Counselling · Intermediate · Respiratory

Discharge Counselling: Asthma Action Plan and Inhaler Technique

Practise this PLAB 2 counselling station on Asthma. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor on the respiratory ward. Mr Adam Patel, a 42-year-old man, has been admitted with acute asthma exacerbation treated with high-dose corticosteroids, nebulisers, and continuous oxygen. He is now clinically stable and ready for discharge. Before discharge, you need to counsel him on his personalised asthma action plan, teach proper inhaler technique, identify his triggers, discuss medication adherence, and arrange appropriate follow-up. This is a COUNSELLING scenario where you educate a patient about his condition and self-management after an acute event.

Background notes: PMH: Asthma (diagnosed age 23, previously well-controlled), Allergic rhinitis (seasonal), Eczema (mild

What this station tests

  • Converting a frightening hospital admission into lasting behaviour change: using the patient's motivation while it is high without being preachy
  • Addressing preventer non-adherence: explaining the concept of silent inflammation and why feeling well does not mean asthma has gone away
  • Teaching the traffic light asthma action plan: green (well-controlled), amber (worsening, action needed), red (emergency, call 999)
  • Practical inhaler technique teaching: checking and correcting technique, considering spacer use, demonstrating the key steps
  • Trigger identification and practical management: viral infections, pets, exercise, pollen

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, establish what patient already knows and understands.
  • 1-3 min — Explain Condition: Explain diagnosis or condition using chunk-and-check technique. Use simple language, avoid jargon.
  • 3-5 min — Management Options: Discuss treatment options. Shared decision-making. Risks, benefits, alternatives.
  • 5-7 min — Address Concerns: Explore and address specific concerns. Check understanding. Discuss lifestyle implications.
  • 7-8 min — Closing: Summarise agreed plan. Safety netting. Arrange follow-up. Written information offer.

Consultation approach

The opening

Discharge counselling after an acute admission is about converting a frightening experience into lasting behaviour change. The patient is motivated right now because they were scared. The candidate must capitalise on this without lecturing. Mr Patel is 42, being discharged after 3 to 4 days in hospital for an acute asthma exacerbation. He was not taking his preventer inhaler regularly because he felt well. Open with: 'Mr Patel, how are you feeling now compared to when you came in?' He will express relief and say the experience was the scariest thing that has happened to him. Use this as the foundation for the counselling.

Core approach

Explore what led to the admission. He was diagnosed with asthma at 23, previously well-controlled on fluticasone/salmeterol, but stopped taking the preventer regularly because he felt fine. He developed a cold which triggered the exacerbation. He woke unable to breathe and called an ambulance. This narrative reveals the core behaviour to address: preventer non-adherence driven by the 'I feel fine so I don't need it' belief.

Address the non-adherence directly but non-judgmentally: 'A lot of people stop taking their preventer when they feel well because the asthma seems to have gone away. But asthma is a chronic condition: even when you feel fine, the inflammation in your airways is still there. The preventer keeps that inflammation under control. When you stop it, the inflammation builds up silently until a trigger like a cold tips you over into an attack.'

Teach the asthma action plan using traffic light zones. Green (well-controlled): no symptoms, taking preventer daily, using reliever less than 3 times a week. Amber (worsening): increasing reliever use, waking at night, symptoms with usual activities. This is when he needs to double his preventer dose and see his GP within 48 hours. Red (severe): unable to speak in full sentences, reliever not working, breathing very fast, feeling frightened. Call 999.

Teach inhaler technique practically. Check his current technique. The commonest errors: not shaking the inhaler, breathing in too fast (should be slow and steady), not holding breath for 10 seconds, not waiting between puffs. If he uses a dry powder inhaler, the technique is different (sharp, fast inhalation). Consider whether a spacer would improve drug delivery.

Identify his triggers: viral infections (the cause of this admission), cats (he has a cat at home), exercise, pollen season (allergic rhinitis). Discuss practical trigger management.

Closing and safety netting

Discharge medications: he should leave with a clear understanding of his preventer (take every day, even when well), his reliever (for breakthrough symptoms only, not as routine), and a tapering course of oral prednisolone if prescribed. Explain the importance of completing the steroid course.

Follow-up: GP review within 48 hours of discharge. Asthma nurse review within 4 weeks. Annual asthma review ongoing. He should have a written asthma action plan before leaving. Offer smoking cessation support if applicable (check smoking status).

Close by reinforcing his motivation: 'You said this was the scariest thing that has happened to you. The preventer inhaler is the single most important thing you can do to prevent it happening again. It takes 30 seconds twice a day.' Safety net: 'If your symptoms return and your reliever is not controlling them, do not wait. Come back.'

How examiners mark this station

Examiners will assess your ability to explain asthma and its management in a patient-centred way. Domain 2 (Clinical Management) and Domain 3 (Interpersonal Skills) are equally weighted and primary. Expect marks for accurate information delivery, shared decision-making, chunk-and-check technique, and addressing the patient's specific concerns. Domain 1 (Data Gathering) is assessed through how well you establish the patient's baseline understanding and elicit their concerns.

Domain 1: Data Gathering, Technical and Assessment Skills (Supporting)

Scores well: Exploring the sequence of events leading to admission. Identifying non-adherence as the root cause. Assessing current inhaler technique. Identifying triggers (cat, viral infections, pollen).

Costs marks: Not exploring why he stopped taking the preventer. Not checking inhaler technique. Not identifying triggers.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Clear discharge medication plan. Traffic light action plan explained. Inhaler technique checked and corrected. Trigger management discussed. Follow-up arranged: GP 48 hours, asthma nurse 4 weeks. Steroid course completion emphasised. Safety netting for return of symptoms.

Costs marks: Vague discharge advice. No action plan. No inhaler technique. No follow-up arrangement. No safety netting.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Using his fear from the admission as motivation without being manipulative. Non-judgmental approach to non-adherence. Empowering him with self-management tools rather than creating dependence on medical review. Checking understanding at each stage.

Costs marks: Being judgmental about non-adherence. Lecturing rather than counselling. Not using his current motivation. Overloading with information without checking understanding.

Common examiner feedback (and how to fix it)

Did not provide adequate explanation or plan to the patient

Fix: Use chunk-and-check: deliver one concept, check understanding, then move to the next. Offer all relevant treatment options with risks and benefits before helping the patient decide.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Before and during counselling, explicitly ask what concerns the patient most. Respond to emotional cues with empathic statements before continuing with information.

Common mistakes in this station

  1. Lecturing about non-adherence rather than exploring it. Mr Patel already knows he should have been taking his preventer. Saying 'you must take your inhaler every day' is less effective than explaining why he felt fine without it (silent inflammation) and what changed when he stopped (vulnerability to triggers). Understanding drives adherence; instruction alone does not.
  2. Not teaching inhaler technique. Prescribing the right medication with poor technique means the drug does not reach the airways. Candidates who skip technique teaching miss a core counselling element. Even a brief check and correction scores well.
  3. Not providing a written asthma action plan or explaining the traffic light system. Verbal advice alone is forgotten within hours of discharge. The structured action plan gives the patient a framework for self-management between appointments.

Resitting PLAB 2?

If counselling stations have been a challenge, the most common issue is information overload: delivering too much clinical detail without checking understanding. Practise the chunk-and-check technique until it becomes automatic. Remember that shared decision-making, not lecturing, is what scores highly in Domain 3.

Example opening

Hello, my name is Dr [Name]. I understand you've come in today to discuss [topic]. Before I explain things, could you tell me what you've been told so far, so I know where to start?

Frequently asked questions

What is the best way to structure this asthma counselling consultation?

Discharge counselling after an acute admission is about converting a frightening experience into lasting behaviour change. The patient is motivated right now because they were scared. The candidate must capitalise on this without lecturing.

Where are marks won and lost in this asthma station?

Examiners reward: Exploring the sequence of events leading to admission. Identifying non-adherence as the root cause. Assessing current inhaler technique. Candidates are penalised for: Not exploring why he stopped taking the preventer. Not checking inhaler technique. Not identifying triggers.

Where do candidates most often go wrong in this station?

Lecturing about non-adherence rather than exploring it. Mr Patel already knows he should have been taking his preventer. Saying 'you must take your inhaler every day' is less effective than explaining why he felt fine without it (silent inflammation) and what changed when he stopped (vulnerability to triggers).

Can I do well in this station without real-world experience of asthma?

This station rewards process over personal experience. The skill being assessed: Addressing preventer non-adherence: explaining the concept of silent inflammation and why feeling well does not mean asthma has gone away. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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