Asthma control and action plans
- 1Dept of Medicine, Division of Respirology, University of Toronto, Toronto, ON, Canada
- 2Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, QC, Canada
- 3Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada
- 4The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Andrew Kouri, Division of Respirology, 1 King's College Circle, 6263 Medical Sciences Building, Toronto, ON, M5S 1A8, Canada. E-mail: andrew.kouri{at}mail.utoronto.ca
Abstract
Arguments over semantics will not advance our common goal of improving AAP uptake http://ow.ly/rSaq30fRila
From the authors:
We would like to thank I. Amirav and M.T. Newhouse for their correspondence in response to our recent paper, “An evidence-based, point-of-care tool to guide completion of asthma action plans in practice” [1]. They raise an important issue surrounding confusion between the concepts of poor baseline asthma control and acute changes in symptoms that merit activation of the “yellow zone” of the asthma action plan (AAP). Although, contrary to their contention, this discussion does not affect the objective or outcome of our analysis, which was to provide a practical, evidence-based guide to populating the AAP yellow zone, it merits further discussion.
I. Amirav and M.T. Newhouse argue that the expression “acute loss of asthma control”, used in Canadian guidelines and in our paper, should not be used in the context of an AAP. They raise a concern that this terminology may be confused by patients and clinicians to be a measure of baseline asthma control, which is a different concept, requiring periodic determination by healthcare providers through both a retrospective assessment of symptoms and an understanding of risk factors for poor outcomes. We agree that these are distinct concepts that are often confused by practitioners. However, these authors fail to recognise that the reason for confusion between poor control at baseline and acute loss of control in an AAP is not simply due to use of the phrase “acute loss of asthma control” but rather because the thresholds used to describe these states are often identical. Our comprehensive review of 69 AAPs used in randomised controlled trials (RCTs) and by asthma programmes around the world demonstrated that thresholds for the first action point in AAPs (usually called the yellow zone) were often based on the same thresholds that guidelines have defined for baseline control [2]. These included the frequency of daytime symptoms, night-time symptoms, rescue bronchodilator use, absenteeism and exercise limitation. Given that there is no objective evidence for what should constitute an appropriate threshold for acute worsening that merits a transient escalation in therapy, historically, authors appropriated baseline control thresholds in the original AAPs that were tested in RCTs, and these criteria became entrenched after initial studies showed beneficial effects of those AAPs. Thus, although acute worsening requiring transient escalation in therapy and generalised poor control requiring escalation in baseline therapy are distinct management concepts, the thresholds used to define them overlap significantly.
Authors also imply that Canadian guidelines “support combining, in an AAP, instructions for the self-management of transient acute exacerbations with advice regarding the treatment of poorly controlled asthma”. Rather, Canadian guidelines, like all other international guidelines, consider and provide explanations and recommendations for these concepts separately and distinctly. Furthermore, contrary to the authors' contention that “none of the US, British, Australian or European guidelines use this term”, the “control” descriptor for AAPs is not only used by Canadian guidelines, but by the latest British and US asthma guidelines, and the Global Initiative for Asthma (GINA) strategy document. British (British Thoracic Society/Scottish Intercollegiate Guidelines Network) guidelines describe the content of AAPs as “specific advice about recognising loss of asthma control, assessed by symptoms or peak flows or both” and emphasise the importance of AAPs “so that the patient is aware of the action to take if their control deteriorates” [3], the US (National Heart, Blood and Lung Institute) guidelines recommend that AAPs “encompass instructions both for daily actions to keep asthma controlled and for actions to adjust treatment when symptoms or exacerbations occur” [4] and the GINA strategy recommends that controller medication should be increased as part of an AAP “when there is a clinically important change in the patient's usual level of asthma control” [5].
We also note that there “is no international consensus of the best terms to use to describe worsening asthma”, according to the Cochrane Airways Group editorial board, and contrary to what I. Amirav and M.T. Newhouse claim [6]. Like the international asthma guideline groups cited above, our author group of clinical respirologists and primary care physicians believes that our intended audience of primary care physicians would understand that “acute loss of asthma control” is synonymous with “acute asthma worsening” or “transient acute exacerbation.” Communication of these concepts to patients should of course be individualised to each patient's needs and level of understanding.
Despite overwhelming evidence for their benefit and consistent international guideline recommendations for their use for over 20 years now, AAPs are seldom used in practice. I. Amirav and M.T. Newhouse's contention that use of the “control” terminology contributes to this “poor compliance” with AAPs is unfounded, and ignores robust literature on the actual barriers and enablers to AAP use [7]. Barriers exist at the level of providers, the practice environment and the overall healthcare system. By developing an evidence-based, point-of-care tool providing guidance on AAP yellow-zone formulation, we sought to address a well-described clinician knowledge barrier.
Unsupported arguments focusing on semantics miss the forest for the trees and will not advance our common goal of improving AAP uptake. Although we fully acknowledge that other barriers, including clinician time, patient–clinician communication and point-of-care availability, must also be addressed, we believe that addressing knowledge was an important first step. We entreat all of our colleagues in the respiratory community to rise to this important implementation challenge.
Footnotes
Conflict of interest: None declared.
- Received September 15, 2017.
- Accepted September 18, 2017.
- Copyright ©ERS 2017