Asthma Management Handbook

Assessing asthma triggers

Recommendations

Assess each patient’s asthma triggers to identify those that are clinically relevant to the individual and whether they are potentially avoidable.

Table. Summary of asthma triggers Opens in a new window Please view and print this figure separately: https://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).

List important triggers on the person’s written asthma action plan.

How this recommendation was developed

Consensus

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

More information

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)12
  • allergens plus viruses.34
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Thunderstorm-triggered asthma

Certain types of thunderstorms in spring or early summer in regions with high grass pollen concentrations in the air can cause life-threatening allergic asthma flare-ups in sensitised individuals, even if they have not had asthma before.5, 6, 7, 8, 9 People at risk of acute asthma flare-ups triggered by a thunderstorm include those with seasonal allergic rhinitis (with or without asthma), those with asthma (or a history of asthma), and those with undiagnosed asthma.6

Epidemics of thunderstorm-triggered asthma can occur when such a storm travels across a region and triggers asthma in many susceptible individuals, causing a high demand on ambulance and health services.7 However, epidemic thunderstorm asthma events are uncommon.

Data from thunderstorm asthma epidemics suggest that the risk of asthma flare-ups being triggered by a thunderstorm is highest in adults who are sensitised to grass pollen and have seasonal allergic rhinitis (with or without known asthma).6 The worst outcomes are seen in people with poorly controlled asthma. Regular treatment with an inhaled corticosteroid asthma preventer was significantly protective in a well-conducted Australian case-control study.9

Prevention and management are based on:10

  • year-round asthma control, including inhaled corticosteroid-containing preventers where indicated
  • preventive inhaled corticosteroid treatment for adults and adolescents with asthma who have known or suspected allergy to grass pollens (e.g. concomitant allergic rhinitis, a history of spring flare-ups in asthma symptoms) but are not already taking regular medication. Treatment should at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, asthma should be managed according to age group.
  • preventive intranasal corticosteroid treatment for adults and adolescents with seasonal allergic rhinitis, because it can be reasonably assumed that they are allergic to ryegrass pollen. Treatment should start at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, allergic rhinitis should be managed according to age group.
  • advice for at-risk patients to avoid being outdoors just before and during thunderstorms in spring and early summer, especially during wind gusts that precede the rain front
  • advice to ensure appropriate access to relievers during grass pollen season.
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References

  1. 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
  2. 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
  3. 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
  4. 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/
  5. D'Amato G, Vitale C, D'Amato M, et al. Thunderstorm-related asthma: what happens and why. Clin Exp Allergy. 2016; 46: 390-6.
  6. Davies J, Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Final report. Victorian State Government Department of Health and Human Services, Melbourne, 2017.
  7. Victoria State Government Department of Health and Human Services,. The November 2016 Victorian epidemic thunderstorm asthma event: an assessment of the health impacts. The Chief Health Officer’s Report, 27 April 2017. Victorian Government, Melbourne, 2017.
  8. Marks GB, Colquhoun JR, Girgis ST, et al. Thunderstorm outflows preceding epidemics of asthma during spring and summer. Thorax. 2001; 56: 468-71. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746065/
  9. Girgis ST, Marks GB, Downs SH, et al. Thunderstorm-associated asthma in an inland town in south-eastern Australia. Who is at risk?. Eur Respir J. 2000; 16: 3-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10933077
  10. National Asthma Council Australia. Thunderstorm asthma. An information paper for health professionals. NACA, Melbourne, 2017.