Asthma Management Handbook

Providing post-acute care

Recommendations

After dyspnoea or difficulty breathing has resolved and symptoms have stabilised, observe the patient for at least 1 hour.

How this recommendation was developed

Consensus

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

If the patient is already using (or has been prescribed) inhaled corticosteroids, check adherence and inhaler technique, and instruct them to continue their inhaled corticosteroid.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Edmonds et al. 20121

For adults who have not been prescribed inhaled corticosteroids, prescribe inhaled corticosteroid and arrange comprehensive assessment in 2–4 weeks to review the treatment regimen (e.g. refer to person’s GP or arrange specialist assessment).

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Edmonds et al. 20121

For children not currently taking a preventer, consider whether preventer treatment is indicated. Arrange a follow-up appointment in 2–4 weeks to review the treatment regimen (e.g. refer to child’s GP or arrange specialist assessment).

Note: The need for preventer in children should be assessed based on the pattern of symptoms between flare-ups, not on the severity of symptoms seen during a flare-up.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Edmonds et al. 20121

For patients treated in acute care services, complete all of the following:

  • Ensure that the patient (or carer) is able to monitor and manage asthma at home.
  • Check the patient has a reliever medicine and assess their inhaler technique.
  • Provide a spacer, if needed.
  • Advise patient (or carer) to make an appointment with their usual GP within 2–4 weeks (or earlier if necessary).
  • For patients with severe acute asthma or a previous presentation, consider arranging referral to a consultant/respiratory physician.
  • Provide an interim asthma action plan, including instructions on when and how to reduce reliever dose and instructions on preventer use. Explain that the person needs their own written asthma action plan prepared by their usual doctor (e.g. GP or respiratory physician).
  • Provide a copy of the discharge summary to the patient’s usual GP.
How this recommendation was developed

Consensus

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

At the follow-up review, the patient’s usual doctor (e.g. GP) should:

  • try to identify trigger factors associated with the acute asthma episode
  • review the written asthma action plan
  • review the person's reliever use and give instructions about when to go back to usual as-needed reliever regimen
  • review the person’s regular medicines regimen
  • offer specialist review if the person has had more than one emergency visit to health services for acute asthma within the previous 12 months or repeated corticosteroid treatments.
How this recommendation was developed

Consensus

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

Routine treatment with antibiotics is not recommended after acute 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):

  • Black, 20072
  • Fonseca-Aten et al. 20063
  • Graham et al. 20014
  • Johnston, 20065
  • Johnston et al. 20066
  • Koutsoubari et al. 20127

More information

Interim asthma action plans

The purpose of the interim action plan is to provide written instructions until the person returns to their usual doctor or nurse practitioner for review of their written asthma action plan.

The interim action plan should include (all of):

  • the patient’s name
  • instructions for oral corticosteroid course (dose, duration, when to take)
  • instructions for reliever dose in immediate post-acute period (dose, how to take including use of spacer, duration of this dose)
  • instructions for when to go back to usual as-needed reliever regimen (clearly state the number of actuations to be taken as needed)
  • instructions for preventer
  • what to do if symptoms getting worse or recur within hours of taking reliever
  • instruction to make appointment with usual doctor e.g. GP.
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Antibiotics in acute asthma

Antibiotics are not used routinely in the management of acute asthma but should be used if they would otherwise be indicated, e.g. for specific comorbidities or when there is evidence of an infective exacerbation or previous positive microbiology.

The role of atypical bacterial infections (e.g. Chlamydophyla pneumonia, Mycoplasma pneumonae) in asthma is under investigation. Atypical bacterial infections may make acute asthma more severe, especially in patients with poorly controlled asthma. Macrolide antibiotics and telithromycin (a ketolide antibiotic not registered in Australia) are active against atypical bacteria and have anti-inflammatory activity.5

Overall, evidence from randomised clinical trials does not support the routine use of antibiotics in managing acute asthma. Evidence from one clinical trial suggested that telithromycin might help improve asthma symptoms when given after acute asthma, but it was associated with nausea.26

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References

  1. Edmonds ML, Milan SJ, Brenner BE, et al. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database Syst Rev. 2012; 12: CD002316. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002316.pub2/full
  2. Black PN. Antibiotics for the treatment of asthma. Curr Opin Pharmacol. 2007; 7: 266-71. Available from: http://www.sciencedirect.com/science/article/pii/S1471489207000616
  3. Fonseca-Aten M, Okada PJ, Bowlware KL, et al. Effect of clarithromycin on cytokines and chemokines in children with an acute exacerbation of recurrent wheezing: a double-blind, randomized, placebo-controlled trial. Ann Allergy Asthma Immunol. 2006; 97: 457-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17069099
  4. Graham V, Lasserson TJ, Rowe BH. Antibiotics for acute asthma. Cochrane Database Syst Rev. 2001; Issue 2: CD002741. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002741/full
  5. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext
  6. Johnston SL, Blasi F, Black PN, et al. The Effect of Telithromycin in Acute Exacerbations of Asthma. N Engl J Med. 2006; 354: 1589-1600. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa044080#t=article
  7. Koutsoubari I, Papaevangelou V, Konstantinou GN, et al. Effect of clarithromycin on acute asthma exacerbations in children: an open randomized study. Pediatr Allergy Immunol. 2012; 23: 385-90. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1399-3038.2012.01280.x/full