Every year, the Global Initiative for Asthma (GINA)organizes World Asthma Day to bring greater awareness and to promote improved care for asthma patients. On the first Tuesday of May, promotional and educational events are held around the world to increase awareness around this condition. Each year, a central theme is chosen, and activities are aligned to it. This year’s theme is “STOP for Asthma” where STOP is an acronym for: “Symptom Evaluation, Test Response, Observe and Assess, Proceed to Adjust Treatment.”

The theme is especially relevant for many parts of the world where a diagnosis of asthma is still a taboo. As a result, many people delay treatment or are inadequately managed. One of the cornerstones of managing asthma is for you and your caregiver is to “know your asthma”. The “know” here is a collection of three critical aspects:

1. what are the things that trigger your asthma
2. Manage risk factors that can be mitigated (controlled, reduced or removed)
3. Monitor yourself for symptoms like cough and shortness of breath. This shortness can be measured with the help of a simple tool such as the Peak Flow Meter

A patient can easily “know” their asthma by carefully monitoring their life style and disease status over a period. This can be aided by using an Asthma Diary that helps record these factors. Once the triggers are known and the degree of breathlessness is charted out, the patient can work with their doctor to manage their disease. These are important aspects of any Asthma management plan which are outlined in the GINA guidelines. The pocket guidecan be downloaded via the GINA website for easy reference. As per these guidelines, every asthma patient should have a written action plan that includes:

1. Self-monitoring for symptoms and lung function (Peak Expiratory Flow Rates-PEFR)
2. Regular medical review
3. Medication plan-
1. Patients’ usual medications for asthma
2. When and how to increase medications
3. How to reach for help if symptoms do not improve

Management of asthma involves two key aspects: prevention and treatment.

Prevention encapsulates avoidance of triggers, reduction of risks and use of preventive/controller medications such as inhaled steroids. These preventive steps help reduce the inflammation inside the airways thus helping airways to recover. Successful implementation of a preventive strategy will also mean that the airways are free from the long-term effects of repeated acute episodes. Inadequately managed asthma leads to progressive damage to the airways which worsens the condition in the long run^1,2. Additionally, poorly controlled Asthma leads to increased healthcare costs³.

Treatment involves the use of reliever medications which help relax the airways (bronchodilators) to improve the airflow and thus bring relief. However, this is easier said than done. For a patient this requires a lot of work and focus. This aspect was highlighted in a study on patients with chronic conditions which included 142 patients with lung diseases. In this study patients mentioned the following factors to be a burden in varying degrees⁴:

• The time needed to take/organize treatment
• The time needed for tests
• The time needed for self-monitoring
• The time needed for refills
• The time needed for doctor visits

Therefore, it is important that healthcare providers help develop a support structure around their patients. There is evidence to show that having a patient adhere to a written asthma action plan helps improve outcomes⁵.The action plan should include the patient's immediate family. The support structure should incorporate elements of self-monitoring, reduction/removal of triggers and help the patient modify their lifestyle to reduce the risk. Another important part of any asthma management is the proper use of medications. The patient’s family should be aware and assist in the adherence to medications in the right manner, especially inhalers.

Incorrect use of inhalers has been shown to be an important factor in patients not getting the full benefit of therapy^6,7.

It is important that a detailed discussion happens in the presence of the patient and their immediate caregivers on these aspects of asthma. Providing this asthma education at the time of diagnosis and reinforcing it at all subsequent visits, leads to better outcomes in terms of achieving the goals of asthma therapy: namely few symptoms, no limits on activity, rare exacerbations, and normal lung function⁸. These interactions with the patient and their family help establish a collaborative relationship with the healthcare provider.

One more way to support the patients is through a structured program which enables them to reach out to a healthcare provider for their concerns and issues. The program would involve supporting healthcare providers to manage the activities around educating, counseling and managing asthma patients. It would involve the intervention of a nurse educator who helps bridge the gap between patients’ needs and healthcare providers’ time challenges.

Structured programs have shown improvement in health service use and self-management of asthma⁹. The benefits to patients have been demonstrated even in low resource settings. In a study in Ghana, a structured intervention resulted in significant improvement in asthma specific quality of life and Peak Expiratory Flow Rate (PEFR). The pharmaceutical care intervention consisted of educating patients on their health condition, pharmacotherapy, self-management and inhaler-use technique, where necessary and when to urgently seek medical care¹⁰.

A structured program should include the following activities by trained nurse educators.

1. Patient assessments: (GINA Asthma Assessment Tools- adults, adolescents and children between 6-11 years)

1. PEFR measurements
2. Work with doctor and patient to develop Asthma Action plan
1. Demarcation of Red, Yellow and Green zones based on PEFR measurements
2. Use of medications as per zone
3. Recording and identification of any exacerbations from the last visit
1. Symptoms (Day & Night) cough, breathlessness, disturbance in sleep
2. Signs like wheezing
4. Recording any limitation of daily activities (work/school days missed)
5. Recording use of Short-acting beta-agonists (SABAs)-rescue medications
6. Checking inhaler technique & compliance (Check-Correct and Confirm)
7. Checking completion of diary
8. Listing any known/identified triggers
9. Listing status of co morbidities- rhinitis, obesity, eczema
10. Identify any issues/challenges with treatment adherence

2. Patient counselling:

1. Training patients for use of PEFR, asthma diary and asthma action plan
2. Training patients for the correct use of inhalers and post inhalation care (Maintenance/controller and rescue/reliever medications, breath coordination and use of the device, cleansing of the mouth)
3. Discussion on how to identify triggers and prevention strategies
4. Meeting and discussion health status/progress with the patient and their relatives
3. Scheduling visit appointments for next visit & managing any logistics especially for working/ adolescent participants

Being an asthma patient and managing the disease and lifestyle requires effort. This also means managing many aspects of ones’ psyche. Moving from denial to acceptance to effective asthma management. This includes the initial acceptance of the diagnosis, the treatment modalities, and living a modified life. Many patients are often lost on this journey or simply give up. A carefully designed asthma care plan can help the patients live a complete and satisfying life. A good plan should include monitoring, education, and support to the patient and their caregivers.

References:

_{1. Haselkorn, T., Fish, J. E., Zeiger, R. S., Szefler, S. J., Miller, D. P., Chipps, Simons, F. E. R., Weiss, S. T., Wenzel, Borish, L., S. E., B. E., Bleecker, E. R. (2009). Consistently very poorly controlled asthma, as defined by the impairment domain of the Expert Panel Report 3 guidelines, increases risk for future severe asthma exacerbations in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study. Journal of Allergy and Clinical Immunology, 124(5). doi:10.1016/j.jaci.2009.07.035}

_{2. Braido, F. (2013). Failure in Asthma Control: Reasons and Consequences. Scientifica, 2013, 1-15. doi:10.1155/2013/549252}

_{3. Accordini, S., Corsico, A. G., Braggion, M., Gerbase, M. W., Gislason, D., Gulsvik, A., Heinrich, J., Janson, C., Jarvis, D., Jõgi, R., Pin, I., Schoefer, Y., Bugiani, M., Cazzoletti, L., Cerveri, I., Marcon, A., Marco, R. D. (2012). The Cost of Persistent Asthma in Europe: An International Population-Based Study in Adults. International Archives of Allergy and Immunology, 160(1), 93-101. doi:10.1159/000338998}

_{4. Tran, V., Barnes, C., Montori, V. M., Falissard, B., & Ravaud, P. (2015). Taxonomy of the burden of treatment: A multi-country web-based qualitative study of patients with chronic conditions. BMC Medicine, 13(1). doi:10.1186/s12916-015-0356-x}

_{5. Gibson, P. G., & Powell, H. (2004). Written action plans for asthma: An evidence-based review of the key components. Thorax, 59(2), 94-99. doi:10.1136/thorax.2003.011858}

_{6. Fink, J. B., & Rubin, B. K. (2005, October 01). Problems With Inhaler Use: A Call for Improved Clinician and Patient Education. Retrieved April 16, 2019, from http://rc.rcjournal.com/content/50/10/1360.short}

_{7. Price, D., Bosnic-Anticevich, S., Briggs, A., Chrystyn, H., Rand, C., Scheuch, G., & Bousquet, J. (2013). Inhaler competence in asthma: Common errors, barriers to use and recommended solutions. Respiratory Medicine, 107(1), 37-46. doi:10.1016/j.rmed.2012.09.017}

_{8. Kelso, J. M. (2016). Do Written Asthma Action Plans Improve Outcomes? Pediatric Allergy, Immunology, and Pulmonology, 29(1), 2-5. doi:10.1089/ped.2016.0634}

_{9. Swanson, V., Wright, S., Power, K. G., Duncan, B., Morgan, J., Turner, E., & Gordon, D. (2000, November). The impact of a structured programme of asthma care in general practice. Retrieved April 16, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/11220984}

_{10. Anum, P. O., Anto, B. P., & Forson, A. G. (2017, February 07). Structured pharmaceutical care improves the health-related quality of life of patients with asthma. Retrieved April 16, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297140/}