-videos/