Asthma Management Handbook

Other comorbidities and asthma

Recommendations

Identify and manage co-occurring allergic rhinitis in adults and children with asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • de Groot et al. 20121
  • Kersten et al. 20122
  • Pawankar et al. 20093
  • Price et al. 20054
  • Thomas et al. 20055
  • Wallace et al. 20086

Consider the possibility of upper airway dysfunction as an alternative or coexisting diagnosis in adults and children with asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Benninger et al. 20117
  • Deckert and Deckert, 20108
  • Weinberger and Abu-Hasan, 20079
  • Morris and Christopher, 201010

Consider the possibility of coexisting obstructive sleep apnoea in people with asthma, particularly in those who are also obese. Offer referral for investigation as appropriate.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Alkhalil et al. 200811
  • Alkhalil et al. 200912
  • Boulet, 200913
  • Dixon et al. 201114
  • Ross et al. 201215
  • Teodorescu et al. 201016
  • Teodorescu et al. 201217

For adults with obstructive sleep apnoea or children with sleep-disordered breathing, offer specialist referral.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For Aboriginal and Torres Strait Islander children, routinely ask about coughing (frequency and quality), even if parents or carers do not mention cough.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Morey et al. 201318

Consider the possibility of other chronic lung disease (e.g. bronchiectasis, chronic suppurative lung disease, pneumonia and COPD) as an alternative or coexisting diagnosis in Aboriginal and Torres Strait Islander adults and children with respiratory symptoms, particularly in remote regions. 

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Chang et al. 200819

In older patients, consider whether the presence of other common comorbid conditions (e.g. obesity, gastro-oesophageal reflux disease, obstructive sleep apnoea syndrome, osteoporosis, hypertension, cardiovascular disease) or their treatments may affect asthma control, increase the potential for drug–interactions, or affect the person’s ability to self-manage their asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Gibson et al. 201020

More information

Upper airway dysfunction

Upper airway dysfunction is intermittent, abnormal adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. It often mimics asthma78 and is commonly misdiagnosed as asthma.910 It can cause severe acute episodes of dyspnoea that occur either unpredictably or due to exercise.9 Inspiratory stridor associated with vocal cord dysfunction is often described as ‘wheezing’,9 but symptoms do not respond to asthma treatment.821

Upper airway dysfunction can coexist with asthma.7 People with asthma who also have upper airway dysfunction experience more symptoms than those with asthma alone and this can result in over-treatment if vocal cord dysfunction is not identified and managed appropriately.7

Upper airway dysfunction probably has multiple causes.7 In some people it is probably due to hyperresponsiveness of the larynx in response to intrinsic and extrinsic triggers.722 Triggers can include exercise, psychological conditions, airborne irritants, rhinosinusitis, gastro-esophageal reflux disease, and medicines.810

Upper airway dysfunction should be considered when spirometry shows normal FEV1/FVC ratio in a patient with suspected asthma10 or symptoms do not respond to short-acting beta2 agonist reliever. The shape of the maximal respiratory flow loop obtained by spirometry may suggest the diagnosis.9 Direct observation of the vocal cords is the best method to confirm the diagnosis of upper airway dysfunction.7

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Allergic rhinitis and asthma: links

Prevalence, aetiology and symptoms

Asthma and allergic rhinitis frequently coexist. At least 75% of patients with asthma also have rhinitis, although estimates vary widely.23

Allergic rhinitis that starts early in life is usually due to a classical IgE hypersensitivity. Adult-onset asthma or inflammatory airway conditions typically have more complex causes. Chronic rhinosinusitis with nasal polyps is not a simple allergic condition and generally needs specialist care.24

Symptoms and signs of allergic rhinitis can be local (e.g. nasal discharge, congestion or itch), regional (e.g. effects on ears, eyes, throat or voice), and systemic (e.g. sleep disturbance and lethargy). Most people with allergic rhinitis experience nasal congestion or obstruction as the predominant symptom. Ocular symptoms (e.g. tearing and itch) in people with allergic rhinitis are usually due to coexisting allergic conjunctivitis.25

Patients may mistake symptoms of allergic rhinitis for asthma. Allergic rhinitis is sometimes more easily recognised only after asthma has been stabilised.

Effects on asthma

The presence of allergic rhinitis is associated with worse asthma control in children and adults.3154

Both rhinitis and asthma can be triggered by the same factors, whether allergic (e.g. house dust mite, pet allergens, pollen, cockroach) or non-specific (e.g. cold air, strong odours, environmental tobacco smoke). Food allergies do not cause allergic rhinitis. Most people with allergic rhinitis are sensitised to multiple allergens (e.g. both pollens and house dust mite), so symptoms may be present throughout the year. Pollens (e.g. grasses, weeds, trees) and moulds are typically seasonal allergens in southern regions, but can be perennial in tropical northern regions.24 Pollen calendars provide information on when airborne pollen levels are likely to be highest for particular plants.

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Allergic rhinitis and asthma: treatment

Intranasal corticosteroids

Intranasal corticosteroids are effective in reducing congestion, rhinorrhoea, sneezing and itching in adults and children with allergic rhinitis,23 and are also effective against ocular symptoms associated with allergic rhinitis.23, 6, 26 Intranasal corticosteroids are more effective in reducing nasal symptoms than other treatments,23, 6 including oral H1-antihistamines6, 27 and montelukast,23, 6 and are at least as effective as intranasal H1-antihistamines.23, 27 The use of intranasal corticosteroids in patients with concomitant allergic rhinitis and asthma may improve asthma control.62

Intranasal corticosteroids are generally well tolerated in long-term use. In patients with asthma already taking inhaled corticosteroids, the intranasal corticosteroid dose should be taken into account when determining the total daily corticosteroid dose.

Patients need careful training to use intranasal sprays correctly. Detailed information and instructional videos for health professionals and patients are available on the National Asthma Council Australia website.

Antihistamines

Intranasal antihistamines reduce all symptoms of allergic rhinitis.27 Some have a more rapid onset of action than intranasal corticosteroids.27 Intranasal antihistamines are as effective as newer, less sedating oral H1-antihistamines,23 but are generally less effective than intranasal corticosteroids for the treatment of allergic rhinitis.6

Second-generation, less sedating oral H1-antihistamines (e.g. cetirizine, desloratadine, fexofenadine, levocetirizine or loratadine) are effective in managing allergic rhinitis symptoms of rhinorrhoea, sneezing, nasal itching and ocular symptoms,28 but are less effective for congestion.29 They are also effective for managing co-occurring ocular symptoms of allergy.6, 30

Specific allergen immunotherapy

Specific allergen immunotherapy (desensitisation) is effective in reducing allergic rhinitis symptoms (See separate topic).23, 31

Decongestants

Intranasal decongestants have a limited role in the management of allergic rhinitis because they should only be used for very short courses (up to 5 days maximum). Repeated or long-term use can cause rebound swelling of nasal mucosa necessitating dose escalation (rhinitis medicamentosa), with a risk of atrophic rhinitis.

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Comorbidity in older adults

Many older people with asthma also have multiple comorbidities and complex healthcare needs.2032 Common conditions in older people that may affect asthma control include:20

  • obesity
  • gastro-oesophageal reflux disease
  • obstructive sleep apnoea syndrome and other sleep disorders
  • osteoporosis (vertebral fractures can impair respiratory capacity)
  • cardiovascular disease (some medicines may worsen asthma).

The presence of diabetes can affect decisions about the use of systemic corticosteroids, while heart disease or anaemia can mimic symptoms.

There is limited clinical trial evidence to guide asthma management in older people with common comorbid conditions, because most asthma treatment trials have excluded people with these conditions.3320 Guidelines for one disease condition may have to be modified for older people with multiple chronic diseases to avoid potential adverse effects including drug–drug interactions.20

Common age-related problems such as cognitive impairment, poor eyesight, hearing loss, poor coordination or osteoarthritis can affect a person’s ability to use inhaler devices correctly.

Medicare items for chronic disease management (e.g. GP Management Plans, Team Care Arrangements, Multidisciplinary Care Plans) apply to patients with asthma.

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Obstructive sleep apnoea and asthma

Links with asthma

The risk of obstructive sleep apnoea is higher among people with asthma than in the general population.12

Obstructive sleep apnoea is associated with upper and lower airway inflammation.13 Pharyngeal inflammation in obstructive sleep apnoea may promote upper airway collapse.13

Obstructive sleep apnoea syndrome is an independent risk factor for asthma flare-ups.12

In adults, unrecognised obstructive sleep apnoea may contribute to persistent asthma daytime or night-time asthma symptoms, based on cohort study evidence.1716

In obese adults, obstructive sleep apnoea may contribute to poor asthma control.14

Obstructive sleep apnoea may also interact with gastro-oesophageal reflux disease to affect asthma control in adults.14

In children, sleep-disordered breathing in children appears to be a risk factor for severe asthma, independent of obesity.15

Effects of obstructive sleep apnoea treatment on asthma

Continuous positive airway pressure (CPAP) may improve asthma in adults with concomitant obstructive sleep apnoea syndrome.11

Among children with obstructive sleep apnoea, asthma control (measured by frequency of acute asthma flare-ups, reliever use, and asthma symptoms) may improve after adenotonsillectomy.34 Tonsillectomy or adenotonsillectomy is indicated in the management of upper airway obstruction in children with obstructive sleep apnoea.35

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Respiratory disease in Aboriginal and Torres Strait Islander peoples

Morbidity and mortality from respiratory diseases among Aboriginal and Torres Strait Islander people is higher than among non-Indigenous Australians across all age groups and regions.36 Among Aboriginal and Torres Strait Islander people living in remote areas, the rate of hospitalisation for respiratory disease is approximately three times the rate among Aboriginal and Torres Strait Islander people living in major cities.37 However, from 1997 to 2010 there was a 39% reduction in deaths due to respiratory disease among Aboriginal and Torres Strait Islander people.38

Detection, diagnosis and management of asthma may be complicated by increased rate of respiratory infections and chronic lung disease in rural remote Aboriginal and Torres Strait Islander communities.

  • Approximately 30% of Aboriginal and Torres Strait Islander people report respiratory problems.19
  • Chronic cough in Aboriginal and Torres Strait Islander children may be under-reported because it is so common that is considered normal by parents and caregivers.18
  • Pneumonia and COPD are the most common causes of hospitalisation for respiratory disease among Aboriginal and Torres Strait Islander people.37 The prevalence of COPD among Aboriginal and Torres Strait Islander people cannot be accurately estimated.39 The rate of death due to COPD among Aboriginal and Torres Strait Islander people is five times the rate among non-Indigenous Australians.40
  • The prevalence of bronchiectasis is disproportionately high in remote Aboriginal communities, particularly in Central Australia, but is underdiagnosed.1941 High-resolution computed tomography of the chest is necessary to diagnose bronchiectasis in adults.19 In Aboriginal and Torres Strait Islander adults, it may be difficult to distinguish between asthma, COPD and bronchiectasis.39 Bronchiectasis is associated with relatively rapid decline in lung function.19 
  • Chronic suppurative lung disease is highly prevalent among Aboriginal and Torres Strait Islander children in remote communities.19 The diagnosis of chronic suppurative lung disease is made in children who have symptoms and signs of bronchiectasis without radiographic features of bronchiectasis.19 In Aboriginal and Torres Strait Islander children, it may be difficult to distinguish between asthma and bronchiectasis or chronic suppurative lung disease.39 
  • Protracted bacterial bronchitis is often misdiagnosed as asthma,42, 43 but can also co-occur with asthma.43 Protracted bacterial bronchitis might precede chronic suppurative lung disease, but this is not yet well understood.43 Inadequate treatment of protracted bacterial bronchitis might put Aboriginal and Torres Strait Islander children at risk for chronic suppurative lung disease.43 Recurrent episodes of protracted bacterial bronchitis that does not resolve after treatment (e.g. a 14-day course of antibiotics) require investigation for chronic suppurative lung disease, bronchiectasis and aspiration.43

Notes

† Chronic suppurative lung disease is defined as a clinical syndrome of respiratory symptoms and signs due to chronic endobronchial suppuration, including continuous, wet or productive cough > 8 weeks, with or without other features (e.g. exertional dyspnoea, symptoms of reactive airway disease, recurrent chest infections, growth failure, clubbing, hyperinflation or chest wall deformity).44

‡ Bronchiectasis is diagnosed in patients with both chronic suppurative lung disease and the presence of radiological features on a chest high-resolution computed tomography scan.44

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Non-respiratory comorbidity among Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples have a high burden of chronic diseases that may affect asthma control and management, including:38

  • diabetes
  • cardiovascular disease
  • kidney disease
  • ear disease
  • mental health problems.
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References

  1. de Groot EP, Nijkamp A, Duiverman EJ, Brand PL. Allergic rhinitis is associated with poor asthma control in children with asthma. Thorax. 2012; 67: 582-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22213738
  2. Kersten ET, van Leeuwen JC, Brand PL, et al. Effect of an intranasal corticosteroid on exercise induced bronchoconstriction in asthmatic children. Pediatr Pulmonol. 2012; 47: 27-35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22170807
  3. Pawankar R, Bunnag C, Chen Y, et al. Allergic rhinitis and its impact on asthma update (ARIA 2008)–western and Asian-Pacific perspective. Asian Pac J Allergy Immunol. 2009; 27: 237-243. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20232579
  4. Price D, Zhang Q, Kocevar VS, et al. Effect of a concomitant diagnosis of allergic rhinitis on asthma-related health care use by adults. Clin Exp Allergy. 2005; 35: 282-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15784104
  5. Thomas M, Kocevar VS, Zhang Q, et al. Asthma-related health care resource use among asthmatic children with and without concomitant allergic rhinitis. Pediatrics. 2005; 115: 129-34. Available from: http://pediatrics.aappublications.org/content/115/1/129.long
  6. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: An updated practice parameter. J Allergy Clin Immunol. 2008; 122: S1-S84. Available from: http://www.jacionline.org/article/S0091-6749(08)01123-8/fulltext
  7. Benninger C, Parsons JP, Mastronarde JG. Vocal cord dysfunction and asthma. Curr Opin Pulm Med. 2011; 17: 45-49. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21330824
  8. Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010; 81: 156-159. Available from: http://www.aafp.org/afp/2010/0115/p156.html
  9. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics. 2007; 120: 855-864. Available from: http://pediatrics.aappublications.org/content/120/4/855.full
  10. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010; 138: 1213-23. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1045155
  11. Alkhalil M, Schulman ES, Getsy J. Obstructive sleep apnea syndrome and asthma: the role of continuous positive airway pressure treatment. Ann Allergy Asthma Immunol. 2008; 101: 350-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18939721
  12. Alkhalil M, Schulman E, Getsy J. Obstructive aleep apnea syndrome and asthma: what are the links?. J Clin Sleep Med. 2009; 5: 71-78. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637171/
  13. Boulet LP. Influence of comorbid conditions on asthma. Eur Respir J. 2009; 33: 897-906. Available from: http://erj.ersjournals.com/content/33/4/897.long
  14. Dixon AE, Clerisme-Beaty EM, Sugar EA, et al. Effects of obstructive sleep apnea and gastroesophageal reflux disease on asthma control in obesity. J Asthma. 2011; 48: 707-13. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3171804/
  15. Ross KR, Storfer-Isser A, Hart MA, et al. Sleep-disordered breathing is associated with asthma severity in children. J Pediatr. 2012; 160: 736-42. Available from: http://www.jpeds.com/article/S0022-3476(11)01047-X/fulltext
  16. Teodorescu M, Polomis DA, Hall SV, et al. Association of obstructive sleep apnea risk with asthma control in adults. Chest. 2010; 138: 543-50. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2940069/
  17. Teodorescu M, Polomis DA, Teodorescu MC, et al. Association of obstructive sleep apnea risk or diagnosis with daytime asthma in adults. J Asthma. 2012; 49: 620-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3626099/
  18. Morey MJ, Cheng AC, McCallum GB, Chang AB. Accuracy of cough reporting by carers of Indigenous children. J Paediatr Child Health. 2013; 49: E199-203. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23438209
  19. Chang AB, Grimwood K, Maguire G, et al. Management of bronchiectasis and chronic suppurative lung disease in indigenous children and adults from rural and remote Australian communities. Med J Aust. 2008; 189: 386-93. Available from: https://www.mja.com.au/journal/2008/189/7/management-bronchiectasis-and-chronic-suppurative-lung-disease-indigenous
  20. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816547
  21. Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?. Eur Respir J. 2011; 37: 194-200. Available from: http://erj.ersjournals.com/content/37/1/194.long
  22. Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol. 2011; 106: 267-274. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21457874
  23. Brożek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol. 2010; 126: 466-476. Available from: http://www.jacionline.org/article/S0091-6749(10)01057-2/fulltext
  24. National Asthma Council Australia. Managing allergic rhinitis in people with asthma. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/allergic-rhinitis-asthma-hp
  25. Spangler DL, Abelson MB, Ober A, Gotnes PJ. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther. 2003; 25: 2245-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14512132
  26. Hong J, Bielory B, Rosenberg JL, Bielory L. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: A systematic review. Allergy Asthma Proc. 2011; 32: 22-35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21262095
  27. Kaliner MA, Berger WE, Ratner PH, Siegel CJ. The efficacy of intranasal antihistamines in the treatment of allergic rhinitis. Ann Allergy Asthma Immunol. 2011; 106: S6-s11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277531
  28. Bachert C, Maspero J. Efficacy of second-generation antihistamines in patients with allergic rhinitis and comorbid asthma. J Asthma. 2011; 48: 965-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21970671
  29. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008. Allergy. 2008; 63: 8-160. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2007.01620.x/full
  30. Howarth PH. Assessment of antihistamine efficacy and potency. Clin Exp Allergy. 1999; 29 Suppl 3: 87-97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10444220
  31. Lin S, Erekosima N, Kim J, et al. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: A systematic review. JAMA. 2013; 309: 1278-1288. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23532243
  32. Goeman DP, Douglass JA. Optimal management of asthma in elderly patients: strategies to improve adherence to recommended interventions. Drugs Aging. 2007; 24: 381-394. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17503895
  33. deShazo RD, Stupka JE. Asthma in US seniors: part 2. Treatment. Seeing through the glass darkly. Am J Med. 2009; 122: 109-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19100959
  34. Kheirandish-Gozal L, Dayyat EA, Eid NS, et al. Obstructive sleep apnea in poorly controlled asthmatic children: effect of adenotonsillectomy. Pediatr Pulmonol. 2011; 46: 913-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156307/
  35. Paediatrics & Child Health Division, of The Royal Australasian College of Physicians, Australian Society of, Otolaryngology Head and Neck Surgery. Indications for tonsillectomy and adenotonsillectomy in children. Royal Australasian College of Physicians and Australian Society of Otolaryngology Head and Neck Surgery, Sydney, 2008.
  36. O'Grady KA, Revell A, Maguire GP, et al. Lung health care for Aboriginal and Torres Strait Islander Queenslanders: breathing easy is not so easy. Aust Health Rev. 2011; 35: 512-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22126958
  37. MacRae A, Thomson N, Anomie, et al. Overview of Australian Indigenous health status. Perth, 2012. Available from: http://www.healthinfonet.ecu.edu.au/health-facts/overviews
  38. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detail analysis. Australian Institute of Health and Welfare, Canberra, 2013. Available from: http://www.aihw.gov.au/publication-detail/?id=60129543821&tab=2
  39. O’Grady KF, Revell A, Maguire G, et al. Lung Health Services for Aboriginal and Torres Strait Islander Peoples in Queensland. Queensland Health, Brisbane, 2010. Available from: http://www.lungfoundation.com.au/professional-resources/publications/
  40. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  41. Chang AB, Masel JP, Boyce NC, et al. Non-CF bronchiectasis: clinical and HRCT evaluation. Pediatr Pulmonol. 2003; 35: 477-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12746947
  42. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23175647
  43. Chang AB, Redding GJ, Everard ML. Chronic wet cough: Protracted bronchitis, chronic suppurative lung disease and bronchiectasis. Pediatr Pulmonol. 2008; 43: 519-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18435475
  44. Chang AB, Bell SC, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. Med J Aust. 2010; 193: 356-65. Available from: https://www.mja.com.au/journal/2010/193/6/chronic-suppurative-lung-disease-and-bronchiectasis-children-and-adults-australia