Patient education
Because asthma is a chronic but variable disease, patients and their families must be prepared to make lifestyle changes and adhere to drug therapy for long periods, even at times when symptoms are not evident. They must also be capable of making rapid decisions about symptom severity, self-medication and the need to seek medical advice. Many authorities consider education to be an integral component of asthma management.[1–3]
Although much information has been gathered on the role of education in asthma, efforts to evaluate the benefits of asthma education have been hampered by a lack of control groups and by the need for the concomitant use of inhaled glucocorticosteroids.[4–10] In addition, studies are often limited to evaluating the influence of education on the use of health services and knowledge.[4–7, 11–17] Recently, many randomized, controlled trials with parallel groups have assessed the impact of asthma education on health care costs, patient well-being and environmental control.[8, 11–37] Many have involved multiple interventions, including education, self-monitoring using PEF or symptoms, using programs of varying duration and intervals.[8, 11–13, 15, 18–28, 30–35]
Some studies and a recent meta-analysis suggest that many educational programs do not result in a significant reduction in asthma-related morbidity,[8, 21–23, 27, 31–33, 36–38] although benefits were observed in studies that included asthma patients with high morbidity, such as those who had been admitted to hospital or had visited the emergency room in the past.[11–13, 28] The reasons offered for this limited success include suboptimal asthma management, short follow-up (1 year) and contamination of the control group.
A decrease in the number of admissions to hospital and visits to the emergency room has been documented, in specific subgroups of patients who are frequent users of health resources,[11, 12, 18–20, 28, 30, 34, 35] but other positive results have been less consistent.
A number of studies have tried to evaluate the impact of asthma education on patient well-being.[5–9, 18–24, 26–28, 30–35] They suggest that, in addition of knowledge, patients gained such benefits as positive attitudes; greater family communication; increased physical activity and feelings of control; increased use of objective measures of airflow obstruction (e.g., PEF) to determine asthma severity; improved treatment compliance, self-management, inhaler technique, quality of life and pulmonary function; and reduced asthma severity, school absenteeism, emergency room visits, admissions to hospital, health care use and health care costs. However, improvements were not consistent across the studies and were sometimes short lived.
Reports of an improvement in environmental control in subjects sensitized to household dust mites after participation in an asthma education program29 are promising, as they imply that, over time, the reduced exposure to allergen as a result of education may help to reduce airway responsiveness. Asthma education had no significant impact on patients sensitized to their domestic animals39; 1 year of reinforcement might not be long enough to persuade clients to give up a pet.
Strategies and methods
Education about asthma should be aimed at altering patients' behaviour rather than simply providing knowledge. The diverse range of educational strategies and methods used include individual teaching, small-group sessions, computer games, large-group lectures, checklists, video and audio tapes, workbooks and booklets, diaries, Internet web sites, problem-solving sessions and repeated audits. Published programs have been implemented in physicians' offices and administered by community agencies and hospitals in education centres. Community education programs should be coordinated with the treating physician.
Some programs are based, at least in part, on the PRE-CEDE model, which uses predisposing, reinforcing and enabling factors.40 Predisposing factors include previous personal knowledge, attitudes, beliefs, values and perceptions. Reinforcing factors, which are essential to determine whether behaviours will persist, include positive and negative reinforcement by health providers and members of the patient's social network and self-reinforcement arising from reduced symptoms of asthma. Enabling factors are the resources available to change behaviour; they include skills possessed by the learners, financial resources and resources available to the educator. Understanding the causes of the patient's behaviour is important so that education can be modified accordingly. Recognizing past experiences with asthma enhances the patient's learning experience and increases its relevance.
Few studies have addressed the optimal method for educational intervention. There appear to be few differences in outcome between educational programs focused on individuals and those using small groups, although small-group teaching resulted in a slight decrease in frequency of exacerbations,[8, 9, 11, 12–21, 25, 26, 39] possibly because of the influence of peer support. In studies comparing group teaching with one-on-one counseling,[41–43] prospective assessment of asthma outcomes over 1 year was similar in the 2 groups. However, a retrospective analysis of asthma morbidity carried out 1 year later revealed a decrease in the use of health services by people who had taken part in small-group educational sessions.27
According to theory, interventions involving multiple educational methods may be most effective. Programs relying primarily on giving books or videotapes to asthma patients were successful only in improving knowledge.[15–17] Most programs that have focused on self-management skills, have been able to enhance other asthma outcomes.[11–14, 18–22, 24–29, 31, 32] It also seems clear that patients and their family should both be involved in the management of the disease. To build skills, the patients must be engaged interactively in the education program, rather than simply acting as passive recipients, and they must receive frequent feedback. Repetition of information is desirable because, without reinforcement, knowledge decreases over time. Development of problem-solving skills should help the patient adopt new behaviours.37 Programs for children should be inviting and developmentally appropriate. An educational program's goals should be stated, and the program adjusted to the needs of the patient.
Components of an asthma education programs may include:
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information about airway inflammation and bronchospasm using figures to illustrate the concept; the rationale and methods for avoiding irritants and relevant allergens
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description of the rationale, correct use and side effects of preventive medications and bronchodilators
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demonstration and practice of inhaler technique and monitoring using symptoms or PEF meters
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description of criteria for control and steps to take when control deteriorates
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discussion of the action plan and an attempt to improve the patient's and family's understanding and willingness to implement the plan when it is needed41
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demonstration of techniques for successful communication with health care professionals
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emphasis on the need for regular follow-up
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discussion of intolerance to sulfites or acetylsalicylic acid
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specific information on food allergy
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discussion, when relevant, of conditions such as pregnancy.
Asthma education should begin in the physician's office43 and must include a written action plan.[8, 24, 26, 27, 32] Asthma education is unlikely to be effective in the absence of effective asthma therapy.21 An educational program may be carried out in brief segments to meet the constraints of a busy office and also keep from overwhelming the patient with information. Subsequent visits can verify and reinforce previous subjects and introduce new topics.
Teaching activities in the emergency department and hospital wards benefit from obvious relevance and the absence of travel or scheduling difficulties, but may suffer because the patient and family are too distressed to benefit from the efforts.38 However, this may be the best place to start an educational intervention as a high proportion of patients fail to return for asthma education after their hospital stay or visit to an emergency department.[11, 12] A particular educational opportunity may arise when patients in hospital are being observed to ensure that they are stable before discharge.12 Education in the emergency department should focus on why the exacerbation occurred and the need for follow-up.
School-based programs may have a wide reach and can increase the school's sensitivity to issues concerning childhood asthma. However, this route has not been well studied. Programs that include assignments requiring parental involvement provide instruction for both child and parent.
Training for educators
Health care providers teaching patients with asthma should have the basic skills and knowledge necessary to transmit current principles of asthma self-management and to assess individual needs and the efficacy of the teaching.44 Educational programs for asthma educators have been developed in various regions in Canada, and national certification for asthma educators is now available. This may standardize the information provided and improve the quality of asthma education.
Home monitoring
By modifying their therapy according to a written action plan based on home monitoring of disease severity, patients can improve control of their asthma and avoid visits to acute care facilities.[32–34] Although PEF monitoring has been advocated as useful in detecting asthma exacerbations,[45–47] in most patients symptoms are a more sensitive measure and change earlier in the course of an exacerbation.[48–50] Most studies have shown that symptom-based and PEF-based actions plans had similar effects on asthma morbidity.50
Measurement of PEF may be useful in patients who have difficulty recognizing changes in their symptoms,[45–47] as evidenced by the lack of correlation between FEV1 and symptoms, and by repeated exacerbations requiring urgent treatment while they are using a symptom-based action plan. PEF measurement may also be helpful in patients with very severe asthma23 and to help some patients determine whether symptoms are due to reduced airflow. When PEF is used for asthma monitoring, the best of 3 values is the measure used.
Home PEF monitoring is not the best means of physiologic measurement because it tends to underestimate the degree of airflow obstruction.51 PEF measurement requires instruments capable of rapid response, and correlation between PEF measured with a portable PEF meter and spirometers is poor.[51, 52] PEF meters of the same brand may vary, and readings may change with extended use.53 Significant errors occur in the reading range of many devices: some overreading in the middle flow range and underreading at high flow ranges. However, PEF meters are cost effective and easy to use in the home setting.
PEF devices must be checked regularly for accuracy and reproducibility of results.53 Patients should be asked to bring their meter to clinic visits so that its readings can be compared with spirometry or an office PEF meter. This practice also allows the physician to check the patient's technique. The same device should be used for serial measurements.
Home PEF monitoring should be linked to an appropriate action plan. Patients should be taught about the importance of certain changes that suggest loss of asthma control: nocturnal symptoms; increase in β2-agonist use; diminished response or decreased duration of response to β2-agonists.33 Adherence to action plans appears to be good in only a third of patients; many are reluctant to increase the dosage of inhaled glucocorticosteroids or make self-management decisions when asthma symptoms worsen.54
The roles of education (even a single session), PEF monitoring and action plans advocating patient-initiated changes in medication in achieving improved outcomes have not been studied separately. An action plan typically integrates level of symptoms or PEF and the need for changes in medication into a predetermined therapeutic regimen to prevent deteriorating asthma from developing into a more severe attack. Many plans recommend doubling the dose of inhaled glucocorticosteroid when augmented therapy is indicated and adding an oral glucocorticosteroid and contacting a physician when emergency therapy is indicated.
In most patients, the written action plan should be based on symptoms. Action plans based on the "stoplight" scheme are recommended: these specify the symptom severity or PEF range at which regular treatment should be continued (the "all clear" or "green" zone), augmented (the "caution" or "yellow" zone) and changed to an emergency plan (the "emergency" or "red" zone).
In terms of establishing these PEF ranges, Chang-Yeung48 found that PEF dropped more than 30% from the baseline in only 27% of acute exacerbations in children, although decreases of at least 20% were observed in 51%. Malo49 also found that PEF rarely falls below 70% of personal best during acute exacerbations. Therefore, although it could be recommended that 80% of personal best be used as the cut-off point for the yellow zone and 70% of personal best for the red zone, these values are higher than in previous consensus guidelines, and a 60% limit for initiating oral corticosteroids may be preferable in most instances.
Diary cards may be used to record symptoms, medication use or PEF, although PEF may influence subjective symptom assessment. Compliance problems are common in patients asked to keep long-term diary records. Using an electronic PEF meter with a memory and good compliance with PEF (defined as 50% of the measurements done) fell from 60% in the first 3 months to 30% at 1 year despite education and regular reinforcement.54 Plans involving a greater number of self-care activities, such as PEF monitoring, may not be carried out in patients with more severe disease and poor self-care skills; further research into methods to convince such patients to adhere to an asthma management program is urgently needed.
Baseline morning and evening monitoring should be carried out over a number of weeks and continued regularly, with the frequency adjusted to the severity of the disease. Patients should be alerted to the significance of increased diurnal variation in PEF (greater than 20%). The best method of calculating diurnal variation in home monitoring is controversial. However, dividing the difference between the highest PEF and the lowest PEF during a 14-day period by the highest PEF during that period then multiplying by 100 is simple and satisfactory ([(highest PEF − lowest PEF) ÷ highest PEF] × 100). Diurnal variation should remain below 15% to 20%.
Monitoring in the physician's office
At each visit to the physician's office, the pattern and frequency of the patient's symptoms, especially those at night and with exercise, and β2-agonist use should be documented. Use of the inhalation device should be observed.[55, 56] Physical examination is much less reliable than spirometry for assessing the degree of airflow obstruction.57 Physical findings and office testing represent point-in-time measurements, and greater weight should generally be placed on the history. Normal airflow does not exclude poorly controlled asthma.
History should be obtained from both patient and caregiver even in children under 11 years of age, as such information relates to quality of life and the child's perception of the impact of the illness. A history obtained from older children correlates well with physiologic measures and diary records.58 The frequency of symptoms and exacerbations may be verified more precisely by inspecting the patient's symptom or PEF diary, recognizing that diaries are frequently falsified, particularly in children.59 Use of electronic devices such as portable "electronic organizers," which automatically record the actual time records are made, may improve the accuracy of PEF and other diaries. PEF diaries should be inspected to assess PEF variability which correlates with airway hyperreactivity.
Objective assessment of airflow is important. Spirometry (for measurement of FEV1 and FEV1/forced vital capacity) is more reliable than PEF when carried out according to recommended standards. PEF can frequently result in underestimation of airway obstruction when compared to FEV1.60 A physician treating asthma should have access to a spirometer or have a PEF meter for office use, and testing should be done before and 10-15 minutes after an inhaled β2-agonist. (This also allows the physician to observe how the patient uses the inhalation device.) Spirometers should be calibrated and maintained according to published standards.61 Although reduced airflow usually reflects poorly controlled asthma, in some patients it may represent the best function possible.
Other means have been proposed to assess asthma control, but generally these are technically more difficult and not readily available. Assessment of nonallergic bronchial responsiveness (including exercise-induced bronchoconstriction in people who have symptoms primarily with exercise) may be useful in patients who, despite normal airflow, require excessive medication for symptom control and in those who fail to respond to therapy. It may help the physician correlate symptoms with abnormal airway function or to question the diagnosis or cause of the patient's symptoms (e.g., hyperventilation syndrome). In the future, sputum analysis (differential cell count, measurement of eosinophil cationic protein) may prove to be useful to assess airway inflammation and to manage and monitor asthma.62 Other markers of inflammation, such as blood eosinophil count and blood total IgE concentration, as well as more invasive tests, such as endobronchial biopsies and bronchoalveolar lavage, are currently research tools only.
Follow-up
Regular follow-up is important to maintain good asthma control. Consistent follow-up by a primary health care provider is necessary to assess control of asthma, prescribe and adjust therapy and reinforce patients' knowledge about asthma and compliance with their therapy.63 Convincing families to return for follow-up for nonacute care requires knowledge about the disease.64 Patients with moderate or severe asthma have higher quality-of-life ratings, are more likely to receive anti-inflammatory therapy and are less likely to require acute care in an urgent-care centre, emergency department or hospital when assessed by a specialist, such as an allergist or respirologist.[65, 66] Consideration should be given to referring patients with severe asthma and unacceptable asthma control to an allergist or respirologist. However, improvements in asthma control following referral to an asthma expert diminish in the absence of follow-up by the expert.66
Suggestions for future research
• Future research should focus on the relative importance of monitoring, education and written or electronic self-management plans - including patient-initiated adjustment of medication in response to changes in asthma severity detected by self-monitoring - in improving outcome.
• Randomized trials are needed to determine ideal PEF values for changing therapy and optimal changes in therapy when deterioration is occurring, particularly in children.
• The best method for determining PEF variability requires further study. Development of more reliable PEF meters or other devices for measuring airflow at home should be encouraged. Inexpensive electronic diaries linked to a device for measuring airflow that can be uploaded to a computer in the physician's office should be developed and evaluated.
• Further research is needed to improve self-monitoring techniques in disadvantaged groups.
• More research is needed to determine the most effective interventions and best programs and program duration for modifying behaviour, reducing morbidity and improving clinical outcome and quality of life. There is a need to compare small-group teaching with one-on-one counseling.
• Many computer education programs have been developed, although their usefulness remains to be established.
• Research is required to define the role of action plans and peak flow measurement.
• Research is urgently needed to identify effective methods of reaching disadvantaged groups, who are at increased risk of asthma mortality and who are less likely to take advantage of conventional education programs.
• More effective methods for changing particularly resistant behaviours, such as smoking in the home and keeping pets, also require elucidation.
• The impact of training programs for asthma educators must be assessed.
Recommendations
• Asthma education is an essential component of asthma therapy (level I).
• The goal of asthma education is control of asthma via improved knowledge and change in behaviour (level III).
• Asthma education should not rely on written or videotaped material alone (level I).
• Asthma education is effective only in the presence of effective asthma therapy (level III).
• Education must be provided at each patient contact (level II).
• Good communication between health professionnals and coordination of their interventions is essential (level III).
• Patient self-monitoring may be effective using either measurement of PEF or monitoring of asthma symptoms (level I).
• Monitoring PEF may be useful in some patients, particularly those who are poor perceivers of airflow obstruction (level III).
• A written action plan for guided self-management, usually based on an evaluation of symptoms, must be provided for all patients (level II).
• Monitoring of pulmonary function in physicians' offices should be routine (level III).
• Patients with severe or poorly controlled asthma should be referred to an asthma expert (level II).
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