Providing information, skills and tools for asthma self-management for adults
Provide or arrange education in asthma self-management, including (all of):
- self-monitoring of asthma control based on symptoms (and peak expiratory flow monitoring, if used)
- inhaler technique
- a written asthma action plan
- the importance of regular medical review.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):
Check the person’s inhaler technique at each encounter:
- Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
- Demonstrate correct technique using a placebo device and correct any specific errors identified.
- Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
Watch the person use their inhaler – don’t just ask if they think they know how to use it properly.
Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on National Asthma Council Australia’s website.
Advise patients to seek emergency medical care immediately if they experience any of these danger signs:
- severe breathing problems
- symptoms get worse very quickly
- reliever has little or no effect
- difficulty saying sentences
- blue lips
The person and their family should know that they must call an ambulance and give asthma first aid if they see any of these danger signs.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
- 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.1
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.7 In patients with partly and uncontrolled asthma, weekly self-monitoring and monthly treatment adjustment may improve asthma control.8
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.1 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.1
Information alone does not appear to improve health outcomes in adults with asthma, although perceived symptoms may improve.2
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.Close
- 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.9
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
- 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.3 Written asthma action plans are effective if based on symptoms5 or personal best peak expiratory flow (not on percentage predicted).3
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 Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/42
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.Close
- Correct use of inhaler devices
High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,14, 15, 16, 17, 18 even among regular users.19 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.20
Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.14, 21, 19, 22, 23 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.19
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalers include:20
- failing to shake the inhaler before actuating
- holding the inhaler in wrong position
- failing to exhale fully before actuating the inhaler
- actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
- actuating the inhaler too late while inhaling
- actuating more than once while inhaling
- inhaling too rapidly (this can be especially difficult for chilren to overcome)
- multiple actuations without shaking between doses.
Common errors for dry powder inhalers include:20
- not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
- failing to exhale fully before inhaling
- failing to inhale completely
- inhaling too slowly and weakly
- exhaling into the device mouthpiece before or after inhaling
- failing to close the inhaler after use
- using past the expiry date or when empty.
Other common problems include:
- difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
- inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
- inability to generate adequate inspiratory flow for the inhaler type
- failure to use a spacer when appropriate
- use of incorrect size mask
- inappropriate use of a mask with a spacer in older children.
How to improve patients’ inhaler technique
Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.20 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.26, 14, 27, 28 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.27 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).12, 25
The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.Close
- 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.29
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.30Close
- 'Wheeze-detecting' devices
Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio recording and analysis.
There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma control in adults or children, or in distinguishing wheeze from other airway sounds in children.
- Over-reliance on these devices could result in over- or under-treatment.
- 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.31 Mechanisms may include effects of stress on the immune system31 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.32 There is a complex interrelationship between:32
- 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’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.33 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.32
Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.32 Poor health literacy has been associated with poor asthma control,34 poor knowledge of medications,35 and incorrect inhaler technique.35 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.32 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.32 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.32
Australian research suggests that there are probably many Australians with limited health literacy.36 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).32 However, even well-educated patients might have trouble with basic health literacy skills.32
Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.32 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.32 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.37 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.32
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.Close
- Gibson PG, Powell H, Wilson A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD001117. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001117/full
- Gibson PG, Powell H, Wilson A, et al. Limited (information only) patient education programs for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 1: CD001005. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001005/full
- Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004; 59: 94-99. Available from: http://thorax.bmj.com/content/59/2/94.full
- National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2008. Available from: http://www.nationalasthma.org.au/publication/inhaler-technique-in-adults-with-asthma-or-copd
- Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD004107. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004107/full
- Basheti IA, Bosnic-Anticevich SZ, Armour CL, Reddel HK. Checklists for dry powder inhaler technique: a review and recommendations. Respir Care. In press 2013. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24129338
- van der Meer V, Bakker MJ, van den Hout WB, et al. Internet-based self-management plus education compared with usual care in asthma: a randomized trial. Ann Intern Med. 2009; 151: 110-20. Available from: http://annals.org/article.aspx?articleid=744598
- van der Meer V, van Stel HF, Bakker MJ, et al. Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study. Respir Res. 2010; 11: 74. Available from: http://respiratory-research.com/content/11/1/74
- Wilson SR, Strub P, Buist SA, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010; 181: 566-77. Available from: http://ajrccm.atsjournals.org/content/181/6/566.full
- Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
- Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
- Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
- Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
- Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
- Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
- Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
- Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
- National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
- Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
- Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
- Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
- Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
- Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
- Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
- Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
- Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924
- Jansen J, McCaffery KJ, Hayen A, et al. Impact of graphic format on perception of change in biological data: implications for health monitoring in conditions such as asthma. Prim Care Respir J. 2012; 21: 94-100. Available from: http://www.nature.com/articles/pcrj20124
- Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans?. Thorax. 2004; 59: 922-4. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746886/
- Yonas MA, Lange NE, Celedon JC. Psychosocial stress and asthma morbidity. Curr Opin Allergy Clin Immunol. 2012; 12: 202-10. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320729/
- Rosas-Salazar C, Apter AJ, Canino G, Celedon JC. Health literacy and asthma. J Allergy Clin Immunol. 2012; 129: 935-42. Available from: http://www.jacionline.org/article/S0091-6749(12)00128-5/fulltext
- Ratzan S, Parker R. Introduction. In: Selden C, Zorn M, Ratzan S, Parker R, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, USA, 2000; v-vi. Available from: http://www.nlm.nih.gov/archive//20061214/pubs/cbm/hliteracy.html
- Adams RJ, Appleton SL, Hill CL, et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol. 2009; 124: 601-603. Available from: http://www.jacionline.org/article/S0091-6749(09)00859-8/fulltext
- Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005; 172: 980-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718412/
- Adams RJ, Appleton SL, Hill CL, et al. Risks associated with low functional health literacy in an Australian population. Med J Aust. 2009; 191: 530-4. Available from: https://www.mja.com.au/journal/2009/191/10/risks-associated-low-functional-health-literacy-australian-population
- Clarke SA, Calam R. The effectiveness of psychosocial interventions designed to improve health-related quality of life (HRQOL) amongst asthmatic children and their families: a systematic review. Qual Life Res. 2012; 21: 747-64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21901377