Asthma Management Handbook

Checking whether the person has problems taking their medicine

Recommendations

Check that the patient or parent/carer understands:

  • the condition
  • the current treatment plan, including when and how much to take
  • the actions to take when symptoms worsen.

Make sure they have an up-to-date written asthma action plan.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

Do not assume that the recorded dose is the dose the person is currently taking.

Ask which asthma medicines the person is using, how, at what dose, and when.

Note: Use non-judgmental words and an empathic tone, e.g: Acknowledge that many people don’t take their medication every day for different reasons.

Ask: In the last four weeks:

  • How many days a week would you have taken your preventer medication? None at all? One? Two? (etc).

  • ​How many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)

  • Each time, how many puffs would you take? One? Two? (etc).

Do you find it easier to remember your medication in the morning, or the evening?

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to named source(s):

  • Foster et al. 20121

Last reviewed version 2.0

Ask the person or parents about how they are managing with their asthma medication, to identify any common barriers to optimal use of medicines. Encourage them to tell you if they don’t see the value of taking it, or if the cost of medicine is a burden.

Common barriers include:

  • misunderstanding purpose of medicines
  • concerns about side effects
  • taking wrong dose
  • skipping doses or delaying buying prescription medicines to save on treatment costs
  • incorrect inhaler technique
  • poor perception of airflow limitation
  • social pressure from peer group, employer, colleagues or family (e.g. expectation that should have grown out of asthma)
  • beliefs about health that conflict with or undermine confidence in conventional asthma medicines.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

If the cost of medicines is problem, consider whether there are any ways to reduce cost to the person.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to named source(s):

  • Reddel et al. 2018 2

Last reviewed version 2.0

If you suspect over-reliance on short-acting beta2 agonist reliever and low use of preventer for a patient for whom a preventer has been prescribed, counsel the person about the risk of reliever over-use.

Note:

Sample:

Many people see their reliever as convenient, safe and effective, but don’t feel comfortable taking a preventer every day.

In reality it’s the other way around: we know that people who rely too much on their reliever have a higher risk of very severe and even life-threatening asthma attacks. On the other hand, taking a low dose of a preventer every day is much safer and protective.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to named source(s):

  • Reddel et al. 2017 3

Last reviewed version 2.0

Check inhaler technique by asking the person to demonstrate how they use their inhaler while watching carefully and checking against the checklist of correct steps for the particular device type. Correct any problems by demonstrating proper technique and coaching the person, then checking technique is now correct.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

For patients who have difficulty using their asthma medicines, consider referral to an asthma educator, MedsCheck by a community pharmacist, or Home Medicines Review by an accredited pharmacist (if eligible) – particularly for those who need to take multiple medicines (e.g. for concurrent conditions).

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

More information

Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.4

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

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Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.5 Written asthma action plans are effective if based on symptoms6 or personal best peak expiratory flow (not on percentage predicted).5

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans78 is available online.

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Written asthma action plans for children

Every child with asthma should have their own written asthma action plan.

A systematic review found that the use of written asthma action plans significantly reduces the rate of visits to acute care facilities, the number of school days missed and night-time waking, and improves symptoms.9 

For children and adolescents, written asthma action plans that are based on symptoms appear to be more effective than action plans based on peak expiratory flow monitoring.9

A written asthma action plan should include all the following:

  • a list of the child’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on what to do in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name and contact details of the child’s emergency contact person (e.g. parent)
  • the name of the person writing the action plan, and the date it was issued.

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate)
  • Children’s written asthma action plans.

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans78 is available online.

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Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,10, 11,1212, 13 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.10, 11, 14, 15, 16, 17

Poor asthma symptom control is often due to incorrect inhaler technique.18, 19

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

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Administration of inhaled medicines in children: 1-5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

Types of inhalers suitable for preschool children

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with actuating the device.20 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.20

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.21 Filter studies have shown high day-to-day variability in delivered doses in preschool children.20 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

Pressurised metered-dose inhalers plus spacers for relievers

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.20 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.22

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).23 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.24

Face masks for infants

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face.

When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.22 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

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Administration of inhaled medicines in children: 6 years and over

Parents, carers and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children (depending on the child’s age, ability, and with individualised training) can learn to use a range of inhaler types, including manually actuated pressurised metered-dose inhalers with spacers, breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).25, 26, 27, 28, 29

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.27

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.30

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Home Medicines Review and MedsCheck

Home Medicines Review

A Home Medicines Review involves the patient, their GP, an accredited pharmacist and a community pharmacy. Referral (Medicare Item 900) may be either direct to an accredited pharmacist, or to a community pharmacy that uses the services of an accredited pharmacist.

The accredited pharmacist visits the patient at their home, reviews their medicine regimen and provides a report to the person’s GP and usual community pharmacy. The GP and patient then agree on a medication management plan.

The aims of Home Medicines Review include detecting and overcoming any problems with the person’s medicines regimen, and improving the patient’s knowledge and understanding of their medicines.

Patients could be eligible for a Home Medicines Review if they (any of):

  • take more than 12 doses of medicine per day
  • have difficulty managing their own medicines because of literacy or language difficulties, or impaired eyesight
  • visit multiple specialists
  • have been discharged from hospital in the previous four weeks
  • have changed their medicines regimen during the past 3 months
  • have experienced a change in their medical condition or abilities
  • are not showing improvement in their condition despite treatment
  • have problems managing their delivery device
  • have problems taking medicines because of confusion, limited dexterity or poor eyesight.

MedsCheck

MedsCheck involves review of a patient’s medicines by a registered pharmacist within the pharmacy.

Patients are eligible if they take multiple medicines, and they do not need a referral from a GP.

The pharmacist makes a list of all the person’s medicines and medication or monitoring devices, and discusses them with the patient to identify any problems. If necessary, the pharmacist refers any issues back to the person’s GP or other health professional.

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Self-monitoring in adults using peak expiratory flow

Peak flow monitoring is no longer routinely used in Australia, but is recommended for patients with severe asthma, a history of frequent flare-ups, or poor perception of airflow limitation.

Peak expiratory flow can be monitored at home using a mechanical or electronic peak flow meter, either regularly every day or when symptoms are worse. For patients who are willing to measure peak flow regularly, morning and evening readings can be plotted on a graph or recorded in a diary.

When peak flow monitoring results are recorded on a graph, the same chart should be used consistently so that patterns can be recognised. Flare-ups are easier to detect when the chart or image has a low ratio of width to height (aspect ratio), i.e. is compressed horizontally.31

When a person’s written asthma action plan is based on peak expiratory flow, instructions should be based on personal best, rather than predicted values. Personal best can be determined as the highest reading over the previous 2 weeks. When a person begins high-dose inhaled corticosteroid treatment, personal best peak expiratory flow reaches a plateau within a few weeks with twice daily monitoring.32

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Managing the costs of asthma medicines

Most adults and older adolescents with asthma should be taking a preventer inhaler to minimise symptoms, prevent loss of lung function over time, and to reduce the risk of flare-ups and asthma-related death.

For most patients, most of these benefits can be achieved with low doses of inhaled corticosteroids, provided that they are taken regularly and with correct inhaler technique.2

Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (microg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Despite PBS subsidisation, out-of-pocket cost is a major factor contributing to poor adherence to treatment to asthma treatment in Australia.2

The average cost to patients of treatment with low-dose inhaled corticosteroid is significantly lower than for combinations of an inhaled corticosteroid and a long-acting beta2 agonist.2

The dose, frequency of administration and number of actuations in the inhaler affect the cost to the patient, so prescribing choices could make the treatment more affordable.2 The cost of preventer treatment to the patient per month can range from less than $1 to more than $50.2

Prescribers should consider cost as a factor when prescribing, and should explain the cost of each option when discussing treatment options with the person.

Patients can save costs by using their inhaler correctly, so that the medicine is not wasted and the maximal therapeutic benefit is achieved from the lowest possible dose.

Short-acting beta2 agonists are generally less expensive per inhaler unit than preventers, so patients with financial concerns might try to manage with reliever only. Pharmacists and prescribers should discuss the different purposes of relievers and preventers, emphasising that overreliance on relievers increases the risk of severe flare-ups, and does not treat asthma itself. Long-term costs may be reduced through better control with regular preventer treatment.

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Psychosocial factors affecting asthma self-management

Psychosocial factors can affect asthma symptoms and outcomes in children and adults. These can include biological, individual, family and community-level factors, which can have synergistic effects in an individual with asthma.33 Mechanisms may include effects of stress on the immune system33 and effects of life circumstances on patients’ and families’ ability to manage asthma.

Relationships between psychosocial and cultural factors

Important influences on asthma outcomes include the person’s asthma knowledge and beliefs, confidence in ability to self-manage, perceived barriers to healthcare, socioeconomic status, and healthcare system navigation skills, and by the quality of interaction and communication between patient and healthcare provider.34 There is a complex interrelationship between:34

  • patient factors (e.g. health literacy, health beliefs, ethnicity, educational level, social support, cultural beliefs, comorbidities, mental health)
  • healthcare provider factors (e.g. communication skills, teaching abilities, available time, educational resources and skills in working with people from different backgrounds)
  • healthcare system factors (e.g. the complexity of the system, the healthcare delivery model, the degree to which the system is oriented towards chronic disease management or acute care, and the degree to which the system is sensitive to sociocultural needs).

Health literacy

‘Health literacy’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.35 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.34

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.34 Poor health literacy has been associated with poor asthma control,36 poor knowledge of medications,37 and incorrect inhaler technique.37 Aspects of health literacy that have been associated with poorer asthma outcomes in adults include reading skills, listening skills, numeracy skills, and combinations of these.34 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.34 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.34

Australian research suggests that there are probably many Australians with limited health literacy.38 It may be possible to identify some groups of patients more likely to have inadequate health literacy, such as people living in regions with low socioeconomic status, and those with low English literacy (e.g. people with limited education, members of some ethnic minorities, immigrants, and the elderly).34 However, even well-educated patients might have trouble with basic health literacy skills.34

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.34 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.34 Accordingly, all self-management skills need to be explained carefully, simply and repeatedly, and all written material should be clear and easy to read. Special consideration is needed for patients from culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander people.

Psychosocial support and improving health literacy

Psychosocial interventions that include asthma education may improve health-related quality of life for children and adolescents with asthma and their families.39 However, simply providing education might not improve a person’s health literacy, since it also depends on other factors like socioeconomic status, social support, and is influence by the provider and the healthcare system.34

Asthma Australia provides personal support and information for people with asthma and parents of children with asthma through the Asthma Australia Information line by telephone on 1800 Asthma (1800 278 462) or online.

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Psychosocial factors affecting adolescent health

Adolescence is a time of rapid growth and physical, cognitive, emotional and social development. An adolescent’s age is not a reliable indicator of maturity in each of these areas.40

Mental health disorders (e.g. depression, anxiety, eating disorders) are common and clinically important among young people.40 A significant proportion of adult mental health problems emerge during adolescence.40

Adolescence is also a time when people can begin risky behaviours (e.g. smoking, poor eating habits, physical inactivity, and drug and alcohol use), which can continue into adulthood.40, 41 Although smoking rates among adolescents and young people are declining,42 approximately 6% of adolescents aged 15–17 years smoke, and 4% smoke at least daily.43 Smoking rates are higher among Aboriginal and Torres Strait Islander young people, young people living in rural and remote communities, and young people of lower socioeconomic status.4442

Adolescents with chronic disease show higher rates of health risk behaviours than healthy adolescents.4045 Some risk behaviours are based on incorrect health beliefs (e.g. the myth that smoking cannabis is good for asthma).

Risk-taking behaviour – as well as poor understanding of their health condition – may contribute to the higher rate of food-induced fatal anaphylaxis among adolescents and young adults, compared with other age groups.46

Depression, risk behaviours and poor adherence to medicines are interrelated.47 Adolescents with asthma who adhere poorly to asthma treatment and hide their asthma are more likely to start smoking than other adolescents with asthma.48 Among adolescent boys, those with lower quality of life are most likely to start smoking.48

Adolescents often wish to discuss their health concerns with health professionals but are reluctant to discuss sensitive issues unless asked directly and confidentially.40

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Living with asthma

People’s experiences of asthma

More than three-quarters of Australians with asthma describe their general health as ‘good’ to ‘excellent’.49 However, the experience of living with asthma differs between individuals.

Experiences of asthma reported in research studies are diverse. They include:50

  • frightening physical symptoms experience as ‘panicky’, a sensation of ‘choking’, ‘breathing through a straw’, ‘suffocating’ or ‘drowning’
  • feeling judged by others (family, employers/colleagues)
  • self-judgement (e.g. believing that asthma is not a legitimate reason for absence from work)
  • fearing dependency on medications
  • fearing or experiencing side effects from medication
  • fearing unpredictability of asthma symptoms that could occur while out
  • wishing to be ‘normal’.

Living with severe asthma

Studies of adults with severe asthma have identified frequently reported needs and goals, including:51

  • achieving greater personal control over their conditions by gaining knowledge about symptoms and treatment. This included receiving more information about asthma from health professionals.
  • being able to ask questions without feeling rushed during consultations
  • being involved in making decisions about their treatment
  • striving for a normal life.

People with severe asthma report a range of problems, including:5152

  • troublesome adverse effects of oral corticosteroids (e.g. weight gain, ‘puffy face’, anxiety, irritability and depression) – these can affect social relationships and cause some people reduce or stop their use
  • feelings of panic and fear of asthma symptoms – some people avoid activities and situations due to severe asthma
  • emotional distress
  • stigma
  • restrictions on social life or ability to play with children
  • restrictions on everyday activities including chores or leisure activities
  • effects on working life, including absences or the need to change occupation or give up work
  • being misunderstood by other people, who expect the person’s asthma to be readily controlled as for milder asthma
  • a sense of lack of support from their healthcare providers, including the perception that doctors did not have time to discuss asthma.

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Asthma self-management for adults

Effective self-management requires:

  • adherence to the agreed treatment regimen
  • correct use of inhaler devices for asthma medicines
  • monitoring asthma control (symptoms, with addition of peak expiratory flow for some patients)
  • having an up-to-date written asthma action plan and following it when asthma worsens
  • management of triggers or avoidance (if appropriate)
  • regular medical review.

Self-monitoring of asthma

Self-monitoring by the patient, based on symptoms and/or peak expiratory flow, is an important component of effective asthma self-management.53

For most patients, a daily diary is not necessary. Patients should be trained to take note if their symptoms worsen or their reliever use increases, so they can implement their written asthma action plan and/or get medical care as appropriate.

Internet-based self-management algorithms in which patients adjust their treatment monthly on the basis of control scores have been reported to be more effective than usual care.54 In patients with partly and uncontrolled asthma, weekly self-monitoring and monthly treatment adjustment may improve asthma control.55

Asthma self-management education

Patients need careful asthma education to enable them to manage their asthma effectively.

Education in asthma self-management that involves self-monitoring (by either peak expiratory flow or symptoms), regular medical review and a written action plan improves health outcomes for adults with asthma.53 Training programs that enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.53

Information alone does not appear to improve health outcomes in adults with asthma,  although perceived symptoms may improve.56

Structured group asthma education programs are available in some regions. Contact Asthma Australia in your state or territory for information about available asthma education programs.

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Asthma self-management for adolescents

Children’s knowledge of asthma improves during adolescence.57 However, the latest available data show that less than one in five (18%) Australian adolescents has a written asthma action plan, and only 28% have discussed their asthma management plan with their GP within the previous 12 months.58

During adolescence, young people get their asthma knowledge mainly from parents.57 Adolescents whose parents were born overseas in countries with a lower asthma prevalence may have less knowledge of asthma. Chronic disease carries stigma in some communities, particularly Asian cultures. Children and adolescents from culturally and linguistically diverse communities may be expected to self-manage at a younger age and with less monitoring by parents, and so may need more support and education.

Specialised asthma nurses and asthma and respiratory educators are an invaluable resource for instruction, training and providing support for adolescents with asthma and their families.

Self-management programs

Asthma self-management education programs designed for adolescents can improve asthma-related quality of life,59606162 improve asthma knowledge,596063 improve ability to use a spacer correctly,59 improve adolescents’ confidence or belief in their ability (self-efficacy) to manage their asthma,5962 increase behaviour to prevent asthma symptoms,62 increase use of preventer medicines,62 increase use of written asthma action plans,62 reduce symptoms5962 reduce limitation of activity due to asthma,62 reduce school absences due to asthma,5962 and reduce rates of acute care visits, emergency department visits, and hospitalisations.62

However, there is not enough evidence to determine which types of self-management programs for adolescents are most effective or the most important components of programs. (Few RCTs directly compared different programs.)

Most of the asthma programs designed for adolescents have been run in schools.

Peer-led asthma programs

Several studies have shown that adolescents can be trained to teach their peers about asthma self-management and motivate them to avoid smoking.606164 Asthma self-management programs for adolescents that use peer leaders can:

  • significantly influence self-management behaviour, compared with adult-led programs64
  • achieve clinically important improvements in health-related quality of life,6061 increase adolescents’ belief in their ability (self-efficacy) to resist smoking,60 and increase asthma self-management knowledge60 (compared with adolescents at schools not involved in this type of program60 or with baseline61)
  • may be particularly beneficial for boys from low socioeconomic status background.61

The Triple A (Adolescent Asthma Action) program is a school-based peer-led adolescent asthma self-management education program developed in Australia.65

Use of technology to support self-care

Providing asthma education messages through technologies that adolescents use every day (e.g. internet, phones, interactive video)666768 may be an effective way to deliver asthma health messages, compared with traditional media or with strategies that are not tailored for adolescents.

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Asthma education programs for parents/carers and children

Asthma education for children and/or caregivers reduces the risk of emergency department visit for asthma, compared with usual care.69

However, the most effective components of education have not been clearly identified.6970 There have been relatively few Australian controlled trials assessing education programs.70

There is not enough evidence to tell whether asthma education programs in the child’s home are more effective in helping control asthma than asthma education provided somewhere else or standard care,70 or to identify which types of education is more effective.

All age groups

A systematic review71 found that asthma education programs were associated with moderate improvement in lung function and with a small reduction in school absence, restriction of physical activity, and emergency department visits. The greatest effects were in children with more severe asthma.71

Another systematic review found that educational programmes for the self-management of asthma in children and adolescents improved lung function, reduced the number of school days missed and the number of days with restricted activity, reduced the rate of visits to an emergency department, and possibly reduced the number of disturbed nights.72

0-5 years

There is little evidence about the effects of education for parents of preschool-aged children with asthma or wheezing. Most studies have investigated the effects of asthma management education for older children and their parents.20 Limited evidence suggests that:

  • education for parents of preschool children (e.g. written information and review by a health professional, small-group teaching by nurses or education in the family’s home) may help improve asthma control20
  • education programs are more likely to be effective if they involve multiple sessions, each longer than 20 minutes’ duration.20

Opportunistic asthma education

In addition to the types of structured or formal asthma education evaluated in research trials, all health professionals who work with children with asthma and their parents/carers can provide asthma education whenever the opportunity occurs.

Table. Childhood asthma education checklist Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/30

Resources

Education resources are available from the National Asthma Council Australia, Asthma Australia, and the Asthma Foundation in your state or territory.

Last reviewed version 2.0

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