Asthma Management Handbook

Starting treatment and reviewing response in adults

Recommendations

After making the diagnosis of asthma, begin treatment for 4–6 weeks with either of the following:

  • short-acting beta2 agonist taken as needed
  • regular treatment with an inhaled corticosteroid (plus short-acting beta2 agonist taken as needed).

Table. Initial treatment choices (adults and adolescents not already using a preventer)

Clinical situation

Suggested starting regimen †

Alternative options and notes

Symptoms less than twice per month and no flare-up that required oral corticosteroids within previous 12 months

SABA as needed

 

Symptoms twice per month or more

Regular ICS starting at a low dose (plus SABA as needed)

Montelukast

Cromones§

Waking due to asthma symptoms at least once during the past month

Regular ICS starting at a low dose (plus SABA as needed)

If patient also has frequent daytime symptoms consider either of:

  • medium- to high-dose ICS (plus SABA as needed)
  • (private prescription) combination low-dose ICS/LABA#

Oral corticosteroids required for an asthma flare-up within the last 12 months (even if symptoms infrequent, e.g. less than twice per month on average)

Regular ICS starting at a low dose (plus SABA as needed)

 

History of artificial ventilation or admission to an intensive care unit due to acute asthma (even if symptoms infrequent, e.g. less than twice per month on average)

Regular ICS starting at a low dose (plus SABA as needed)

  • Monitor frequently

 

Patient not currently taking a preventer whose symptoms are severely uncontrolled or very troublesome

Regular ICS (plus SABA as needed)

For very uncontrolled asthma at presentation (e.g. frequent night waking, low lung function), consider (either of):

  • high-dose ICS (then down-titrate when symptoms improve)
  • a short course of oral corticosteroids in addition to ICS

Consider (private prescription) combination ICS/LABA#

† When prescribing inhaled asthma medicines, take into account the person’s preferences, ability to use the device, and cost issues.

§ Requires multiple daily doses and daily maintenance of inhaler.

‡ PBS status as at October 2016: Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special Authority is available for Department of Veteran’s Affairs gold card holders or white card holders with approval for asthma treatments.

# PBS status as at October 2016: ICS/LABA combination therapy as first-line preventer treatment is not subsidised by the PBS, except for patients with frequent symptoms while taking oral corticosteroids.

Asset ID: 32

Close
How this recommendation was developed

Consensus

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

Arrange to check response to treatment after 4–6 weeks. Depending on the severity of initial symptoms, consider also monitoring progress and clinical signs during the treatment trial.

Table. Steps for conducting a treatment trial

  1. Document baseline lung function.
  2. Document baseline asthma control using a validated standardised tool such as the Asthma Score.
  3. Discuss treatment goals and potential adverse effects with the person.
  4. Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).
  5. At an agreed interval, measure asthma control and lung function again and document any adverse effects.
  6. If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment and consider referral for specialist consultation.

Asset ID: 36

Close

Note: Although response to initial asthma treatment supports the diagnosis of asthma, respiratory symptoms and low lung function may improve spontaneously (e.g. if they were due to a respiratory infection). Conversely, lack of response to treatment does not necessarily rule out asthma.

How this recommendation was developed

Consensus

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

Also consider a treatment trial if asthma is strongly suspected but spirometry before and after bronchodilator does not demonstrate clinically important reversible airflow limitation (change in FEV1 of at least 200 mL and 12% from baseline) and other investigations have not confirmed variable airflow limitation.

How this recommendation was developed

Consensus

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

If there is no clear response to initial treatment, after confirming correct inhaler technique and good adherence, consider further investigations or referral to confirm or exclude the diagnosis of asthma.

Table. Conditions that can be confused with asthma in adults and adolescents

Conditions characterised by cough

Pertussis (whooping cough)

Gastro-oesophageal reflux

Rhinosinusitis/upper airway cough syndrome

Adverse effect of medicines (e.g. ACE inhibitors)

Bronchiectasis

Chronic obstructive pulmonary disease

Pulmonary fibrosis

Large airway stenosis

Habit-cough syndrome

Inhaled foreign body

Conditions characterised by wheezing

Respiratory infections

COPD

Upper airway dysfunction

Conditions characterised by difficulty breathing

Breathlessness on exertion due poor cardiopulmonary fitness

Hyperventilation

Anxiety

Chronic heart failure

Pulmonary hypertension

Lung cancer

Sources

Therapeutic Guidelines Limited. Therapeutic Guidelines: respiratory. Version 4. West Melbourne: Therapeutic Guidelines Limited; 2009.

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007; 120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855

Asset ID: 83

Close

How this recommendation was developed

Consensus

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

More information

Definition of variable expiratory airflow limitation

Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1 may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC indicates airflow limitation.1 Normal FEV1/FVC values derived from population studies vary,23 but are usually greater than:2

  • 0.85 in people aged up to 19 years
  • 0.80 in people aged 20–39 years
  • 0.75 in people aged 40–59 years
  • 0.70 in people aged 60–80 years.

In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio, because normal values in children change considerably with age.3

Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.

Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the following are recorded:

  • a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children) 10–15 minutes after administration of bronchodilator
  • clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)
  • a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing uses different criteria for exercise-induced bronchoconstriction)
  • a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks of treatment with an inhaled corticosteroid
  • clinically important variation in peak expiratory flow (diurnal variability of more than 10%)
  • a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

Notes

Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a spirometry visit.

A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.41 A clinically important increase in FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVC may vary due to factors such as variation in inspiratory volume or expiratory time.

The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important improvement in response to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted normal range.

The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may develop fixed airflow limitation.

Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled corticosteroid.

Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe acute infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection. Reduction in lung function during a respiratory tract infection with improvement in lung function after its resolution, commonly occurs in people with asthma, but can also be seen in patients with COPD or in healthy people without either asthma or COPD.5,6

Close
Spirometry in diagnosis and monitoring

Spirometry is the best lung function test for diagnosing asthma and for measuring lung function when assessing asthma control. Spirometry can:

  • detect airflow limitation
  • measure the degree of airflow limitation compared with predicted normal airflow (or with personal best)
  • demonstrate whether airflow limitation is reversible.

It should be performed by well-trained operators with well-maintained and calibrated equipment.7, 4

Before performing spirometry, check if the person has any contraindications (e.g. myocardial infarction, angina, aneurysm, recent surgery, suspected pulmonary embolism, suspected pneumothorax, fractured ribs). Advise them to stop if they become dizzy.

Clearly explain and physically demonstrate correct spirometry technique: 8

  • Sit upright with legs uncrossed and feet flat on the floor and do not lean forward.
  • Breathe in rapidly until lungs feel absolutely full. (Coaching is essential to do this properly.)
  • Do not pause for more than 1 second.
  • Place mouthpiece in mouth and close lips to form a tight seal.
  • Blast air out as hard and fast as possible and for as long as possible, until the lungs are completely empty or you are unable to blow out any longer.
  • Remove mouthpiece.

Repeat the test until you obtain three acceptable tests and these meet repeatability criteria.

Acceptability of test

A test is acceptable if all the following apply:

  • forced expiration started immediately after full inspiration
  • expiration started rapidly
  • maximal expiratory effort was maintained throughout the test, with no stops
  • the patient did not cough during the test
  • the patient did not stop early (before 6 seconds for adults and children over 10 years, or before 3 seconds for children under 10 years).

Record the highest FEV1 and FVC result from the three acceptable tests, even if they come from separate blows.8

Repeatability criteria

Repeatability criteria for a set of acceptable tests are met if both of the following apply:7

  • the difference between the highest and second-highest values for FEV1 is less than 150 mL
  • the difference between the highest and second-highest values for FVC is less than 150 mL.

For most people, it is not practical to make more than eight attempts to meet acceptability and repeatability criteria.8

Testing bronchodilator response (reversibility of airflow limitation)

Repeat spirometry 10-15 minutes after giving 4 separate puffs of salbutamol (100 mcg/actuation) via a pressurised metered-dose inhaler and spacer.8 (For patients who have reported unacceptable side-effects with 400 mcg, 2 puffs can be used.)

For adults and adolescents, record a clinically important bronchodilator response if FEV1 increases by ≥ 200 mL and ≥ 12%.8

For children, record a clinically important bronchodilator response if FEV1 increases by
≥ 12%.8

Close
Confirming the diagnosis of asthma in adults and adolescents

A prior diagnosis of asthma reported by a patient should be corroborated by documentation of how the diagnosis was confirmed at the time, or by current evidence.

Reports from around the world show that 25–35% of people with a diagnosis of asthma in primary care may not actually have asthma.9101112 Wheezing and other respiratory symptoms do not always mean a person has asthma. Airflow limitation demonstrated on spirometry can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe acute viral infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection.

Once a person is already taking regular treatment with a preventer, it may be more difficult to confirm the diagnosis because variability in lung function often decreases with treatment.

Table. Confirming the diagnosis of asthma in a person using preventer treatment Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/9

Close
Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1314

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,15, 16, 17, 18, 19 even among regular users.20 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.21

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.15, 22, 20, 23, 24 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.20

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.25, 26

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:21

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:21

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.21 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.27, 15, 28, 29 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.28 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).13, 26

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.25, 15, 16 

Close

References

  1. 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
  2. National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Full report 2007. US Department of Health and Human Services National Institutes of Health, Bethesda, 2007. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report
  3. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675
  4. Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009; 18: 130-147. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995
  5. Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev Respir Dis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724
  6. Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901
  7. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26: 319-338. Available from: http://erj.ersjournals.com/content/26/2/319
  8. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
  9. Lucas AE, Smeenk FW, Smeele IJ, van Schayck CP. Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study. Fam Pract. 2008; 25: 86-91. Available from: http://fampra.oxfordjournals.org/content/25/2/86.full
  10. Luks VP, Vandemheen KL, Aaron SD. Confirmation of asthma in an era of overdiagnosis. Eur Respir J. 2010; 36: 255-260. Available from: http://erj.ersjournals.com/content/36/2/255.full
  11. Marklund B, Tunsäter A, Bengtsson C. How often is the diagnosis bronchial asthma correct?. Fam Pract. 1999; 16: 112-116. Available from: http://fampra.oxfordjournals.org/content/16/2/112.full
  12. Aaron SD, Fergusson D, Dent R, et al. Effect of weight reduction on respiratory function and airway reactivity in obese women. Chest. 2004; 125: 2046-52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15189920
  13. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  14. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  15. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  16. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  17. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  18. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  19. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  20. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  21. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  22. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  23. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  24. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  25. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
  26. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
  27. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
  28. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
  29. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924