Asthma Education in Canada The role of the Canadian Network For Asthma Care (CNAC) R. L. (Bob) Cowie MD Asthma For Africa Congress February 2001

CANADIAN NETWORK FOR ASTHMA CARE (CNAC) CNAC was formed to improve the care provided for those with asthma in Canada. Membership includes several professional organisations (Nurses, Pharmacists, Physiotherapists, Respiratory Therapists, Family and Emergency Physicians), Federal government, Lung Association, Asthma Society of Canada, Allergy/Asthma Information Association and pharmaceutical companies with involvement in asthma.

CANADA * * * * * *

“The bottom line in asthma management is patient education” Roger C. Bone Am J Med 1993;94:561-3

Asthma Management Guidelines “The properly educated patient is well situated to achieve and maintain control or the best result.” Education should provide: 1. Understanding and avoidance of causes of airway disease 2.Knowledge of the nature of the disease 3. How to assess the severity of the disease 4.A definition of control of the disease 5.Information about the role of the different forms of medication and their side-effects 6.Instruction in the proper technique of administration of medications 7.Instruction in monitoring their disease and an action plan to for self-adjustment of medication Canadian guidelines 1990 JACI 1990;85:

“SAPS endorses the trend towards encouraging patients to participate in informed decision- making as regards treatment” “Patients should have a relevant understanding of the nature of asthma and its treatment” “Patients should be given clear instructions to avoid tobacco smoke and other recognised precipitants of asthma” “Patients should have a self-management plan which includes monitoring and a written guidance plan. SA Guidelines. SAMJ 1992;81:319-22

I think that the bottom line is relevant, expert and consistent patient education In our efforts to educate those with asthma nothing is more destructive than inconsistent information about their disease and its management

INHALER TECHNIQUE At its most basic, patients with asthma require education about the use of their inhaler devices.

INHALER (MDI) TECHNIQUE In a study of patients (mean MDI use 7 yrs) nurses and physicians, Correct inhaler (MDI) technique was observed in: Patients 67/746 (9% ) Nurses70/466 (15%) Physicians120/428(28%) Plaza, Respiration 1998;65:195

INHALER TECHNIQUE Can you list 10 points which your patients need to know about using a metered dose inhaler? Why not write them down quickly and see if you know all of the 5 major items which patients (and physicians) often get wrong

INHALER TECHNIQUE Hold the inhaler mouthpiece down Remove the cap Place mouthpiece in your mouth Start to inhale Breathe out gently Wait 30 seconds before next dose

INHALER TECHNIQUE Hold the inhaler mouthpiece down Remove the cap Shake the inhaler Breathe out gently and fully Place mouthpiece in your mouth Start to inhale Release one dose While continuing to inhale slowly for approximately 2 seconds Hold your breath in for up to 10 secs Breathe out gently Wait 30 seconds before next dose

TRUE OR FALSE? The technique for use of a Turbuhaler and of a metered dose inhaler are so similar that patients may use one or the other interchangeably?

TRUE OR FALSE? ? Do any of you have patients who use Pulmicort by Turbuhaler and Ventolin by MDI?

Turbuhaler v MDI Mouthpiece up for Turbuhaler, down for MDI Always shake MDI never shake Turbuhaler Breathe in slowly with MDI, breathe in fast with Turbuhaler. Keep your inhaled steroid MDI in the bathroom next to your toothbrush, keep the Turbuhaler in a dry environment More?

Education is not enough Many education programs do just that - they educate their subjects and then do simple before and after knowledge tests The real purpose of asthma education is to change BEHAVIOUR and that must be tested by randomised controlled trials and measurement of an appropriate outcome

EXAMPLE Education can inform your patient that inhaled corticosteroids play a fundamental role in controlling asthma but this is of little value if it does not also result in improved adherence with regular and appropriate use of their medication AND improved disease control.

CALGARY ASTHMA PROGRAM P < 00001

Young Adult Asthma Program Emergency/Casualty Visits P =.00001

Did we do anything useful? Can we take the credit for our patient’s improvement?

YAAP PRE & POST ED VISITS Not significant

ACTION PLAN STUDY We invited individuals with asthma who had been treated in one of our city emergency departments within the previous 6 months to attend for asthma education and to enter and action plan study

SYMPTOM ACTION PLAN (sample) If you are well, continue with: Flixotide 1 puff twice each day Ventolin 2 puffs as required If you get a cold, start waking at night with asthma or need to use Ventolin every day: Flixotide 2 puffs twice per day Ventolin 2 puffs as required If your Ventolin does not work as well or the effect lasts less than 2 hours: Add prednisone 50 mg each day for 7 days and inform your physician If your Ventolin lasts only half an hour or less or you have difficulty speaking: Go to the emergency/casualty department

PEF ACTION PLAN (sample) Your normal peak flow is l/min If your Peak flow is greater than 360 l/min and varies by less than 90 l/min during the day continue with: Flixotide 1 puff twice each day Ventolin 2 puffs as required If your peak flow is below 360 l/min or varies by 90 or more Flixotide 2 puffs twice per day Ventolin 2 puffs as required If your peak flow is less than 250 l/min Add prednisone 50 mg each day for 7 days and inform your physician If your peak flow is less than 150 l/min: Go to the emergency department

ACTION PLAN STUDY #Subjects attending ER

ACTION PLAN STUDY # emergency visits

USE OF ACTION PLANS This study showed that in this population (those requiring recent ED treatment) a peak flow based action plan resulted in a change of behaviour. Other studies have confirmed that action plans can (but do not always) change behaviour.

THE GAP In the Asthma in Canada survey 21% remembered ever having an action plan but only 11% of those (23/1001) thought that their action plan told them what to do if their asthma symptoms increased. This shows the gap between what we believe and what our patients do

Conclusions Asthma education is complex, educators must have adequate asthma knowledge and educator training. Education programs must be appropriately structured and evaluated Asthma education programs should be more widely available

CNAC APPROVED ASTHMA EDUCATOR PROGRAMS AsthmaTrec© (offered through and by several of the Provincial Lung Associations) Professional Certification in Asthma Management (ProCAM) \ ÉDUQUER À MAÎTRISER L'ASTHME (offered in French only) Asthma Educator Program of The Michener Institute for Applied Health Sciences Diploma in Asthma Care of the National Asthma & Respiratory Training Centre - Warwick, UK

CERTIFIED ASTHMA EDUCATOR Those who successfully complete one of the approved asthma educator courses are eligible to write the CNAC Asthma Educator Certification examination. Those successful in the examination are then designated Certified Asthma Educator (CAE)

CERTIFIED ASTHMA EDUCATION PROGRAMS CNAC has created a register of patient education programs in Canada and is currently developing a set of specifications for such programs. Suggested requirements include trained personnel, appropriate space and time and a method to measure behaviour change in those they educate

Sometimes our education has surprising results