Asthma Management Handbook

Starting treatment and reviewing response in adults


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)



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 March 2019: 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 March 2019: 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.

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How this recommendation was developed


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.

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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


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


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)


Chronic obstructive pulmonary disease

Pulmonary fibrosis

Large airway stenosis

Habit-cough syndrome

Inhaled foreign body

Conditions characterised by wheezing

Respiratory infections


Upper airway dysfunction

Conditions characterised by difficulty breathing

Breathlessness on exertion due poor cardiopulmonary fitness



Chronic heart failure

Pulmonary hypertension

Lung cancer


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:

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How this recommendation was developed


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.


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

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 microg/actuation) via a pressurised metered-dose inhaler and spacer.8 (For patients who have reported unacceptable side-effects with 400 microg, 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

Last reviewed version 2.0

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:

Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,13, 14,1515, 16 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.13, 14, 17, 18, 19, 20

Poor asthma symptom control is often due to incorrect inhaler technique.21, 22

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

Last reviewed version 2.0



  1. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from:
  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:
  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:
  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:
  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:
  6. Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245. Available from:
  7. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26: 319-338. Available from:
  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:
  10. Luks VP, Vandemheen KL, Aaron SD. Confirmation of asthma in an era of overdiagnosis. Eur Respir J. 2010; 36: 255-260. Available from:
  11. Marklund B, Tunsäter A, Bengtsson C. How often is the diagnosis bronchial asthma correct?. Fam Pract. 1999; 16: 112-116. Available from:
  12. Nathan, A. M., de Bruyne, J., Khalid, F., Arumugam, K.. Caesarean section and asthma in Malaysian children: a case-control study. Asian Pac J Allergy Immunol. 2012; 30: 204-8. Available from:
  13. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from:
  14. 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:
  15. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. 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:
  16. 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:
  17. 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:
  18. Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from:
  19. 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:
  20. 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:
  21. Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. J Asthma. 2014; 51: 440-5.
  22. Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: