Completing a MART asthma action plan with your patients

These guidance notes are for our MART asthma action plan which is for patients who are on a MART regime with formoterol-containing ICS-LABA inhaler (without a separate reliever inhaler)  

If your patient has been prescribed a preventer inhaler, or a non-MART ICS-LABA inhaler, with a separate SABA reliever inhaler, please refer to our preventer/reliever asthma action plan guidance notes

Find all our asthma action plans here.

Our MART asthma action plan is only for steroid inhalers that also contain formoterol – such as Symbicort, Fostair, DuoResp, Fobumix, Luforbec and Wockair. 

Not all dose specifications for these inhalers are licensed for MART. Please check your patient’s inhaler brand.

A MART treatment plan offers benefits to you and your patients:

• Flexible dosing to address symptoms when they come on
• Lower steroid load overall
• Lower rate of asthma exacerbations
• Reduces the risk of SABA reliever overuse and preventer underuse
• Fewer inhalers prescribed – cheaper for patients and better for the environment.

You can signpost your patient to more information about the MART regime on our website.

In between regular asthma reviews, your patients need to know what to do to manage their asthma well.  

A MART asthma action plan tells your patients:

• which medicines they need to take every day and how often
• what to do if their asthma symptoms get worse
• what emergency action to take if they have an asthma attack.

An asthma action plan supports patients to take the right actions at the right time and lower the risk of a potentially fatal asthma attack.
 

Use our guide to help you complete our MART asthma action plan together with your patient and any carers.
Once your patient’s plan is complete and up to date, save a copy to their notes. It’s important to replace any older plans with a newly updated one.

Section 1: Everyday asthma care (green)

Support your patient to use their MART inhaler every day as prescribed to prevent asthma symptoms.

Here you can specify the number of puffs of their MART inhaler your patient needs to take every day, morning and evening.

Explain to your patients that as well as everyday maintenance, they can also use their MART inhaler as a reliever to quickly treat symptoms when they come on.

Make sure your patient understands the maximum number of puffs per day they can take, including maintenance and reliever doses. You can write this in the box.

You can find this information in the medicine prescribing details for your patient’s specific inhaler on the British National Formulary website.

When completing this section:

Highlight the importance of taking their MART inhaler every day, even if they feel well. 

• Tell them the name of their inhaler and what medicines it contains.
• Explain that the formoterol part of the inhaler works as well as a reliever inhaler, but it also gives a small dose of anti-inflammatory steroid medicine, which can help prevent more symptoms and asthma attacks.
• If your patient has a pMDI MART inhaler, explain the benefits of using a spacer.
• Stress the importance of good inhaler technique. Show them the best way to use their inhaler. Signpost them to our inhaler technique videos and let them know that their pharmacist can also help.
• Share a link, or print out, our health advice page on MART. 

There is also a box at the bottom of section 1 to list any other medicines and devices your patient uses every day to keep their asthma under control, such as montelukast, antihistamines, nasal sprays, spacers or peak flow meters. 

Stress the importance of making an urgent appointment if their symptoms flare up again and explain the best way of getting in touch.

Section 2: When I feel worse (amber)

Support your patient to recognise when their asthma is getting worse and know what to do to manage worsening symptoms.

You can specify extra puffs they can take of their MART inhaler to get symptoms back under control. You can use the box to specify how many puffs they can take of their MART inhaler to help deal with symptoms.

Let them know the maximum dose they can take in a day. Consult the BNF (British National Formulary) as different MART inhalers have different maximum doses.

Make patients aware that they must seek help from their doctor, nurse or other healthcare professional if:  

• they need to use the maximum daily dose of their MART inhaler and their symptoms are not improving or
• they’re regularly using extra doses of their MART inhaler most days. Advise your patient after how many weeks they should seek help if this is the case.  

Based on your knowledge of your patient, you may want to set additional thresholds for seeking help of taking action. There is a box at the bottom of section 2 where you can write down other advice for if their symptoms flare up.  

Rescue packs of oral steroids 

Occasionally a patient may be prescribed a rescue pack of oral steroids (usually prednisolone) to keep at home. 

Make sure they have clear, written instructions on when to start taking the medicines, at what dose, and for how long. 

Make them aware that they need to see their GP or asthma nurse:

• as soon as possible after starting the course 
• urgently if symptoms get worse or their peak flow drops
• if they don’t feel better before the end of the course.

BTS/SIGN Guidelines for adults suggest 40-50mg daily of prednisolone for at least five days, or until recovery.

When completing Section 2:

Stress the importance of acting quickly to avoid symptoms building up into an asthma attack.

• Explain that needing to use their MART inhaler as a reliever inhaler most days for a number of weeks to deal with symptoms is a sign that their asthma is not well controlled, and they should speak to their GP or asthma nurse. There is space for you to indicate the number of weeks at which you think they should contact their doctor, nurse or other healthcare professional.
• Talk to them about the best way to navigate the urgent appointment system at their GP practice, and suitable alternatives, such as calling 111, or accessing local walk-in centres.

Section 3: In an asthma attack (red)

Make sure your patient, and anyone caring for them, can recognise signs of an asthma attack and when they need to take action. 

This section sets out:

• The signs and symptoms of an asthma attack
• What to do in an asthma attack
• When to call 999 
• When to contact their GP after an attack.

For more information, signpost your patients to the MART asthma attack advice on our MART page.

It is essential that you protect your patient by giving them clear instructions about taking extra doses of their MART inhaler and when to seek urgent or emergency clinical help, including:  

• How many puffs to take of their MART inhaler if their symptoms flare up
• How long they should wait between puffs
• When to call 999 if there is no improvement
• How many puffs to continue taking while waiting for the ambulance.

Make sure your patient understands that if they are on a MART regime, they need to follow asthma attack advice specific to their individual MART inhaler.

If they call for help, they need to explain they use a MART inhaler and do not have a blue reliever inhaler with them.

What to do if you have an asthma attack (MART)

1. Sit up straight - try to keep calm.
2. Take one puff of your MART inhaler every 1 to 3 minutes up to six puffs.
3. If you feel worse at any point OR you do not feel better after six puffs call 999 for an ambulance.
4. If the ambulance has not arrived after 10 minutes and your symptoms are not improving, repeat step 2.
5. If your symptoms are not better after repeating step 2, and the ambulance has still not arrived, contact 999 again immediately.

If you do not have your MART inhaler with you and need to use a blue reliever inhaler, take one dose every 30-60 seconds up to a maximum of 10 puffs and call 999 for an ambulance.

When completing Section 3, emphasise the importance of:

• seeking help urgently by calling 999 if their inhaler is not helping
• getting a same-day appointment if they managed an asthma attack at home
• booking a follow-up appointment with their GP within 48 hours of being discharged, if they went to hospital with an asthma attack
• a post-asthma attack follow-up review to look at what triggered the attack, review their treatment plan and inhaler technique, and discuss ways to reduce the risk of future attacks. 

Talk to your patient about the best way to navigate the urgent appointment system at their GP practice, and suitable alternatives, such as A&E, 999 or local walk-in centres. 

Peak flow – All sections

In all three sections, there is an option to add your patient’s peak flow scores.

• In section 1 you can note down your patient’s personal best score – the score that is usual for them when they are well. Your patient needs to have kept a peak flow diary for at least two weeks to establish a best score.
• In section 2 note down the peak flow score suggesting worsening symptoms. This is a score that is lower than their personal best score.
• In section 3 note down the peak flow score signalling an asthma attack.

Not all your patients will be using peak flow long term to manage their asthma. Monitoring peak flow at home is most useful at key times, such as after an asthma attack, or if your patient’s treatment plan has changed.

If your patient is using peak flow monitoring as part of their asthma management plan, whether that’s in the short or long term, it is important to make them aware that:

• Peak flow scores do not always change when symptoms get worse. It’s important to take action when symptoms worsen, whatever their peak flow score. For example, if they’re having symptoms at night or on waking, they need urgent assessment, even if their peak flow score is the same.
• Peak flow can pick up changes in the airways, before they have symptoms. If your patient’s peak flow score is lower than normal, it could be an early sign that their asthma is getting worse, and they should seek help and advice.

You can signpost your patient to our page on peak flow for more information and advice.

• A personal best peak flow score, or a score that is at least 80% of their personal best score, indicates well-controlled asthma.  
• A peak flow 75% or below their best score will require optimisation of care and self-care if this persists.
• A peak flow below 50% or below their best score indicates that your patient might be having an asthma attack and they should take urgent action 

Asthma triggers

Write down any triggers and allergies that you and your patient have identified in the ‘My asthma triggers’ section of the asthma action plan.

Stress the importance of minimising their risk by:

• taking their MART inhaler every day, as prescribed
• avoiding their triggers when possible, like cigarette smoke, air pollution and pets
• managing triggers like hay fever with antihistamines
• understanding that if exercise triggers symptoms, it can be a sign of poor control and they should see their GP
• taking extra care with food or other known allergies.

You can signpost your patients to our asthma triggers pages for more information and advice about triggers.

Asthma review

In the ‘My asthma review’ section of the plan, there is space for you to write in your patient’s next review date.

When considering the timing and frequency of asthma reviews, consider: 

• your patient’s level of asthma control and if they need a review more frequently than once a year
• the pattern of asthma symptoms and when they tend to be worse - for example, in response to seasonal triggers 
• your patient’s preferences and ease of attending - for example, if they work, or have children or other dependents to consider
• if you can safely conduct an asthma review online or over the phone 
• Setting up repeat prescriptions based on your predictions of how long their inhaler should last. Keep in mind that with MART, your patient may need more frequent prescriptions, so setting up the prescription so that it offers flexibility is essential.

Your patient’s asthma action plan is designed to be an easy to refer to self-management tool. 

To help your patient use their plan effectively, they could:

• Keep a copy of their updated plan on their phone, tablet or laptop. You could email them an electronic version. If this is not possible, they could they take a photo of the plan to keep on their phone. Make sure your patient remembers to replace it each time their plan is updated.
• Encourage your patient to keep a hard copy on their fridge or somewhere obvious, so it reminds them what they need to do to stay on top of their asthma.
• Suggest your patient shares their asthma action plan with friends, family and colleagues. They could send them the photo on their phone or tell them where a paper version is kept. This could be lifesaving if your patient experiences an asthma attack.
• Bring their plan along to every appointment.

A written asthma action plan is only one part of helping people maintain good control of their asthma.

Pinnock and Taylor explain the application of PRISMS to people with asthma (PDF), which includes:  

• giving patients information about their asthma – for example, signposting them to the Asthma + Lung UK website
• let them know about the Asthma and Lung UK Helpline.
• encouraging patients to make the most of a supportive community, such as the Health Unlocked asthma community forum, where they can share experiences and get support from others with asthma

Find all our asthma action plans, which are available in a range of languages, on our healthcare professionals resources pages. They are free to download or order.