Cochrane review: Written action plans for asthma in children
Authors: Bhogal S , Zemek R , Ducharme FM 
Published: July 2007

Background

While all asthma consensus statements recommend the use of written action plan (WAP) as a central part of asthma management, a recent systematic review of randomised trials highlighted the paucity of trials where the only difference between groups was the provision or not of a written action plan.

Objectives

The objectives of this review were firstly to evaluate the independent effect of providing versus not providing a written action plan in children and adolescents with asthma, and secondly to compare the effect of different written action plans.

Search strategy

We searched the Cochrane Airways Group Specialised Register (November 2004), which is derived from searches of CENTRAL, MEDLINE, EMBASE, CINAHL, as well as handsearched respiratory journals, and meeting abstracts. We also searched bibliographies of included studies and identified review articles.

Selection criteria

Randomised controlled trials were included if they compared a written action plan with no written action plan, or different written action plans with each other.

Data collection and analysis

Two authors independently selected the trials, assessed trial quality and extracted the data. Study authors were contacted for additional information.

Main results

Four trials (three RCTs and one quasi‐RCT) involving 355 children were included. Children using symptom‐based WAPs had lower risk of exacerbations which required an acute care visit (N = 5; RR 0.73; 95% CI 0.55 to 0.99). The number needed to treat to prevent one acute care visit was 9 (95% CI 5 to 138). Symptom monitoring was preferred over peak flow monitoring by children (N = 2; RR 1.21; 95% CI 1.00 to 1.46), but parents showed no preference (N = 2; RR 0.96; 95% CI 0.18 to 2.11). Children assigned to peak flow‐based action plans reduced by 1/2 day the number of symptomatic days per week (N = 2; mean difference: 0.45 days/week; 95% CI 0.04 to 0.26). There were no significant group differences in the rate of exacerbation requiring oral steroids or admission, school absenteeism, lung function, symptom score, quality of life, and withdrawals.

Authors' conclusions

The evidence suggests that symptom‐based WAP are superior to peak flow WAP for preventing acute care visits although there is insufficient data to firmly conclude whether the observed superiority is conferred by greater adherence to the monitoring strategy, earlier identification of onset of deteriorations, higher threshold for presentation to acute care settings, or the specific treatment recommendations.

Plain language summary

This review examines the net impact of providing written action plans to children with asthma and their parents

We did not find any trial examining the benefit of providing versus not providing a written action plan to children with asthma.

Four clinical trials with 355 children were identified which compared the effect of symptom‐based versus to peak flow written action plans when all other co‐interventions were similar. Children assigned to a symptom‐based plan less frequently required an acute care visit for asthma compared to those who received a peak flow based plan. Most other outcomes were similar with the exception of more children intending to continue using the symptom‐based compared to the peak‐flow based written action plan.