Asthma Management Handbook

Checking whether current prescribed treatment is appropriate

Recommendations

Assess and record the person’s level of recent asthma symptom control.

Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)

Good control

Partial control

Poor control

All of:

  • Daytime symptoms ≤2 days per week
  • Need for SABA reliever ≤2 days per week
  • No limitation of activities
  • No symptoms during night or on waking

One or two of:

  • Daytime symptoms >2 days per week
  • Need for SABA reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

Three or more of:

  • Daytime symptoms >2 days per week
  • Need for SABA reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

SABA: short-acting beta2-agonist

† SABA, not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

Note: Recent asthma symptom control is based on symptoms over the previous 4 weeks.

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Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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How this recommendation was developed

Consensus

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

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For adults, check risk factors and make sure the current treatment regimen is suitable for any risk factors identified.

Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>3 canisters per year)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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How this recommendation was developed

Consensus

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

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Check the preventer dose that the person is currently taking.

How this recommendation was developed

Consensus

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

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If the person’s asthma is uncontrolled despite appropriate preventer treatment for their age, check adherence and inhaler technique carefully before optimising the treatment regimen.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

More information

Classification of asthma severity and recent asthma symptom control in adults

Recent asthma symptom control

Recent asthma symptom control in adults is defined by frequency of symptoms, the degree to which symptoms affect sleep and activity, and the need for reliever medication over the previous 4 weeks.

Recent asthma symptom control is a component of overall asthma control. The other component is the risk of future events (e.g. flare-ups, life-threatening asthma, accelerated decline in lung function, or adverse effects of treatment).

Any experience of flare-ups or night-time waking due to asthma symptoms, even if infrequent, usually indicates that the person needs regular preventer treatment.

Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)

Good control

Partial control

Poor control

All of:

  • Daytime symptoms ≤2 days per week
  • Need for SABA reliever ≤2 days per week
  • No limitation of activities
  • No symptoms during night or on waking

One or two of:

  • Daytime symptoms >2 days per week
  • Need for SABA reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

Three or more of:

  • Daytime symptoms >2 days per week
  • Need for SABA reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

SABA: short-acting beta2-agonist

† SABA, not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

Note: Recent asthma symptom control is based on symptoms over the previous 4 weeks.

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Severity

Severity of asthma in adults is defined by the type and amount of treatment needed to maintain good control, not by the severity of acute flare-ups.

For patients prescribed a preventer, asthma severity can only be determined after using a preventer for at least 8 weeks and after checking adherence and inhaler technique.

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Classification of recent asthma symptom control in children

Ongoing review of asthma involves both assessing recent asthma symptom control and assessing risks for poor asthma outcomes such as flare-ups and adverse effects of medicines.

Recent asthma symptom control is assessed according to the frequency of asthma symptoms over the previous 4 weeks.

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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Table. Risk factors for life-threatening asthma flare-ups in children

Asthma-related factors

Poor asthma control

Admission to hospital in preceding 12 months

History of intubation for acute asthma

Over-use of short-acting beta2 agonist reliever

Abnormal spirometry findings

Reversible expiratory airflow limitation on spirometry despite treatment

Poor adherence to preventer

Incorrect inhaler technique for preventer

Poor adherence to asthma action plan

Exposure to clinically relevant allergens

Exposure to tobacco smoke

Other clinical factors

Allergies to foods, insects, medicines

Obesity

Family-related factors

Frequent failure to attend consultations/lack of follow-up after an acute flare-up

Significant parental psychological or socioeconomic problems

Parent/carer unequipped to manage asthma emergency

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Assessing recent asthma control in adults: symptoms

Questionnaires

Questionnaire-based tools can be used to standardise review of asthma symptoms, e.g.:

  • Primary care Asthma Control Screening tool (also known as Pharmacy Asthma Control Screening tool)1 – a quick screening test to detect poor asthma control, developed and validated for use with Australian patients attending primary care
  • UK Royal College of Physicians ‘3 Questions’2, 3
  • Asthma Score (also known as Asthma Control Test).4
  • Asthma Control Questionnaire (ACQ)

The questionnaires can be completed on paper in the waiting room and scored by the practice nurse. They have also been administered via an application on hand-held personal electronic devices, 56 or by telephone.7

Note: Clinicians and researchers should only use the versions of the ACQ and Asthma Score that have been validated for use in the Australian population. The wording and layout of questionnaires must not be changed.

Table. Primary care Asthma Control Screening tool (PACS)

Have you experienced any of the following more than once a week in the last month? Yes No
Symptoms of asthma, cough, wheeze, shortness of breath
  •  
  •  
Waking at night because of asthma
  •  
  •  
Chest tightness on waking
  •  
  •  
Difficulty in performing vigorous activity like running, lifting heavy objects, exercise
  •  
  •  
Difficulty in performing moderate activities like vacuuming, climbing flights of stairs
  •  
  •  

Interpretation: ‘Yes’ to any question indicates that the person may have poorly controlled asthma, so more detailed assessment is needed.

Source: LeMay KS, Armour CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J; 2014. Available from: http://dx.doi.org/10.4104/pcrj.2014.00011

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Table. UK Royal College of Physicians ‘3 Questions’ screening tool

In the last month: Yes No
Have you had difficulty sleeping because of your asthma symptoms (including cough)?
  •  
  •  
Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
  •  
  •  
Has your asthma interfered with your usual activities (e.g. housework, work/school etc)?
  •  
  •  

Inerpetation:

No to all three questions indicates good control.

Yes to 2 or 3 questions indicates poor control.

Yes to 1 question indicates that more detailed questioning is needed to assess level of asthma control (using another validated questionnaire or by asking about frequency of daytime symptoms, reliever requirement, limitation of activities and symptoms at night or on waking during the previous month).

Note: This test provides a quick and easy way of confirming someone’s asthma control is good, or identifying those who need more assessments.

Sources

Thomas M, Gruffydd-Jones K, Stonham C et al. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians ‘3 Questions’. Prim Care Respir J 2009; 18: 83-8. Available from: http://www.nature.com/articles/pcrj200845

Pinnock H, Burton C, Campbell S et al. Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study. Prim Care Respir J 2012; 21: 288-94. Available from: http://www.nature.com/articles/pcrj201252

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Symptom-guided management

Data from one UK study suggest that, for the majority of patients attending primary care, asthma symptoms are concordant with eosinophilic airway inflammation, and that symptoms can therefore be used as a guide to changing anti-inflammatory treatment.8

However, if symptoms do not improve as expected after a change in treatment, or if the person continues to experience flare-ups, it is necessary to measure lung function and consider other possible causes:

  • Respiratory symptoms in a person with asthma may be due to non-asthma factors (e.g. cough due to post-nasal drip, shortness of breath due to obesity). Increasing the preventer treatment in such patients could result in unnecessarily high doses. A careful history (with lung function measurement in some patients) is necessary to confirm that symptoms are due to asthma, before deciding to change a person’s treatment.
  • Patients vary in their ability to perceive airflow limitation, so symptoms may be an unreliable measure of asthma control in some patients. Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).

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Assessing asthma control in adults: spirometry

Spirometry is necessary when making the diagnosis of asthma and when establishing the patient’s baseline and personal best status.

In ongoing asthma management, spirometry is useful in the following clinical situations:

  • During a flare-up, spirometry provides objective evidence about the severity of bronchoconstriction.
  • After a dose adjustment (either an increase or a decrease), change in lung function measured by spirometry provides additional information about the response to treatment.
  • Spirometry can help identify if the person’s symptoms may be due to non-asthma conditions (e.g. for a patient with frequent respiratory symptoms, FEV1 above 80–90% predicted should prompt consideration of an alternative cause).
  • Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).
  • Repeating spirometry over time may identify lung function decline that is more rapid than expected decline due to ageing alone, so the person can be referred for specialist review. (Spirometry should be repeated approximately every 1–2 years in most patients but more frequently as indicated by individual needs.)

There are limits to the amount of information that can be gained from spirometry alone:

  • For an individual, spirometry readings are not closely reproducible between visits, so only a change in FEV1 of greater than 0.2 L and 12% from baseline can be considered clinically meaningful in adults.9
  • Older people with long-standing asthma may develop fixed (irreversible or incompletely reversible) airflow limitation. Reliance solely on lung function expressed as percentage predicted value as a guide to adjusting preventer treatment would risk dose-escalation and over-treatment in these patients.
  • At the population level, spirometry correlates poorly with symptom-based measures of asthma control,10 so in individual patients it is not possible to predict lung function from symptoms or vice versa.

To obtain reliable, good-quality readings, the spirometer must be well maintained and correctly calibrated, and the operator must be adequately trained and experienced.

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Assessing risk factors for adverse asthma outcomes in adults

Predicting poor asthma outcomes

As well as assessing recent asthma symptom control, it is necessary to assess each patient’s risk of future asthma events or adverse treatment effects. (Recent asthma symptom control and risk of adverse events are both components of overall asthma control.)

Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>3 canisters per year)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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Poor clinical control, as indicated by frequent asthma symptoms and frequent reliever use, is a very strong predictor of the risk of flare-ups in the future. Any asthma flare-up during the previous 12 months indicates higher risk of flare-up over the next 12 months. A history  of artificial ventilation due to acute asthma, and admission to an intensive care unit due to acute asthma have been associated with increased risk of near-fatal asthma,11 but there is not enough evidence to indicate how long this risk may persist over a person’s lifetime. Other risk factors indicate increased probability of future flare-ups or accelerated decline in lung function, independent of the person’s level of recent asthma symptom control.412

Other factors may increase a person’s risk of treatment-associated adverse effects. The most important of these are prescription of high dose treatment and frequent courses of oral steroids.

People with risk factors need more frequent asthma review, a carefully tailored written asthma action plan, and close attention to adherence and correct inhaler technique.

Inflammatory markers

Inflammatory markers, such as sputum eosinophil percentage or exhaled nitric oxide, are used in research and for managing severe asthma in patients attending secondary or tertiary care. Elevated sputum eosinophil levels and, to a lesser extent, elevated exhaled nitric oxide, are associated with increased risk of flare-ups. At present, treatment based on inflammatory markers is not recommended for routine use in primary care.

The value of inflammatory markers is being evaluated:

  • Adjusting asthma treatment by monitoring exhaled nitric oxide does not reduce the rate of flare-ups or improve asthma control in adults and children, compared with adjusting treatment according to clinical symptoms or spirometry, based on a meta-analysis of randomised controlled clinical trials.13 However, many of the studies were not optimally designed to answer this question,14 and some comparator regimens did not match current recommended treatment options.
  • In some studies, asthma treatment algorithms based on monitoring sputum eosinophil counts reduced flare-ups, compared with control-based management.15, 16 However, most studies assessing treatment guided by sputum eosinophilia have been conducted in selected populations in a few research centres, and therefore may not apply to the general community population. Assessment of sputum inflammatory cells is not generally available at present even in secondary care.
  • Limited evidence8 suggests that patients whose symptoms do not match their degree of eosinophilic inflammation may benefit more from treatment monitoring using sputum eosinophil count than other patients.
  • Monitoring inflammatory markers might enable safer down-titration of maintenance inhaled corticosteroid doses.

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Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on:

  • recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups 
  • the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days)
  • the frequency of flare-ups
  • spirometry in children who are able to perform the test reliably.

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Lung function tests

Frequent spirometry to guide asthma treatment in children has not been shown to achieve superior outcomes to symptom-based treatment.21 Current evidence does not support use of home spirometers to guide asthma treatment in children.22 However, low FEV1 predicts clinically significant flare-ups, so spirometry should be performed at asthma reviews for children who are old enough to do the test.
The quality and utility of spirometry depends on the skill, clinical expertise and experience of the person doing and interpreting spirometry.

The results of one study in children aged 6–16 years with moderate atopic asthma suggest that asthma treatment guided by airway hyperresponsiveness (measured by bronchial provocation testing) may have a benefit over symptom-guided treatment in improving lung, but this effect was lost after 3–7 years of usual care.2324 Repeated bronchial provocation testing is not feasible in clinical practice.

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum eosinophil count, exhaled nitric oxide measurement) are not recommended in primary care to guide treatment decisions, but are increasingly used in specialist clinics.

Asthma treatment guided by sputum eosinophil count has been shown to reduce the frequency of flare-ups in adults with asthma, but there is insufficient evidence to ascertain its value for children.25

Exhaled nitric oxide measurement may be useful in guiding asthma management in some children. In children not taking inhaled corticosteroid, a high nitric oxide level probably predicts a good short-term response to inhaled corticosteroid treatment,26 but it does not distinguish between asthma and eosinophilic bronchitis and is often high in children with atopy. There is insufficient evidence to ascertain whether a low exhaled nitric oxide level predicts successful withdrawal from inhaled corticosteroids without asthma relapse,26 or safety of treating asthma without inhaled corticosteroids.

A Cochrane review27 found that exhaled nitric oxide-guided management was significantly better than other approaches to adjusting medicines for reducing the number of children with flare-ups and the number of children who needed oral corticosteroids, but did not reduce the frequency of flare-ups or the rate of flare-ups requiring hospitalisation, improve lung function or symptoms scores, or reduce inhaled corticosteroid doses. The authors concluded that it could not be recommended for all children but may be beneficial for a subset not yet defined.27

Towards personalised asthma care

Emerging understanding of asthma phenotypes and of genetic factors that predict therapeutic response to preventer options is leading to the possibility of personalised, genomics-based treatment for asthma in children.28 In the near future, individual tailored therapy is may replace the standardised step model based on population data.

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Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.29 Written asthma action plans are effective if based on symptoms30 or personal best peak expiratory flow (not on percentage predicted).29

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans3132 is available online.

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Written asthma action plans for children

Every child with asthma should have their own written asthma action plan.

A systematic review found that the use of written asthma action plans significantly reduces the rate of visits to acute care facilities, the number of school days missed and night-time waking, and improves symptoms.33 

For children and adolescents, written asthma action plans that are based on symptoms appear to be more effective than action plans based on peak expiratory flow monitoring.33

A written asthma action plan should include all the following:

  • a list of the child’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on what to do in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name and contact details of the child’s emergency contact person (e.g. parent)
  • the name of the person writing the action plan, and the date it was issued.

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate)
  • Children’s written asthma action plans.

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans3132 is available online.

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What is severe asthma?

Definitions

Severe asthma is asthma that remains uncontrolled despite high-dose inhaled corticosteroids plus long-acting beta2 agonist (with correct inhaler technique and good adherence) or maintenance oral corticosteroids, or that requires such treatment to prevent it becoming uncontrolled.34

Severe asthma is sometimes also called ‘severe refractory asthma' or 'severe treatment-resistant asthma'. However, the introduction of monoclonal antibody therapies has demonstrated that significant improvements can be seen in asthma that was previously termed ‘refractory’.

Asthma is considered to be uncontrolled if any of the following are identified:

  • poor symptom control, e.g. during previous 4 weeks any of:
    • symptoms during night or on waking
    • limitation of activities due to asthma
    • daytime symptoms on more than 2 days per week
    • need for short-acting beta2 agonist reliever on more than 2 days per week (not including doses taken prophylactically before exercise).
  • frequent severe flare-ups (e.g. more than one flare-up requiring treatment with oral corticosteroids in the previous year)
  • serious flare-ups (e.g. hospital admission, intensive care unit admission, or mechanical ventilation in the previous year)
  • persistent airflow limitation (e.g. detected by spirometry).

Patients with severe asthma are a subgroup of those with difficult-to-treat asthma. Difficult-to-treat asthma is defined as asthma that remains uncontrolled despite treatment with a high dose of an inhaled corticosteroid combined with a long-acting beta2 agonist.

Not all patients with difficult-to-treat asthma have severe asthma. Difficult-to-treat asthma includes asthma that is uncontrolled due to suboptimal adherence, inappropriate or incorrect use of medicines, environmental triggers or comorbidities. Patients whose asthma control improves rapidly after such problems are corrected are not considered to have severe asthma.34

Prevalence

Severe asthma is uncommon. Less than 4% of adults with asthma have severe asthma.35

Description

Severe asthma appears to be a distinct disease (or group of diseases) with different pathobiology from that of milder forms of asthma. It is rare for mild asthma to progress to severe asthma.36

Severe asthma imposes a high burden of disease due to symptoms, flare-ups, medication-related adverse effects and costs.37, 38

Bronchiectasis, granulomas and other auto-immune disease processes can coexist with severe asthma.36, 39 Aspirin-exacerbated respiratory disease can present as severe asthma.

Patterns of airway inflammation vary among people with severe asthma,40 which suggests that the underlying pathophysiology varies.

Inflammatory patterns identified in adults in research studies include eosinophilic (elevated sputum eosinophil count), neutrophilic (elevated sputum neutrophil count), mixed (elevated sputum eosinophil and neutrophil counts) and paucigranulocytic (sputum eosinophil and neutrophil counts within normal range).41 However, these tests are not routinely available in practice to guide treatment.

Some patients with severe asthma show sustained eosinophilia on blood tests despite good adherence to treatment with high doses of inhaled corticosteroids36, 42

Current research aims to predict which treatments will be most effective in an individual according to the findings of a range clinical investigations (e.g. sputum cell counts, peripheral blood white cell counts, fraction of exhaled nitric oxide [FeNO]) and on other clinical features such as age of asthma onset, relationship of allergies to asthma symptoms or presence of nasal polyposis. Few studies have been conducted to identify severe asthma phenotypes among children with severe asthma.40

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Common reasons for poor response to preventer treatment

Apparent lack of response to asthma treatment is commonly due to one or more of the following:43

  • poor adherence (which may be due to lack of perceived need for the medication, concern about potential or actual side-effects, cost of medicines, a busy lifestyle, misunderstanding of the purpose and effects of asthma medicines, or inability to follow the medical instructions)
  • poor inhaler technique
  • mishandling devices (e.g. failure to clean spacer, allowing mouthpiece of dry-powder inhalers to become blocked)
  • incorrect dose or frequency
  • empty inhaler
  • expired medicines
  • continued exposure to smoke or allergen triggers.

Failure to identify these causes before adjusting medicines could result in over-medication with preventers.

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References

  1. LeMay KS, Armous CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J. 2014; 23 (1): 79-84. Available from: http://www.nature.com/articles/pcrj201411
  2. Thomas, M, Gruffydd-Jones, K, Stonham, C, et al. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians ‘3 Questions’. Prim Care Respir J. 2009; 18: 83-88.
  3. Hoskins, G., Williams, B., Jackson, C., et al. Assessing asthma control in UK primary care: use of routinely collected prospective observational consultation data to determine appropriateness of a variety of control assessment models. BMC Fam Pract. 2011; 12: 105. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196897
  4. Thomas M, Kay S, Pike J, et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009; 18: 41-49. Available from: http://www.nature.com/articles/pcrj200910
  5. Peters SP, Jones CA, Haselkorn T, et al. Real-world Evaluation of Asthma Control and Treatment (REACT): Findings from a national Web-based survey. J Allergy Clin Immunol. 2007; 119: 1454-1461. Available from: http://www.jacionline.org/article/S0091-6749(07)00619-7/fulltext
  6. Juniper EF, Langlands JM, Juniper BA. Patients may respond differently to paper and electronic versions of the same questionnaires. Resp Med. 2009; 103: 932-934. Available from: http://www.resmedjournal.com/article/S0954-6111(08)00385-5/fulltext
  7. Kosinski M, Kite A, Yang M, et al. Comparability of the Asthma Control Test telephone interview administration format with self-administered mail-out mail-back format. Curr Med Res Opin. 2009; 25: 717-727. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19196218
  8. Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med. 2008; 178: 218-224. Available from: http://ajrccm.atsjournals.org/content/178/3/218.full
  9. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from: http://erj.ersjournals.com/content/26/5/948
  10. Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006; 117: 549-556. Available from: http://www.jacionline.org/article/S0091-6749(06)00174-6/fulltext
  11. Turner MO, Noertjojo K, Vedal S, et al. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998; 157: 1804-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9620909
  12. 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
  13. Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
  14. Gibson PG. Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for asthma treatment algorithm studies. Clin Exp Allergy. 2009; 39: 478-490. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19260871
  15. Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008; 32: 545-554. Available from: http://erj.ersjournals.com/content/32/3/545.long
  16. Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012; 67: 199-208. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20937641
  17. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): a caregiver-completed questionnaire for preschool-aged children. J Allergy Clin Immunol. 2009; 123: 833-9. Available from: http://www.jacionline.org/article/S0091-6749(09)00212-7/fulltext
  18. Zeiger RS, Mellon M, Chipps B, et al. Test for Respiratory and Asthma Control in Kids (TRACK): clinically meaningful changes in score. J Allergy Clin Immunol. 2011; 128: 983-8. Available from: http://www.jacionline.org/article/S0091-6749(11)01287-5/fulltext
  19. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol. 2007; 119: 817-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17353040
  20. Liu AH, Zeiger RS, Sorkness CA, et al. The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. J Allergy Clin Immunol. 2010; 126: 267-73, 273.e1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624640
  21. Abramson MJ, Schattner RL, Holton C et al. Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials. Pediatr Pulmonol 2015; 50: 947-54. (Available from: https://www.ncbi.nlm.nih.gov/pubmed/25200397
  22. Deschildre A, Beghin L, Salleron J, et al. Home telemonitoring (forced expiratory volume in 1 s) in children with severe asthma does not reduce exacerbations. Eur Respir J. 2012; 39: 290-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21852334
  23. Nuijsink M, Hop WC, Sterk PJ et al. Long-term asthma treatment guided by airway hyperresponsiveness in children: a randomised controlled trial. Eur Respir J 2007; 30: 457-66. (Available from: https://www.ncbi.nlm.nih.gov/pubmed/17537770
  24. Nuijsink M, Vaessen-Verberne AA, Hop WC et al. Long-term follow-up after two years of asthma treatment guided by airway responsiveness in children. Respir Med 2013; 107: 981-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23672993
  25. Petsky HL, Li A, Chang AB. Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev 2017; 8: Cd005603. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28837221
  26. Lehtimaki L, Csonka P, Makinen E et al. Predictive value of exhaled nitric oxide in the management of asthma: a systematic review. Eur Respir J 2016; 48: 706-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27492830
  27. Petsky HL, Kew KM, Chang AB. Exhaled nitric oxide levels to guide treatment for children with asthma. Cochrane Database Syst. Rev 2016; Issue 11: CD011439. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27825189/
  28. Turner S, Francis B, Vijverberg S et al. Childhood asthma exacerbations and the Arg16 beta2-receptor polymorphism: A meta-analysis stratified by treatment. J Allergy Clin Immunol 2016; 138: 107-13.e5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26774659
  29. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004; 59: 94-99. Available from: http://thorax.bmj.com/content/59/2/94.full
  30. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD004107. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004107/full
  31. Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
  32. Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
  33. Zemek RL, Bhogal S, Ducharme FM. Systematic Review of Randomized Controlled Trials Examining Written Action Plans in Children - What Is the Plan?. Arch Pediatr Adolesc Med. 2008; 162: 157-63. Available from: http://archpedi.jamanetwork.com/article.aspx?articleid=379087#tab1
  34. Chung, K F, Wenzel, S E, Brozek, J L, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014; 43: 343-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24337046
  35. Hekking, P. P., Wener, R. R., Amelink, M., et al. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015; 135: 896-902. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25441637
  36. Wenzel, S. E., Brillhart, S., Nowack, K.. An invisible disease: severe asthma is more than just "bad asthma". Eur Respir J. 2017; 50: . Available from: http://erj.ersjournals.com/content/50/3/1701109.long
  37. Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med. 2017; 377: 965-976. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28877019
  38. Foster JM, McDonald VM, Guo M, Reddel HK. "I have lost in every facet of my life": the hidden burden of severe asthma. Eur Respir J 2017; 50: Available from: https://www.ncbi.nlm.nih.gov/pubmed/28931662/
  39. Chalmers, J. D., Sethi, S.. Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults. NPJ Prim Care Respir Med. 2017; 27: 18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28270656
  40. Papi, A., Brightling, C., Pedersen, S. E., Reddel, H. K.. Asthma. Lancet. 2018; 391: 783-800. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29273246
  41. Centre of Excellence in Severe Asthma,, Severe asthma toolkit. **, Centre of Excellence in Severe Asthma 2018. Available from: https://toolkit.severeasthma.org.au
  42. Papi, A., Ryan, D., Soriano, J. B., et al. Relationship of inhaled corticosteroid adherence to asthma exacerbations in patients with moderate-to-severe asthma. J Allergy Clin Immunol Pract. 2018; : . Available from: https://www.ncbi.nlm.nih.gov/pubmed/29627457
  43. Bush A, Saglani S. Management of severe asthma in children. Lancet. 2010; 376: 814-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816548