CME ArticleAsthma education and monitoring: what has been shown to work
Introduction
Asthma is the most common chronic disease of childhood, with millions of children affected worldwide.1 Over the past decade, guidelines for the diagnosis and treatment of asthma, such as the Global Initiative on Asthma (GINA) guidelines, have increasingly adopted an evidence-based approach for retrieving and analysing published studies.2 Consequently, recommendations from such guidelines are increasingly viewed as being firmly based on published evidence, and are widely used in clinical practice. One notable example is that inhaled corticosteroid therapy is now widely accepted as first-choice maintenance treatment for childhood asthma,3, 4 illustrating that evidence-based medicine is particularly useful to evaluate drug therapy.5 It is less clear, however, whether randomized controlled trials and meta-analyses of results of such studies in systematic reviews are as valid and useful to study complex interventions where a comprehensive set of medical deliberations, technical skills and local circumstances, which are all difficult to standardize, may influence the outcomes studied.6 Because the education of asthmatic children and their parents is such a complex intervention, evaluating the effects of this intervention with evidence-based medicine techniques is fraught with difficulties. It should come as no surprise, therefore, that systematic reviews of education in childhood asthma have come to divergent conclusions,7, 8 and that many studies have been eliminated from systematic reviews because of insufficient methodological quality or clinical heterogeneity.7, 9, 10, 11
This review will first summarize the results of systematic reviews of education in childhood asthma, and subsequently will discuss these findings in a clinical framework. Because the majority of educational interventions in asthma also comprise a certain degree of monitoring of disease activity, the different approaches to asthma monitoring in children will also be discussed.
Section snippets
Systematic reviews of education in asthma
The Cochrane Library contains four systematic reviews on educational strategies in childhood asthma.
What can be learned from systematic reviews on education in childhood asthma?
It is clear from the discussion above that very few firm conclusions can be drawn on the effects of education in children with asthma. There is little doubt that education in itself is useful (Table 1).11, 15 This is, of course, both not very surprising and not very helpful to practice – no paediatrician in his or her right mind would try to treat a chronic condition in a child without at least some basic explanation to the child and parents on the nature of the disorder and the logic of its
The problem of clinical heterogeneity
So far, all studies on asthma education have lumped together all patients with asthma. All systematic reviews have noted that clinical heterogeneity is a major problem, not only because of the differences between educational programmes, but also because of differences between asthma patients. Any given educational approach may be useful in some children with asthma but not in others. What is useful for school-aged children may not work in toddlers.19 What is valid for chronic persistent asthma
Education: what should be explained to parents and children?
No studies have evaluated which components of asthma education determine its success. Virtually all studies have examined a comprehensive package of educational and monitoring strategies (Table 2) and, because this is the only approach that has been extensively studied, guidelines tend to recommend application of the entire programme.2 Although this may be regarded as the safest approach (the effects of this package have been demonstrated), it is not necessarily the most effective one. In
Monitoring: symptoms or peak flow?
An integral component of asthma education and follow-up is monitoring of disease activity. Self-management of asthma in children relies heavily on the ability of patients and parents to gauge the severity of the disorder on a day-to-day basis, and to respond appropriately to imminent deterioration. Home monitoring can be either symptom-based or peak flow-based. Guidelines prefer home monitoring of peak flow, primarily because it is assumed that many children with asthma are ‘poor perceivers’ of
Conclusions
Education of children with asthma and their parents is effective in improving clinically relevant outcomes. Common sense dictates that these improvements are most likely to be achieved if the health care team, the child with asthma and his or her parents work together in a partnership.2 This should include extensive education of the patient and parents on causal mechanisms of asthma, identification of trigger factors and treatment. Adherence to maintenance medication and correct use of the
Educational aims
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To understand the basic principles of education in childhood asthma, and to be able to discuss why education is useful
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To be able to point out the limitations in the present asthma education literature, in particular the lack of studies of the individual components of education
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To understand the importance of correct inhalation technique and its training
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To be able to explain why home peak flow monitoring is of no value
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