Patient discussions

Supported self-management

Ensure your patient understands that effective home management of symptoms greatly improves outcome. Encourage daily self-monitoring, e.g., checking and recording peak expiratory flow (PEF) using a peak flow meter. When the patient discusses these results with you, subsequent adjustment of medications can be made. Emphasise that attending follow-up is essential for a long and healthy life with asthma. Always check the patient is using medications and delivery devices correctly.

The use of a written, personalised asthma action plan should be strongly encouraged to support self-management.[1][55][56][147] Asthma and Lung UK: adult asthma action plan Opens in new window The asthma action plan can help your patient to recognise when their asthma is deteriorating and how to respond appropriately: for example, increasing usual reliever and controller treatment, and determining when to seek medical help.[1][85] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

Proactively address common barriers to adherence. These are often driven by lack of disease education (e.g., not knowing when to take medication; lack of belief that medication will improve asthma control).[148] Strategies including text/audiovisual message reminders, written action plans, and motivational interviewing may improve inhaler adherence.[149] Enhanced support may be required for patients transitioning into adulthood, as some studies report reduced adherence in patients aged >18 years.[150]

Telemedicine appears to be effective at improving asthma control and quality of life in adults with asthma.[151] eHealth interventions are effective at improving adherence to inhaled corticosteroid, particularly mobile device-based studies that include audiovisual and text message reminders.[152] Digital health technology that includes interactive features, such as daily diary entries, is associated with increased asthma control; the same is true for multidimensional interventions that combine several different types of digital health technology.[153]

Pharmacist-led interventions can also improve inhaler technique and medication adherence in adults with asthma.[154][155]

Modifiable risk factors

Discuss environmental control strategies, including identifying and eliminating exposure (indoor or outdoor, e.g., at home or work) to allergens and irritants that can cause or worsen asthma, including house-dust mites, animals, cigarette smoke and other respiratory irritants, chemicals, and pollens and grasses.[1] If you suspect an occupational cause, see Occupational asthma. Guidelines vary in their recommendations regarding allergen mitigation, so consult local guidance to inform the discussion with your patient. 

Give advice about non-pharmacological therapies and strategies when appropriate (e.g., physical activity, weight loss, avoidance of triggers).[55] Help the patient identify foods they are sensitive to and should therefore avoid. Counsel the patient about the dangers of smoking and second-hand tobacco smoke exposure, and offer support to stop smoking. Direct or passive exposure to cigarette smoke adversely affects quality of life, lung function, need for rescue medications for acute episodes of asthma, and long-term control with inhaled corticosteroids.[55] If the patient is overweight, encourage them to lose weight via weight loss interventions, including dietary and exercise-based programmes.[55]

Also counsel your patient about avoiding specific drugs (e.g., aspirin and non-steroidal anti-inflammatory drugs, beta-blockers) where necessary, and treatment of comorbidities (e.g., gastro-oesophageal reflux, infections).[1]

Immunisation

Vaccination schedules vary by location; consult local guidance for recommendations. Further information on UK and US vaccines, and special patient populations, can be found in their respective vaccination schedules. UKHSA: complete routine immunisation schedule Opens in new window CDC: ACIP recommendations Opens in new window​ See Secondary prevention.

Mental health

Make mental health referrals where necessary. Patients with asthma are at risk of depression and anxiety; drug treatment and cognitive behaviour therapy may be suitable, although evidence is limited.[1] Patients with asthma have a significantly increased risk of suicidal ideation, suicide attempts, and suicide mortality.[117]

Peak flow measurement animated demonstration
Peak flow measurement animated demonstration

How to use a peak flow meter to obtain a peak expiratory flow measurement.

Inhaler choice

Consider patient concerns about inhaler choice, including environmental issues. Asthma and Lung UK: inhaler use and choices Opens in new window[156]

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