Highlights of Version 2.0 update
Version 2.0 of the Australian Asthma Handbook, published March 2019, is a major update to version 1.0, published in 2014.
Table. Australian Asthma Handbook Version 2.0 major section revisions Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/124
Table. Australian Asthma Handbook Version 2.0 major section revisions
Australian Asthma Handbook Version 2.0 major section revisions
|Acute asthma||Oxygen||Revision of oxygen saturation thresholds for initiating supplemental oxygen and targets for oxygen saturation.|
|Anaphylaxis||Addition of alert to acute asthma management algorithms with hyperlinks to current ASCIA guidelines.|
|Adrenaline||Update of evidence and clarification of role of adrenaline in acute asthma management.|
|Systemic corticosteroids||Update of evidence and revision of dose recommendations for children (loading doses no longer recommended).|
|Ipratropium bromide||Update of evidence and revision of recommendations for initial bronchodilator to include routine use of ipratropium for patients with severe or life-threatening acute asthma.|
|Magnesium sulfate||Update of evidence.|
|Aminophylline||Addition of IV aminophylline to options for add-on treatment for patients with inadequate response to initial treatment|
|Hospital admission||Revision of criteria for admission to include risk factors for poor outcomes.|
|Inhaled corticosteroids||Amendments to emphasise recommendation to prescribe inhaled corticosteroids at discharge (if indicated) to reduce future risk of flare-ups.|
|Discharge checklist||Revision of discharge recommendations to promote effective transition to primary care, including appointment within 3 days in addition to review of asthma at 2–4 weeks.|
|Discharge plans||Addition of templates for discharge plans (interim asthma action plans) for children and adults.|
|Management of asthma in children||Age-based recommendations||
Restructure to separate recommendations for children 1–5 years and children aged 6 years and over.
Addition of new figure: Stepped approach to adjusting asthma medication in children aged 1–5 years.
|Infants 0–12 months||Removal of recommendations for children under 12 months, with clarification that diagnosis and management of asthma in infants is not recommended within primary care.|
Simplification of terminology for describing symptom patterns in infants 1–5 years: removal of term ‘multiple-trigger wheeze’, separate classification systems for wheezing disorders (where asthma diagnosis uncertain) and asthma replaced by single classification system.
Symptom patterns integrated into treatment tables for each age group:Classification of asthma and indications for initiating preventer treatment in children aged 6–11
|Risk factors for flare-ups||Addition of new table: Risk factors for life-threatening asthma flare-ups in children|
|Short-acting beta2 agonists||Simplification of recommendation against the use of short-acting beta2 agonists in infants; recommendation against use extended to all infants under 12 months, consistent with current bronchiolitis management guidelines.|
|Indications for preventer treatment||
Separate tables for classification of symptom patterns and indications for preventer treatment replaced by a single table for each age group:Classification of asthma and indications for initiating preventer treatment in children aged 6–11
|Approach to monitoring and adjusting treatment||Update of evidence for effects of management guided by various approaches to monitoring (lung function tests, exhaled nitric oxide, sputum eosinophil count).|
|Stepping up||Simplification/reorganisation of advice for stepping up in each age group.|
|Stepping down||Update of evidence and simplification/reorganisation of advice for stepping down in each age group.|
|Cromones||Removal of sodium cromoglycate and nedocromil from main recommendations for preventer therapy.|
|Montelukast||Update of evidence for efficacy, update of evidence for behavioural and/or neuropsychiatric adverse effects.|
|Tiotropium||Addition of information on tiotropium following TGA approval for use in children aged 6 years and over.|
|Inhaled corticosteroids||Update of evidence for efficacy of increasing the dose at the onset of flare-ups, adverse effects.|
|Inhaled corticosteroid/long-acting beta2 agonist combinations||Update of evidence for efficacy in children up to age 12, potential tachyphylaxis with long-acting beta2 agonists.|
|Oral corticosteroids||Update of evidence on short courses of oral corticosteroids to manage flare-ups at home or primary care, as distinct from use in acute care settings.|
|Back-to-school care||Addition of advice on asthma management at the beginning of the school year.|
|Severe asthma||Addition of advice on managing severe asthma in each age group.|
|Management challenges||Structure||Replacement of former Troubleshooting section.|
|Patient/person-centred care||Revision of whole section to emphasise a patient-centred approach to caring for a child or adult with asthma that is not well controlled despite preventer treatment.|
|Living with asthma||Addition of evidence on lived experience of asthma.|
|Cost of asthma medicines||Addition of information about costs of asthma medicines and strategies for minimising costs to patients.|
|Primary prevention of asthma||Risk and protective factors for developing asthma||
Update of evidence for risk and protective factors.
Addition of table: Risk and protective factors for developing asthma
Update of evidence on effects on risk of developing asthma associated with various exposures.
|Paracetamol||Update of evidence for effect of exposure to paracetamol (prenatal, early life) on risk of developing asthma.|
|Nutrition||Update of evidence for effects of nutrition on risk of developing asthma.|
|Restriction diets in pregnancy||Update of evidence for efficacy of restriction diets during pregnancy as a strategy for asthma prevention in children.|
|Dietary supplementation during pregnancy and in newborns||Update of evidence for efficacy of dietary supplementation as a strategy for asthma prevention in children.|
|Allergen avoidance||Update of evidence for efficacy of allergen avoidance as a strategy for asthma prevention in children.|
|Hypoallergenic infant formula||Update of evidence for efficacy of hypoallergenic infant formula as a strategy for asthma prevention in children.|
|Specific allergen immunotherapy||Update of evidence for efficacy of specific allergen immunotherapy as a strategy for asthma prevention in children with allergic rhinitis.|
|Severe asthma in adults and adolescents||Structure||
Replacement of single web page (Managing severe, high-risk and difficult-to-control asthma in adults) with more detailed guidance over four web pages:
|Identifying severe asthma||
Addition of more detailed information on steps for identifying severe asthma in adults and adolescents.
Revision of table: Differential diagnosis of severe asthma in adults.Clarification of definitions of severe asthma and difficult-to-treat asthma.
|Investigations for severe asthma||Update of current practice.|
|Non-pharmacological strategies for managing severe asthma||
Addition of advice on non-pharmacological strategies and general care in the management of severe asthma.
Addition of evidence and information on active Cycle of Breathing technique.
More detailed information and advice on monitoring and managing adverse effects of oral corticosteroids.
Addition of evidence on air temperature control.Update of evidence for bronchial thermoplasty.
|Add-on treatment for managing severe asthma||
Addition of advice on add-on treatments in the management of severe asthma.
Update of evidence for efficacy of various treatment options including:
|Monoclonal antibody therapy||
Advice on providing ongoing care during monoclonal antibody therapy.
Update of evidence on efficacy, including newly introduce benralizumab.Update of TGA-approved indications and PBS listings revised 1 December 2018.
|Lived experience of severe asthma||Addition of evidence from Australian research on lived experience of severe asthma.|
|Resources||Addition of links to Centre of Excellence in Severe Asthma’s Severe asthma toolkit.|
Table. Australian Asthma Handbook Version 2.0 other amendments Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/125
Table. Australian Asthma Handbook Version 2.0 other amendments
Australian Asthma Handbook Version 2.0 other amendments
Places(s) in text
Organisation of information
|Diagnosis in children||Diagnosing asthma in children||Restructure to separate recommendations into subsections for children aged 1–5 years and children aged 6 years and over||Restructured to reflect different approach to, and certainty of, asthma diagnosis in these age groups|
|Preschool children||Revision of subsection headings to delete any references to children aged 0–12 months||Restructured to emphasise the low probability of asthma in infants and for consistency with national guidelines for management of bronchiolitis|
|Stepping up and down in adults||Stepped approach to adjusting asthma medication in adults||Revision of figure to emphasise that a very small proportion of patients should manage asthma with as-needed relievers alone||Amended to emphasise that regular inhaled corticosteroid preventer treatment is indicated for most adults and older adolescents|
|Adolescents||Managing asthma in adolescents||Structure amended to provide access to guidance on asthma in adolescents within main navigation menu on management||Restructured to draw users’ attention to separate guidance on asthma in adolescents|
|Fluticasone furoate||Table. Long-acting bronchodilators for asthma–COPD overlap||Note indicating discard-by intervals for inhalers||Amended to alert prescribers that these inhalers have shorter discard-by date than most|
More Information Topic:
Montelukast for adults and adolescents: psychiatric effects
|Addition of note on potential behavioural and/or neuropsychiatric adverse effect with link to TGA alert||Amended to reflect updated safety information|
|Oral H1 antihistamines in preschool children||Managing allergic rhinitis in children with asthma||Addition of statement on long-term safety profile of cetirizine and confirming that antihistamines can be taken long term||Amended to provide information on a question commonly asked by parents|
|Short-acting beta2 agonists||
More Information Topic:
Over-use of short-acting beta2 agonists
Addition of statements on over-use of short-acting beta2 agonists:
|Amended to reflect updated evidence and to emphasise risk|
More Information Topics:
|Update of evidence and recommendations for inhaler device choice and technique||Amended to reflect information and advice in updated NAC information paper Inhaler technique in people with asthma or COPD|
|Inhaler devices||Table. Types of inhaler devices for delivering asthma and COPD medicines||Update of table||
Amended to remove devices no longer available and to include new devices:
DuoResp Spiromax (budesonide plus formoterol)
Fluair Inhaler (fluticasone propionate)
SalplusF metered dose Inhaler (fluticasone propionate plus salmeterol)
Trelegy Ellipta (fluticasone furoate plus umeclidinium bromide plus vilanterol trifenatate)
|Advice for prevention of thunderstorm asthma||
Blanket advice for at-risk people to avoid being outdoors before and during springtime thunderstorms amended with advice to check pollen counts and avoid thunderstorms only on high-pollen days
Addition of links to pollen count advice for regions where available
Update of published evidence
|Amended to reflect updated evidence and guidance on prevention|
Summary of key clinical changes and clarifications
Highlights of the version 2.0 Australian Asthma Handbook include:
Major update of evidence and advice on:
managing asthma in children
management challenges (previously known as troubleshooting)
Amendments to include latest evidence-based recommendations.
Update on latest treatment options for patients with severe asthma
Amendments to reflect the National Asthma Council Australia's 2018 information paper on Monoclonal antibody therapy for severe asthma.
Update of advice on inhaler technique for people with asthma or COPD
Amendments to reflect the National Asthma Council Australia's 2018 information paper on Inhaler technique for people with asthma and COPD.
Other minor amendments
Various minor amendments and corrections to improve clarity.