Asthma Management Handbook

Managing unavoidable triggers

Recommendations

If clinically relevant triggers cannot be avoided, manage medically or provide advice on self-management.

Table. Summary of asthma triggers Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/52

How this recommendation was developed

Consensus

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

Advise patients that viral respiratory infections are among the most common triggers for flare-ups, including potentially serious acute asthma, in adults and children.

When preparing written asthma action plans, include instructions about managing asthma at the onset of a cold, according to the patient’s age and previous asthma control during respiratory infections.

How this recommendation was developed

Consensus

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

Before prescribing medicines for comorbid conditions, consider potential effects on asthma.

How this recommendation was developed

Consensus

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

If the patient needs to take medicines that may cause bronchoconstriction, provide advice and monitor closely. Consider performing spirometry before and after starting the new medicine.

How this recommendation was developed

Consensus

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

If a patient with asthma has a condition for which treatment with a beta blocker is advisable, choose a cardioselective agent if possible (e.g. atenolol, bisoprolol, metoprolol, nebivolol), but consider the risks, ensure supervision and monitoring of asthma, and warn patients (including those taking ocular preparations) about the risk of serious asthma flare-ups.

How this recommendation was developed

Consensus

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

Manage comorbid medical conditions that may affect asthma control, such as:

  • allergic rhinitis/rhinosinusitis
  • gastro-oesophageal reflux disease
  • nasal polyposis
  • obesity
  • upper airway dysfunction.
How this recommendation was developed

Consensus

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

In pharmacies, when providing or dispensing aspirin or NSAIDs to patients with asthma, ask about previous experience of side-effects.

Advise against aspirin and NSAIDs for anyone who has experienced runny nose or wheezing within 1–2 hours of taking aspirin or NSAIDs.

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):

  • National Asthma Council Australia, 20091

Provide self-management advice to patients whose asthma is affected by emotional or hormonal changes (e.g. menstrual cycle).

How this recommendation was developed

Consensus

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

For pregnant women with asthma or a history of asthma, provide advice on the importance of good asthma control, and closely manage and monitor asthma control.

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):

  • Murphy et al. 20112
  • Namazy et al. 20123

For patients who experience exercise-induced bronchoconstriction, provide treatment and explicit instructions in their written asthma action plan.

Reassure patients that exercise-induced bronchoconstriction can be managed effectively and should not be a reason to avoid physical activity.

How this recommendation was developed

Consensus

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

More information

Respiratory infections

Viral infections

Viral infections are the most common trigger for asthma flare-ups, including serious acute asthma requiring hospital admission.45 Reliever medicines may not be as effective during colds.67

Atopic children with asthma have more severe and persistent virus-induced symptoms (both cold symptoms and asthma symptoms), than those who have asthma but who do not have any allergies.89

Interaction between viral infection and allergens

Viral infections and allergens interact synergistically to increase risk of asthma flare-ups in adults and children.

Atopic people with asthma are at higher risk of hospitalisation due to asthma than those without allergies.10 In atopic children with asthma, the combination of virus detection and sensitisation with high allergen exposure substantially increases the risk of hospitalisation for asthma.11

Advice to patients

Colds and influenza are more common at some times of the year and in different age groups.  The rate of asthma flare-ups in young school-age children peaks in late February approximately 2 weeks after the beginning of the school year, and higher rates of flare-ups continues into early winter. In adults, the peak period of severe viral-associated flare-ups occurs in the winter. Preschool children have about 6–8 colds per year, while school-aged children have about 3–4 colds per year.

In practice, it is not feasible to avoid colds or influenza. Colds and influenza are spread by multiple routes, including airborne transmission of small and large droplets generated by talking and coughing, and transfer by fingers from contaminated items to the nose or eyes.

People with asthma should avoid crowded and enclosed spaces, particularly where there are people with colds. Regular hand washing or using alcohol hand rubs after contact with people or items may reduce risk of transmission, but is unlikely to be effective in practice.

Immunisation

Influenza vaccination reduces the risk of influenza and pneumococcal vaccination reduces the risk of pneumococcal pneumonia. However, the extent to which influenza vaccination and pneumococcal vaccination protect against asthma flare-ups due to respiratory tract infections is uncertain.121314

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Medicines that can trigger asthma

Beta blockers

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.15

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,1617 and asthma deaths have been reported.1819 Changing from timolol (nonselective) to betaxolol (selective) might improve respiratory function.17 Blocking the tear duct for 2–3 minutes after administering drops (punctual occlusion) may reduce risk of respiratory effects by minimising systemic absorption.20

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.16 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.

Known aspirin sensitivity occurs in an estimated:2122

  • 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.23 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).24 Meloxicam has been reported to cause bronchoconstriction at higher doses.24

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.

Management of aspirin-exacerbated respiratory disease involves avoidance of aspirin and NSAIDs.25 Aspirin desensitisation is available.2526

Complementary medicines

Some complementary and alternative medicines may trigger asthma:

  • Echinacea27
  • bee products (pollen, propolis, royal jelly).282930
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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).31 Most foods that contain salicylates contain both salicylic acid and acetylsalicylic acid, and about one-third contain only acetylsalicylic acid.32 Dietary salicylates are generally thought not to cause symptoms in people with aspirin-exacerbated respiratory disease.33 

Salicylate elimination should only be considered under specialist supervision.

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Physiological and psychological changes

Stress, anxiety and extreme emotions

Some patients report asthma flare-ups and asthma symptoms in response to stress and extreme emotions.3435

Adolescents with asthma may experience breathlessness in response to stress (without changes in lung function or other asthma symptoms).36

Laughter

Laughing is a common trigger for wheeze in infants. In children, the presence of respiratory symptoms that are triggered by laughter increases the probability of symptoms being due to asthma.

Hormonal changes

Asthma may worsen during the premenstrual phase in up to 40% of women, possibly due to a reduced response to corticosteroids and bronchodilators.37 However, this rarely causes severe flare-ups.37

Perimenstrual worsening asthma may be relatively common among women with severe or poorly controlled asthma, and may share risk factors with aspirin-exacerbated respiratory disease.38

Asthma control worsens during pregnancy in about one third of women with asthma.39 During pregnancy, approximately 6% of women with asthma are hospitalised with a severe asthma flare-up.4041

Sexual activity

Sexual activity may trigger asthma symptoms possibly due to physical exertion (exercise-induced bronchoconstriction), heightened emotion, or a combination of these factors. Exposure to dust mite allergens in bedding may also be a trigger for people who are sensitised.

People with asthma may experience limitation to sexual activity due to asthma or be concerned about the effect of their asthma on their sex life.4243 However, patients are unlikely to mention concerns about sexual activity to their doctor.43

Practical information for patients about sex and asthma is available from Asthma Australia.

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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)4445
  • allergens plus viruses.1011
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References

  1. National Asthma Council Australia. Aspirin/NSAID-intolerant asthma: pharmacy notes. National Asthma Council Australia, Melbourne, 2009. Available from: http://www.nationalasthma.org.au/health-professionals/primary-care-resources/pain-relievers-and-asthma
  2. Murphy VE, Namazy JA, Powell H, et al. A meta-analysis of adverse perinatal outcomes in women with asthma. BJOG. 2011; 118: 1314-1323. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03055.x/full
  3. Namazy JA, Murphy VE, Powell H, et al. Effects of asthma severity, exacerbations and oral corticosteroids on perinatal outcomes. Eur Respir J. 2012; 41: 1082-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22903964
  4. Yamaya M. Virus infection-induced bronchial asthma exacerbation. Pulm Med. 2012; 2012: 834826. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432542/
  5. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Asthma series no. 4. Cat. no ACM 22. Australian Institute of Health and Welfare, Canberra, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159
  6. Reddel H, Ware S, Marks G, et al. Differences between asthma exacerbations and poor asthma control. Lancet. 1999; 353: 364-369. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9950442
  7. Rueter K, Bizzintino J, Martin AC, et al. Symptomatic viral infection is associated with impaired response to treatment in children with acute asthma. J Pediatr. 2012; 160: 82-7. Available from: http://www.jpeds.com/article/S0022-3476(11)00652-4/fulltext
  8. Olenec JP, Kim WK, Lee WM, et al. Weekly monitoring of children with asthma for infections and illness during common cold seasons. J Allergy Clin Immunol. 2010; 125: 1001-1006.e1. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866802/
  9. Heymann PW, Carper HT, Murphy DD, et al. Viral infections in relation to age, atopy, and season of admission among children hospitalized for wheezing. J Allergy Clin Immunol. 2004; 114: 239-47. Available from: http://www.jacionline.org/article/S0091-6749(04)01311-9/fulltext
  10. 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
  11. 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/
  12. Cates CJ, Jefferson T, Rowe BH. Vaccines for preventing influenza in people with asthma. Cochrane Database Syst Rev. 2008; Issue 2: CD000364.pub3. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000364.pub3/full
  13. Sheikh A, Alves B, Dhami S. Pneumococcal vaccine for asthma. Cochrane Database Syst Rev. 2002; Issue 1: CD002165. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002165/full
  14. Australian Institute of Health and Welfare. Vaccination uptake among people with chronic respiratory disease. Cat. no. ACM 25. Australian Institute of Health and Welfare, Canberra, 2012. Available from: http://www.aihw.gov.au/publication-detail/?id=60129542385
  15. 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
  16. 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/
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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
  26. 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
  27. 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
  28. 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
  29. 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
  30. 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
  31. 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
  32. 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
  33. 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
  34. Busse WW. The brain and asthma: what are the linkages?. Chem Immunol Allergy. 2012; 98: 14-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22767055
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  36. Rietveld S, van Beest I, Everaerd W. Stress-induced breathlessness in asthma. Psychol Med. 1999; 29: 1359-66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10616941
  37. 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
  38. Rao CK, Moore CG, Bleecker E, et al. Characteristics of perimenstrual asthma and its relation to asthma severity and control: data from the Severe Asthma Research Program. Chest. 2013; 143: 984-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23632943
  39. Murphy VE, Gibson PG. Asthma in pregnancy. Clin Chest Med. 2011; 32: 93-110. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21277452
  40. Murphy VE, Clifton VL, Gibson PG. Asthma exacerbations during pregnancy: incidence and association with adverse pregnancy outcomes. Thorax. 2006; 61: 169-76. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2104591/
  41. Ali Z, Ulrik CS. Incidence and risk factors for exacerbations of asthma during pregnancy. J Asthma Allergy. 2013; 6: 53-60. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650884/
  42. Meyer IH, Sternfels P, Fagan JK, Ford JG. Asthma-related limitations in sexual functioning: an important but neglected area of quality of life. Am J Public Health. 2002; 92: 770-2. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447159/
  43. Kaptein AA, van Klink RC, de Kok F, et al. Sexuality in patients with asthma and COPD. Respir Med. 2008; 102: 198-204. Available from: http://www.resmedjournal.com/article/S0954-6111(07)00400-3/fulltext
  44. 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
  45. 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