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Emergency packs for asthma: the simplicity is appealing but overlooks the complexity

2019; Elsevier BV; Volume: 7; Issue: 7 Linguagem: Inglês

10.1016/s2213-2600(19)30186-9

2213-2619

Hilary Pinnock, Elisabeth Ehrlich, Steve Holmes, Liz Steed, Stephanie Taylor,

Health Policy Implementation Science

The suggestion from Duncan Keeley and Martyn Partridge that people with asthma should have an emergency pack comprising a metered dose inhaler and a spacer enabling them to act promptly to an imminent attack is appealing in its simplicity.1Keeley D Partridge MR Emergency MDI and spacer packs for asthma and COPD.Lancet Respir Med. 2019; 7: 380-382Summary Full Text Full Text PDF Scopus (12) Google Scholar Based on overwhelming evidence,2Pinnock H Parke HL Panagioti M et al.Systematic meta-review of supported self-management for asthma: a healthcare service perspective.BMC Med. 2017; 15: 64Crossref PubMed Scopus (155) Google Scholar national and international asthma guidelines have long recommended that everyone with asthma should be offered an action plan that advises them how to recognise and respond to a deterioration in control, and any initiative that facilitates supported self-management deserves to be considered and evaluated carefully. The IMP2ART (improving implementation of asthma self-management as routine) programme of work is developing and evaluating an implementation strategy to embed supported self-management in primary care practice. We recognise that effective implementation strategies are complex (although individual initiatives might be considered simple) because patients, professionals, and practices are being asked to change their habits and routines.3Pinnock H Epiphaniou E Pearce G et al.Implementing supported self-management for asthma: a systematic review of implementation studies.BMC Med. 2015; 13: 127Crossref Scopus (84) Google Scholar The factors underpinning adherence to asthma management strategies are various and complicated.4Lycett H Wildman E Raebel EM Sherlock JP Kenny T Chan AH Treatment perceptions in patients with asthma: Synthesis of factors influencing adherence.Respir Med. 2018; 141: 180-189Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar A pack with emergency inhalers sounds like a simple strategy to facilitate, for example, quadrupling of the dose of inhaled steroids but patients need to recognise deterioration and decide in a timely manner that they need to use the pack. As Keeley and Partridge note, a pack is not a substitute for a supportive self-management conversation tailored to the clinical context and recognising individual patients' experience of successful (or unsuccessful) actions. Organisational strategies will be needed to avoid inappropriate overuse of these packs—a situation that becomes complicated if individuals request multiple packs to ensure they have emergency medication available even when not at home. In the UK, self-management education can be provided by non-prescribing clinicians who might not have accredited asthma training.5Morrow S Daines L Wiener-Ogilvie S et al.Exploring the perspectives of clinical professionals and support staff on implementing supported self-management for asthma in UK general practice: an IMP2ART qualitative study.NPJ Prim Care Respir Med. 2017; 27: 45Crossref Scopus (22) Google Scholar An approved pack with a high-dose inhaler might help to overcome professional reservations about advising patients to initiate short bursts of (inhaled or oral) steroids but will only be implemented effectively and safely if the clinician has the skills—and time within asthma consultations—to support patients to self-manage. Patients need the confidence to use a potentially unfamiliar inhaler in an emergency situation and to avoid unintended consequences such as delays in seeking help with worsening symptoms. Asthma is a variable condition and supported self-management must facilitate prompt response to deteriorating control. Issuing a pack might—or might not—streamline emergency action, and before adoption is considered, its role as part of a complex behaviour change implementation strategy needs to be understood and evaluated. The IMP2ART programme of work is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research (RP-PG-1016-20008). The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health. HP is a member of the British Thoracic Society/Scottish Intercollegiate Guideline Network British Asthma Guideline Development Group. All remaining authors declare no competing interests. Emergency MDI and spacer packs for asthma and COPDIn the UK, an estimated 5·4 million people receive inhaled treatment for asthma1 and 1·2 million receive such treatment for chronic obstructive pulmonary disease (COPD).2 For some, their illness is mild and stable; however, many will have episodes of acute worsening of their condition (exacerbations). Although the likelihood and frequency of exacerbations is reduced if the underlying condition is well managed, many people still suffer exacerbations. Exacerbations are unpleasant, frightening experiences and can lead to acute hospital attendance, admission or, occasionally, death. Full-Text PDF