Q:

5/8/2013
We have patients that refuse/forget to complete a peak flow diary to aid us in preparing an asthma action plan. We were told by the joint commission that we can make an asthma care plan based on symptoms. Do you know how to obtain a copy/template of this type of action plan? Thank you!

A:

Thank you for your inquiry.

I have copied for you below two links which will help you formulate an asthma action plan without the use of a peak flow meter.

1. The first is labeled “Action Plan” and is on the NHLBI.NIH website. The action plan does show peak flow meters, but you can proceed without using a peak flow meter employing the symptom approach only.


2. There is another link to the European Society Journal labeled “Credit Card Plan.” This plan has on one side an action plan using only symptoms, and on the other side, an action plan using only a peak flow meter. The patient can use one, the other, or both, at his/her discretion.

3. I have also copied below abstracts taken from two articles which evaluated the use of the peak flow meter in an action plan. As you can see from these articles, there is evidence that action plans without using a peak flow meter can be effective, and there is controversy whether a peak flow meter adds any value to patients with mild asthma. So, this should give you some reassurance that an action plan without a peak flow meter can be effective.

Thank you again for your inquiry and we hope this response is helpful to you.

Thorax. 1995 Aug;50(8):851-7.
Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee.
Jones KP, Mullee MA, Middleton M, Chapman E, Holgate ST.
Source
Primary Medical Care Group, University of Southampton, UK.
Abstract
Background: Peak flow based asthma self-management plans have been strongly advocated in consensus statements, but convincing evidence for the effectiveness of this approach has been largely lacking.
Methods: A randomised controlled trial was conducted in 25 general practices comparing an asthma self-management programme based on home peak flow monitoring and surgery review by a general practitioner or practice nurse with a programme of planned visits for surgery review only over a six month period.
Results: Seventy two subjects (33 in the self-management group and 39 in the planned visit group) completed the study protocol, but diary card data for at least three months were available on a total of 84 (39 in the self-management group and 45 in the planned visit group). Teaching self-management took longer than the planned visit review. In the self-management group home peak flow monitoring was felt to be useful by doctors and patients in 28 (85%) and 27 (82%) cases, respectively. There were no between group differences during the study period in terms of lung function, symptoms, quality of life, and prescribing costs. Only within the self-management group were improvements noted in disturbance of daily activities and quality of life. Possible explanations for these negative results include small numbers of subjects, the mild nature of their asthma, and inappropriate self-management strategies for such patients.
Conclusions: Rigid adherence to long term daily peak flow measurement in the management of mild asthma in general practice does not appear to produce large changes in outcomes. Self-management and the use of prescribed peak flow meters need to be tailored to individual circumstances.

Abstract
Objectives: To evaluate the independent effect of a written action plan vs no plan and to compare different plans to identify characteristics of effective plans in children with asthma.
Data Sources: We searched the Cochrane Airways Group Clinical Trials Register until March 2006, including MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials, for randomized controlled trials that evaluated asthma action plans in the pediatric population.
Study Selection: Eligible studies were randomized or quasi-randomized controlled trials with participants aged 0 to 17 years diagnosed with asthma. Of 428 citations, 1 trial compared a peak flow-based plan with none and 4 parallel-group trials compared symptom-based plans with peak flow-based plans. Intervention Provision of a written action plan. Control groups received no action plan or another type of plan. All co-interventions (both medical and educational) were similar in both groups. Main Outcome Measure The number of children with at least 1 acute care asthma visit.
Results: Written action plan use significantly reduced acute care visits per child as compared with control subjects. Children using plans also missed less school, had less nocturnal awakening, and had improved symptom scores. As compared with peak flow-based plans, symptom-based plans significantly reduced the risk of a patient requiring an acute care visit.
Conclusions: Although there are limited data to firmly conclude that provision of an action plan is superior to none, there is clear evidence suggesting that symptom-based plans are superior to peak flow-based plans in children and adolescents.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology