Managing avoidable triggers
If clinically relevant triggers are avoidable, discuss with the person to weigh up the feasibility, benefits and costs of trigger avoidance.
Table. Summary of asthma triggers Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/52
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available)
Recommend that patients always avoid tobacco smoke, and that parents ensure children are not exposed to tobacco smoke.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):
- Osborne et al. 20071
Recommend that, where practical, patients avoid or reduce exposure to:
- allergens if person is sensitised (e.g. animal allergens, cockroaches, house dust mite, moulds, occupational allergens, pollens, thunderstorms)
- airborne/environmental irritants (e.g. smoke from bushfires, vegetation reduction fires or indoor wood fires, smoke from cigarettes of any type including cannabis, unflued fuel combustion heating such as gas heaters, cold/dry air, airborne home renovation materials, household aerosols, occupational irritants, outdoor industrial and traffic pollution, thunderstorms, perfumes or spray deodorants and incense)
- dietary triggers known to trigger symptoms in the individual (e.g. food chemicals or additives if person is intolerant, cold drinks).
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):
- Global Initiative for Asthma, 20122
- Jenerowicz et al. 20123
- Jie et al. 20114
- Nasser and Pulimood, 20095
- National Asthma Council Australia, 20126
For patients with aspirin-exacerbated respiratory disease, provide advice about alternative analgesia or anti-platelet therapy.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
Advise patients that some complementary medicines have caused serious allergic reactions in some patients. These include:
- bee products (pollen, propolis, royal jelly)
- garlic supplements.
- Indoor air quality
Epidemiological studies suggest that asthma symptoms are worsened by exposure to range of indoor pollutants, especially environmental tobacco smoke, fuel combustion, damp and moulds.4
Environmental tobacco smoke
Among adults with asthma, exposure to cigarette smoke (smoking or regular exposure to environmental tobacco smoke within the previous 12 months) has been associated with a significantly increased risk of needing acute asthma care within the next 2–3 years.1
Indoor exposure to nitrogen dioxide (e.g. due to gas stoves or heaters in homes, schools or workplaces) increases the risk of asthma symptoms11, 12, 13 and may reduce lung function.12 Most evidence that nitrogen dioxide is an asthma trigger is from studies in children. Preventing exposure (e.g. replacing heaters with non-polluting heaters) improves symptoms of asthma and wheeze in children.14, 15, 16, 13
Woodfire smoke can reduce lung function and increase airway inflammation in children with asthma.17 Inhaled corticosteroids may reduce the effects of wood smoke.
Damp and moulds
Several mould species have been associated with asthma, including Alternaria (e.g. Alternaria alternate), Cladosporium, Aspergillus and Penicillium.18 Two mechanisms have been reported for airway disease due to moulds: allergic sensitisation and reaction to mould aeroirritants.19
Sensitisation to Alternaria has been associated with an increased risk of hospitalisation in children with asthma.18 Epidemiological studies suggest that exposure to damp, mouldy buildings can worsen symptoms in adults and children with asthma18, 20, 21 and is associated with increased risk of asthma flare-ups.
Building repairs to reduce dampness in homes (e.g. leak repair, improvement of ventilation, removal of water-damaged materials) may reduce asthma symptoms and the use of asthma medicines.22 A systematic review and meta-analysis found that damp remediation of houses reduced asthma-related symptoms including wheezing in adults, and reduced acute care visits in children.22 In children living in mouldy houses, reducing damp in the home may reduce symptoms and flare-ups, compared with cleaning advice about moulds.23
There are too few good-quality studies to conclude whether remediation of workplace buildings or schools reduces asthma symptoms.22
Antifungal medication (oral itraconazole) may improve quality of life in people with severe asthma (requiring high-dose inhaled corticosteroid treatment or frequent/continuous courses of oral corticosteroids) who are sensitised to moulds.24 However, antifungal treatment is associated with adverse effects.24
Asthma symptoms can be triggered by strong scents including:
There have been anecdotal reports of asthma triggered by spray deodorants.
Work-exacerbated asthma due to perfumes has also been documented.28Close
- Outdoor air quality
Industrial and traffic pollutants
Overall, epidemiological studies suggest that there is a strong relationship between air pollution and asthma symptoms or flare-ups, including severe acute asthma requiring hospital admission.2, 3 Airborne pollutants associated with worsening of asthma symptoms include:2, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39
- coarse particulate matter (diameter ≤10 micrometre)
- fine particulate matter (diameter ≤2.5 micrometre)
- carbon monoxide
- nitrogen dioxide
- sulphur dioxide
- diesel exhaust (multiple chemicals).
The mechanisms appear to involve airway inflammation and reduction in lung function.
Evidence from regional studies correlating recorded air pollution levels with hospital records show that pollutants from traffic sources are positively associated with emergency department visits for asthma or wheeze. Even low concentrations of ozone and traffic-related air pollutants may increase the risk of serious asthma flare-ups in children.
Simultaneous exposure to pollutants (e.g. diesel exhaust, ozone) and allergens may have synergistic effects.3, 42 Diesel may interact with proteins to cause deposition of allergens deep in respiratory tract.3
High levels of airborne fungi (e.g. Basidiomycetes, Ascomycetes, Deuteromycetes) in urban environments were associated with increased rates of hospitalisation for asthma in a population study.42Close
- Allergens as asthma triggers
Allergens can trigger asthma if the person is sensitised.
Contact with pets (e.g. cats, dogs and horses) can trigger asthma, mainly due to sensitisation to allergens in sebum or saliva. Exposure can trigger flare-ups or worsen symptoms.6
The amount of allergen excreted differs between breeds.6 Although some breeders claim that certain breeds of dogs that are less likely to trigger asthma (‘hypoallergenic’ breeds), allergen levels have not been shown to be lower in the animal’s hair or coat,43 or in owner’s homes44 with these breeds than other breeds.
Cat allergens easily spread on clothing and are found in places where cats have never been.6
Work-related asthma, triggered by animal urine or dander, is seen in animal workers such as breeders, jockeys, laboratory workers, pet shop workers, and people who work in veterinary surgeries.
House dust mite
Exposure to house dust mite antigens is a major asthma trigger in Australia.6
Exposure to pollen can worsen asthma symptoms during the pollen seasons. Pollen counts are generally highest on calm, hot, sunny days in spring, early summer or during the dry season in tropical regions.
Thunderstorms are also associated with asthma flare-ups due to pollen in sensitised individuals (see: Weather events).Close
- Weather events
The mechanisms include increases in the concentration of airborne triggers (e.g. dust, pollution, allergens such as pollens and moulds) and changes in humidity and temperature.5, 46 Another possible mechanism is that osmotic shock may cause rupture of pollen grains (e.g. from grasses), releasing very small starch granules that may allow allergens to penetrate the lower airways.46
High levels of airborne dusts have been associated with epidemics of hospitalisation of children for asthma.47Close
- Home renovation materials
Home renovation materials can trigger asthma either as sensitisers (in patients allergic to the airborne substance) or as irritants.
Home renovators may be exposed to allergens commonly responsible for work-related asthma such as wood dust (e.g. western red cedar, redwood, oak) or isocyanates in adhesives.Close
- Triggers in the workplace
A wide range of occupational allergens has been associated with work-related asthma. Investigation of work-related asthma is complex and typically requires specialist referral.Close
- Bushfire smoke
Exposure to smoke from vegetation fires (e.g. bushfires, back-burning) is associated with asthma symptoms and with increases in emergency department visits and hospital admissions due to asthma flare-ups.48, 49, 50, 51, 52, 53, 54, 55, 56, 57Close
- Cold/dry air as an asthma trigger
Cold air can trigger asthma symptoms due to two mechanisms:58
- response to sudden cooling of the airways
- reflex-mediated lower-airway response to cooling of the skin or upper airways.
Repeated exposure to cold air (e.g. in athletes training in cold, dry air) can also contribute to the development of airway injury and exercise-induced bronchoconstriction.58
Effects may depend on individual susceptibility and the level of ventilation during cold air exposure.Close
- Dietary triggers
Foods are rarely a trigger for asthma.6
Food chemicals and additives
Sulphite additives (widely used as preservative and antioxidants in the food and pharmaceutical industries) have been associated with acute asthma.60
An estimated 3–10% of people with asthma are sensitised to sulphites.60
See also: Dietary salicylates
Wine has been documented to trigger asthma symptoms.61 The mechanism appears to be complex and varies between individuals.61, 62 Components of wine implicated in asthma reactions include sulphite additives and histamines.61
Although sensitivity to sulphites in wine has been demonstrated in individuals in clinical studies, this mechanism does not explain all asthmatic reactions to wine.61, 62, 63 The amount of sulphite in wine varies between brands. In general, there is more preservative in white wine than red wine, and more in cask wine than bottled wine.64
Some challenge studies suggest that antihistamines may reduce the severity of asthma symptoms due to wine.64 In general there is more histamine in red than white wines and more in Shiraz than Cabernet.64
Asthma symptoms provoked by cold drinks are commonly reported anecdotally. Asthma symptoms and a reduction in FEV1 after drinking icy water have been observed in children with asthma.65 Increased bronchial hyperresponsiveness has been observed approximately 90 minutes after ingestion of ice.65
Milk and other dairy foods do not increase mucus.66Close
- Dietary salicylates
Aspirin-exacerbated respiratory disease is a syndrome of airway inflammation that includes asthma, nasal polyposis, chronic rhinosinusitis, and reaction to NSAIDs. It can present with severe sudden-onset asthma. People with aspirin-exacerbated respiratory disease may react to one or more anti-inflammatory agent.
Salicylates are found in some foods (e.g. stone fruits, berries, dried fruits, gherkins, concentrated tomato products, curry powder, paprika, thyme, garam masala, rosemary, tea).67 Most foods that contain salicylates contain both salicylic acid and acetylsalicylic acid, and about one-third contain only acetylsalicylic acid.68 Dietary salicylates are generally thought not to cause symptoms in people with aspirin-exacerbated respiratory disease.69
Salicylate elimination should only be considered under specialist supervision.Close
- Interactions between triggers
Simultaneous exposure to some classes of triggers may have synergistic effects on asthma symptoms and flare-ups, e.g.:
- allergens plus industrial or traffic pollutants (e.g. diesel exhaust, ozone)3, 42
- allergens plus viruses.70, 71
- Elimination diets
Strict dietary elimination and spirometry measurement of FEV1 after double-blind food chemical challenge is the most reliable method for detecting food chemical intolerance in people with asthma.72 Positive responses (reduction in bronchial hyperresponsiveness) to placebo challenge are common during unmodified diets.72
For people with asthma and food intolerances, elimination diets do not always improve bronchial hyperresponsiveness.73Close
- Medicines that can trigger asthma
Beta-adrenergic blocking agents (beta blockers) may cause bronchoconstriction and reduce lung function and should be used with caution in people with asthma.
Risk may be reduced with cardioselective systemic beta blockers (i.e. those that primarily block beta1-adrenergic receptors in the heart rather than beta2-receptors in the airways), such as atenolol, bisoprolol, metoprolol and nebivolol. However, selective beta blockers are not risk-free. A meta-analysis of randomised, blinded, placebo-controlled clinical trials evaluating acute beta blocker exposure in patients with asthma found hat selective beta blockers caused a fall in FEV1 of >20% in one in eight patients, and respiratory symptoms in one in 33 patients.74
Nonselective systemic beta blockers (including carvedilol, labetolol, oxprenolol, pindolol and propranolol) should not be used in people with asthma.
Ocular beta blocker preparations (e.g. timolol) may also impair respiratory function,75, 76 and asthma deaths have been reported.77, 78 Changing from timolol (nonselective) to betaxolol (selective) might improve respiratory function.76 Blocking the tear duct for 2–3 minutes after administering drops (punctual occlusion) may reduce risk of respiratory effects by minimising systemic absorption.79
Prostaglandin analogues (e.g. bimatoprost, latanoprost, travoprost), alpha2-agonists, carbonic acid inhibitors and cholinergic agents are alternative agents for managing intraocular pressure and have minimal effect on airways.75 Note that some preparations are combined with a beta blocker.
Anticholinesterases and cholinergic agents
Cholinesterase inhibitors (e.g. pyridostygmine, neostigmine, donepezil, rivastigmine, galantamine) should be used with caution in people with asthma: they may reduce lung function and theoretically could cause bronchoconstriction.
Cholinergic agents (e.g. carbachol, pilocarpine) might also cause bronchoconstriction.
Aspirin and nonsteroidal anti-inflammatory drugs
Most people with asthma can tolerate aspirin (acetylsalicylic acid) and NSAIDs.
Aspirin-exacerbated respiratory disease is a syndrome of airway inflammation that includes asthma, nasal polyposis, chronic rhinosinusitis and reaction to NSAIDs. It can present with severe sudden-onset asthma.
- 0.5–2.5% of the general population
- 4–11% of adults with asthma
- 30% of patients with asthma and nasal polyposis.
In addition, a substantial proportion may be unaware that they are sensitive to aspirin. Aspirin challenge studies have identified aspirin sensitivity in approximately 5% of children with asthma, 21% of adults with asthma, and 30–42% of people with both asthma and nasal polyposis.
People with aspirin-exacerbated respiratory disease may react to one or more anti-inflammatory agents. In a study of 659 patients with skin or airway reactions to NSAIDs challenged with paracetamol, aspirin and a range of nonselective NSAIDs (COX-1 and COX-2 inhibitors) that included piroxicam, diclofenac, ibuprofen and indomethacin), 76% showed cross-reaction to chemically distinct or unrelated COX-1 inhibitors and 24% reacted only to a single cyclo-oxygenase inhibitor.82 Nonselective NSAIDS available in Australia also include ketoprofen, naproxen and piroxicam. People with NSAID intolerance are unlikely to react to ‘coxib’-type COX-2-selective NSAIDs (celecoxib, etoricoxib, parecoxib).83 Meloxicam has been reported to cause bronchoconstriction at higher doses.83
People with aspirin-exacerbated respiratory disease could be at risk if they use complementary medicines that contain salicylates (e.g. willowbark) or salicin (e.g. meadowsweet).
Challenge testing is sometimes necessary to confirm the diagnosis in people who have not reported a clear association between aspirin and symptoms.
Some complementary and alternative medicines may trigger asthma:Close
- Osborne ML, Pedula KL, O'Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest. 2007; 132: 1151-61. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1085456
- Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
- Jenerowicz D, Silny W, Danczak-Pazdrowska A, et al. Environmental factors and allergic diseases. Ann Agric Environ Med. 2012; 19: 475-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23020042
- Jie Y, Ismail NH, Jie X, Isa ZM. Do indoor environments influence asthma and asthma-related symptoms among adults in homes? A review of the literature. J Formos Med Assoc. 2011; 110: 555-63. Available from: http://www.jfma-online.com/article/S0929-6646(11)00014-3/fulltext
- Nasser SM, Pulimood TB. Allergens and thunderstorm asthma. Curr Allergy Asthma Rep. 2009; 9: 384-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19671382
- National Asthma Council Australia. Asthma and allergy. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/asthma-allergy-hp
- Bullock RJ, Rohan A, Straatmans JA. Fatal royal jelly-induced asthma. Med J Aust. 1994; 160: 44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8271989
- Leung R, Thien FC, Baldo B, Czarny D. Royal jelly-induced asthma and anaphylaxis: clinical characteristics and immunologic correlations. J Allergy Clin Immunol. 1995; 96: 1004-7. Available from: http://www.jacionline.org/article/S0091-6749(95)70242-3/fulltext
- Mullins RJ, Heddle R. Adverse reactions associated with echinacea: the Australian experience. Ann Allergy Asthma Immunol. 2002; 88: 42-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11814277
- Thien FC, Leung R, Plomley R, et al. Royal jelly-induced asthma. Med J Aust. 1993; 159: 639. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8123114
- Kattan M, Gergen PJ, Eggleston P, et al. Health effects of indoor nitrogen dioxide and passive smoking on urban asthmatic children. J Allergy Clin Immunol. 2007; 120: 618-24. Available from: http://www.jacionline.org/article/S0091-6749(07)00962-1/fulltext
- Gillespie-Bennett J, Pierse N, Wickens K, et al. The respiratory health effects of nitrogen dioxide in children with asthma. Eur Respir J Supplement. 2011; 38: 303-9. Available from: http://erj.ersjournals.com/content/38/2/303.long
- Marks GB, Ezz W, Aust N, et al. Respiratory health effects of exposure to low-NOx unflued gas heaters in the classroom: a double-blind, cluster-randomized, crossover study. Environ Health Perspect. 2010; 118: 1476-82. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2957932/
- Pilotto LS, Nitschke M, Smith BJ, et al. Randomized controlled trial of unflued gas heater replacement on respiratory health of asthmatic schoolchildren. Int J Epidemiol. 2004; 33: 208-14. Available from: http://ije.oxfordjournals.org/content/33/1/208.long
- Howden-Chapman P, Pierse N, Nicholls S, et al. Effects of improved home heating on asthma in community dwelling children: randomised controlled trial. BMJ. 2008; 337: a1411. Available from: http://www.bmj.com/content/337/bmj.a1411
- Free S, Howden-Chapman P, Pierse N, Viggers H. More effective home heating reduces school absences for children with asthma. J Epidemiol Community Health. 2010; 64: 379-86. Available from: http://jech.bmj.com/content/64/5/379.long
- Allen RW, Mar T, Koenig J, et al. Changes in lung function and airway inflammation among asthmatic children residing in a woodsmoke-impacted urban area. Inhal Toxicol. 2008; 20: 423-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18302050
- Rao D, Phipatanakul W. Impact of environmental controls on childhood asthma. Curr Allergy Asthma Rep. 2011; 11: 414-20. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166452/
- Hope AP, Simon RA. Excess dampness and mold growth in homes: an evidence-based review of the aeroirritant effect and its potential causes. Allergy Asthma Proc. 2007; 28: 262-70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17619553
- Frisk M, Magnuson A, Kiviloog J, et al. Increased occurrence of respiratory symptoms is associated with indoor climate risk indicators - a cross-sectional study in a Swedish population. Respir Med. 2007; 101: 2031-5. Available from: http://www.resmedjournal.com/article/S0954-6111(07)00189-8/fulltext
- Mendell MJ, Mirer AG, Cheung K, et al. Respiratory and allergic health effects of dampness, mold, and dampness-related agents: a review of the epidemiologic evidence. Environ Health Perspect. 2011; 119: 748-56. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114807/
- Sauni R, Uitti J, Jauhiainen M, et al. Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma. Cochrane Database Syst Rev. 2011; Issue 9: CD007897. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007897.pub2/full
- Kercsmar CM, Dearborn DG, Schluchter M, et al. Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environ Health Perspect. 2006; 114: 1574-80. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626393/
- Denning DW, O'Driscoll BR, Powell G, et al. Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization: The Fungal Asthma Sensitization Trial (FAST) study. Am J Respir Crit Care Med. 2009; 179: 11-8. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200805-737OC
- Al-Rawas OA, Al-Maniri AA, Al-Riyami BM. Home exposure to Arabian incense (bakhour) and asthma symptoms in children: a community survey in two regions in Oman. BMC Pulm Med. 2009; 9: 23. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693130/
- Millqvist E, Lowhagen O. Placebo-controlled challenges with perfume in patients with asthma-like symptoms. Allergy. 1996; 51: 434-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8837670
- Kumar P, Caradonna-Graham VM, Gupta S, et al. Inhalation challenge effects of perfume scent strips in patients with asthma. Ann Allergy Asthma Immunol. 1995; 75: 429-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7583865
- Henneberger PK, Redlich CA, Callahan DB, et al. An official american thoracic society statement: work-exacerbated asthma. Am J Respir Crit Care Med. 2011; 184: 368-78. Available from: http://ajrccm.atsjournals.org/content/184/3/368.long
- Weinmayr G, Romeo E, De Sario M, et al. Short-term effects of PM10 and NO2 on respiratory health among children with asthma or asthma-like symptoms: a systematic review and meta-analysis. Environ Health Perspect. 2010; 118: 449-57. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854719/
- Wiwatanadate P, Liwsrisakun C. Acute effects of air pollution on peak expiratory flow rates and symptoms among asthmatic patients in Chiang Mai, Thailand. Int J Hyg Environ Health. 2011; 214: 251-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21530391
- Iskandar A, Andersen ZJ, Bonnelykke K, et al. Coarse and fine particles but not ultrafine particles in urban air trigger hospital admission for asthma in children. Thorax. 2012; 67: 252-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22156960
- Halonen JI, Lanki T, Yli-Tuomi T, et al. Urban air pollution, and asthma and COPD hospital emergency room visits. Thorax. 2008; 63: 635-41. Available from: http://thorax.bmj.com/content/63/7/635.long
- Stieb DM, Szyszkowicz M, Rowe BH, Leech JA. Air pollution and emergency department visits for cardiac and respiratory conditions: a multi-city time-series analysis. Environ Health. 2009; 8: 25. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2703622/
- Strickland MJ, Darrow LA, Klein M, et al. Short-term associations between ambient air pollutants and pediatric asthma emergency department visits. Am J Respir Crit Care Med. 2010; 182: 307-16. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921597/
- Barnett AG, Williams GM, Schwartz J, et al. Air pollution and child respiratory health: a case-crossover study in Australia and New Zealand. Am J Respir Crit Care Med. 2005; 171: 1272-8. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200411-1586OC
- Slaughter JC, Lumley T, Sheppard L, et al. Effects of ambient air pollution on symptom severity and medication use in children with asthma. Ann Allergy Asthma Immunol. 2003; 91: 346-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14582813
- Delamater PL, Finley AO, Banerjee S. An analysis of asthma hospitalizations, air pollution, and weather conditions in Los Angeles County, California. Sci Total Environ. 2012; 425: 110-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22475217
- Sunyer J, Atkinson R, Ballester F, et al. Respiratory effects of sulphur dioxide: a hierarchical multicity analysis in the APHEA 2 study. Occup Environ Med. 2003; 60: e2. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740605/
- Deger L, Plante C, Jacques L, et al. Active and uncontrolled asthma among children exposed to air stack emissions of sulphur dioxide from petroleum refineries in Montreal, Quebec: a cross-sectional study. Can Respir J. 2012; 19: 97-102. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373279/
- McCreanor J, Cullinan P, Nieuwenhuijsen MJ, et al. Respiratory effects of exposure to diesel traffic in persons with asthma. N Engl J Med. 2007; 357: 2348-2358. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa071535#t=article
- Cowie CT, Ezz W, Xuan W, et al. A randomised cross-over cohort study of exposure to emissions from a road tunnel ventilation stack. BMJ Open. 2012; 2: . Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3425893/
- Dales RE, Cakmak S, Judek S, et al. Influence of outdoor aeroallergens on hospitalization for asthma in Canada. J Allergy Clin Immunol. 2004; 113: 303-6. Available from: http://www.jacionline.org/article/S0091-6749(03)02678-2/fulltext
- Vredegoor DW, Willemse T, Chapman MD, et al. Can f 1 levels in hair and homes of different dog breeds: lack of evidence to describe any dog breed as hypoallergenic. J Allergy Clin Immunol. 2012; 130: 904-9.e7. Available from: http://www.jacionline.org/article/S0091-6749(12)00793-2/fulltext
- Nicholas CE, Wegienka GR, Havstad SL, et al. Dog allergen levels in homes with hypoallergenic compared with nonhypoallergenic dogs. Am J Rhinol Allergy. 2011; 25: 252-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680143/
- Marks GB, Colquhoun JR, Girgis ST, et al. Thunderstorm outflows preceding epidemics of asthma during spring and summer. Thorax. 2001; 56: 468-71. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746065/
- D'Amato G, Liccardi G, Frenguelli G. Thunderstorm-asthma and pollen allergy. Allergy. 2007; 62: 11-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2006.01271.x/full
- Kanatani KT, Ito I, Al-Delaimy WK, et al. Desert dust exposure is associated with increased risk of asthma hospitalization in children. Am J Respir Crit Care Med. 2010; 182: 1475-81. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159090/
- Dennekamp M, Abramson MJ. The effects of bushfire smoke on respiratory health. Respirology. 2011; 16: 198-209. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1843.2010.01868.x/full
- Henderson SB, Johnston FH. Measures of forest fire smoke exposure and their associations with respiratory health outcomes. Curr Opin Allergy Clin Immunol. 2012; 12: 221-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22475995
- Johnston FH, Webby RJ, Pilotto LS, et al. Vegetation fires, particulate air pollution and asthma: a panel study in the Australian monsoon tropics. Int J Environ Health Res. 2006; 16: 391-404. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17164166
- Morgan G, Sheppeard V, Khalaj B, et al. Effects of bushfire smoke on daily mortality and hospital admissions in Sydney, Australia. Epidemiology. 2010; 21: 47-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19907335
- Kunzli N, Avol E, Wu J, et al. Health effects of the 2003 Southern California wildfires on children. Am J Respir Crit Care Med. 2006; 174: 1221-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2648104/
- Henderson SB, Brauer M, Macnab YC, Kennedy SM. Three measures of forest fire smoke exposure and their associations with respiratory and cardiovascular health outcomes in a population-based cohort. Environ Health Perspect. 2011; 119: 1266-71. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230386/
- Vora C, Renvall MJ, Chao P, et al. 2007 San Diego wildfires and asthmatics. J Asthma. 2011; 48: 75-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071160/
- Rappold AG, Stone SL, Cascio WE, et al. Peat bog wildfire smoke exposure in rural North Carolina is associated with cardiopulmonary emergency department visits assessed through syndromic surveillance. Environ Health Perspect. 2011; 119: 1415-20. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3230437/
- Lee TS, Falter K, Meyer P, et al. Risk factors associated with clinic visits during the 1999 forest fires near the Hoopa Valley Indian Reservation, California, USA. Int J Environ Health Res. 2009; 19: 315-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19629821
- Mott JA, Mannino DM, Alverson CJ, et al. Cardiorespiratory hospitalizations associated with smoke exposure during the 1997, Southeast Asian forest fires. Int J Hyg Environ Health. 2005; 208: 75-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15881981
- Koskela HO. Cold air-provoked respiratory symptoms: the mechanisms and management. Int J Circumpolar Health. 2007; 66: 91-100. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17515249
- Howden-Chapman P, Matheson A, Crane J, et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ. 2007; 334: 460. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808149/
- Vally H, Misso NL, Madan V. Clinical effects of sulphite additives. Clin Exp Allergy. 2009; 39: 1643-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19775253
- Vally H, Thompson PJ. Allergic and asthmatic reactions to alcoholic drinks. Addict Biol. 2003; 8: 3-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12745410
- Vally H, Thompson PJ, Misso NL. Changes in bronchial hyperresponsiveness following high- and low-sulphite wine challenges in wine-sensitive asthmatic patients. Clin Exp Allergy. 2007; 37: 1062-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17581200
- Vally H, Thompson PJ. Role of sulfite additives in wine induced asthma: single dose and cumulative dose studies. Thorax. 2001; 56: 763-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745927/
- Australasian Society of Clinical Immunology and Allergy (ASCIA). Alcohol allergy. ASCIA education resources patient information. ASCIA, Sydney, 2010. Available from: http://www.allergy.org.au/patients/product-allergy/alcohol-allergy
- Wilson NM, Dixon C, Silverman M. Increased bronchial responsiveness caused by ingestion of ice. Eur J Respir Dis. 1985; 66: 25-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3979474
- Australasian Society of Clinical Immunology and Allergy (ASCIA). Milk, Mucus and Cough. ASCIA education resources patient information. ASCIA, Sydney, 2010. Available from: http://www.allergy.org.au/images/pcc/ASCIAPCCMilkmucuscough_2015.pdf
- Swain AR, Dutton SP, Truswell AS. Salicylates in foods. J Am Diet Assoc. 1985; 85: 950-60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4019987
- Loblay RH, Soutter VL, Swain AR. Salicylate elimination diets in children. Med J Aust. 2013; 198: 603. Available from: https://www.mja.com.au/journal/2013/198/11/salicylate-elimination-diets-children
- Gray PE, Mehr S, Katelaris CH, et al. Salicylate elimination diets in children: is food restriction supported by the evidence?. Med J Aust. 2013; 198: 600-2. Available from: https://www.mja.com.au/journal/2013/198/11/salicylate-elimination-diets-children-food-restriction-supported-evidence
- Green RM, Custovic A, Sanderson G, et al. Synergism between allergens and viruses and risk of hospital admission with asthma: case-control study. BMJ. 2002; 324: 763. Available from: http://www.bmj.com/content/324/7340/763
- Murray CS, Poletti G, Kebadze T, et al. Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax. 2006; 61: 376-82. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2111190/
- Hodge L, Yan KY, Loblay RL. Assessment of food chemical intolerance in adult asthmatic subjects. Thorax. 1996; 51: 805-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC472547/
- Hodge L, Asthma and food chemical sensitivity (Abstract of research for Master of Science in Medicine, The University of Sydney). Royal Prince Alfred Hospital Allergy Unit, Sydney 1993. Available from: http://www.sswahs.nsw.gov.au/rpa/allergy/research/students/1993/linda.html
- Morales, D. R., Jackson, C., Lipworth, B. J., et al. Adverse respiratory effect of acute beta-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. Chest. 2014; 145: 779-86. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24202435
- Waldock A, Snape J, Graham CM. Effects of glaucoma medications on the cardiorespiratory and intraocular pressure status of newly diagnosed glaucoma patients. Br J Ophthalmol. 2000; 84: 710-3. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1723530/
- Diggory P, Heyworth P, Chau G, et al. Unsuspected bronchospasm in association with topical timolol--a common problem in elderly people: can we easily identify those affected and do cardioselective agents lead to improvement?. Age Ageing. 1994; 23: 17-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8010165
- Odeh, M., Oliven, A., Bassan, H.. Timolol eyedrop-induced fatal bronchospasm in an asthmatic patient. The Journal of family practice. 1991; 32: 97-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1985142
- Taniguchi, M., Kino, H., Mori, M., Nakahama, M.. A case of fatal asthma induced by timolol eye-drop. Nihon Kyobu Shikkan Gakkai zasshi. 1990; 28: 156-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2355677
- Hepsen IF, Yildirim Z, Yilmaz H, Kotuk M. Preventive effect of lacrimal occlusion on topical timolol-induced bronchoconstriction in asthmatics. Clin Experiment Ophthalmol. 2004; 32: 597-602. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15575830
- Chang JE, White A, Simon RA, Stevenson DD. Aspirin-exacerbated respiratory disease: burden of disease. Allergy Asthma Proc. 2012; 33: 117-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22525387
- Pfaar O, Klimek L. Aspirin desensitization in aspirin intolerance: update on current standards and recent improvements. Curr Opin Allergy Clin Immunol. 2006; 6: 161-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16670507
- Dona I, Blanca-Lopez N, Cornejo-Garcia JA, et al. Characteristics of subjects experiencing hypersensitivity to non-steroidal anti-inflammatory drugs: patterns of response. Clin Exp Allergy. 2011; 41: 86-95. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2010.03651.x/full
- Szczeklik A, Sanak M. The broken balance in aspirin hypersensitivity. Eur J Pharmacol. 2006; 533: 145-55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16457808
- White AA, Stevenson DD. Aspirin-exacerbated respiratory disease: update on pathogenesis and desensitization. Semin Respir Crit Care Med. 2012; 33: 588-94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23047310
- Klimek L, Pfaar O. Aspirin intolerance: does desensitization alter the course of the disease?. Immunol Allergy Clin North Am. 2009; 29: 669-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879442