Asthma Management Handbook

Managing flare-ups in adults

Recommendations

Advise patients that if they experience a flare-up (e.g. worsening symptoms over hours or days, or needing reliever again within a few hours), they should increase their reliever use to control symptoms. Include these instructions in the patient's written asthma action plan.

Table. Severity classification for flare-ups (exacerbations)

Severity Definition Example/s
Mild Worsening of asthma control that is only just outside the normal range of variation for the individual (documented when patient is well)

More symptoms than usual, needing reliever more than usual (e.g. >3 times within a week for a person who normally needs their reliever less often), waking up with asthma, asthma is interfering with usual activities

A gradual reduction in PEF† over several days

Moderate

Events that are (all of):

  • troublesome or distressing to the patient
  • require a change in treatment
  • not life-threatening
  • do not require hospitalisation.
More symptoms than usual, increasing difficulty breathing, waking often at night with asthma symptoms
Severe Events that require urgent action by the patient (or carers) and health professionals to prevent a serious outcome such as hospitalisation or death from asthma Needing reliever again within 3 hours, difficulty with normal activity

† Applies to patients who monitor their asthma using a peak expiratory flow meter (single PEF measurements in clinic not recommended for assessing severity of flare-ups).

Note: the ATS/ERS Task Force recommended that severe exacerbations should be defined in clinical trials as the use of oral corticosteroids for 3 or more days. However, this definition is not applicable to clinical practice.

Source: Reddel H, Taylor D, Bateman E et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009; 180: 59-99. Available at: http://www.thoracic.org/statements

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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: https://www.asthmahandbook.org.au/table/show/42

How this recommendation was developed

Consensus

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

Advise patients to keep taking regular preventer during a flare-up (even if they need oral corticosteroids).

How this recommendation was developed

Consensus

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

For patients using a pressurised metered-dose inhaler reliever, advise (and state in a written asthma action plan) to use a spacer during a flare-up to increase the amount of medicine deposited within the airways.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Hall et al. 20111
  • Lipworth and Clark, 19982

Prescribe an increase in preventer and/or a course of oral corticosteroids for patients with (any of):

  • acute asthma symptoms that recur within 3 hours of taking a rapid-onset beta2 agonist reliever
  • increasing difficulty breathing over one or more days
  • night-time asthma symptoms that interfere with sleep over more than one night in a row
  • peak flow below a pre-defined level (for those monitoring peak flow each day; level determined based on individual’s personal best and history of peak flow levels before and during flare-ups).
How this recommendation was developed

Consensus

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

When prescribing oral corticosteroids, the recommended daily dose is oral prednisone or prednisolone 37.5–50 mg for 5–10 days. It is usually not necessary to taper the dose for courses of less than 14 days.

Notes

Dose tapering may be necessary for patients who experience adverse effects.

If a patient needs to take prednisolone for more than 2 weeks, the dose should be tapered before ceasing.

Pregnancy is not a contraindication for oral corticosteroids. Oral prednisone or prednisolone is rated category A for pregnancy.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Cydulka and Emerman, 19983
  • Hasegawa et al. 20004
  • Jones et al. 20025
  • O'Driscoll et al. 19936
  • Rowe et al. 20077

To increase the preventer dose during a flare-up in patients taking regular maintenance inhaled corticosteroid or combination inhaled corticosteroid/long-acting beta2 agonist, consider advising them to quadruple the dose of inhaled corticosteroid by giving an extra inhaler at the onset of a flare-up (e.g. use an extra high-dose inhaled corticosteroid inhaler, in addition to usual dose with usual inhaler, for 2 weeks).

  • Taking short-term high doses of inhaled corticosteroid may not be appropriate for some people, e.g. people who cannot risk dysphonia (e.g. singers, actors, teachers) and people who cannot afford the extra medicine.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • FitzGerald et al. 20008
  • Levy et al. 19969
  • Oborne et al. 200910
  • Quon et al. 201011
  • Reddel and Barnes, 200612
  • Rodrigo, 200613

In patients taking maintenance combination fluticasone propionate/salmeterol, ensure that the total daily dose of salmeterol is 100 mcg/day during a flare-up.

Note: For example, if a patient is currently taking fluticasone propionate/salmeterol 250/25 mcg via pressurised metered-dose inhaler at a dose of 1 puff twice daily, they should increase this to 2 puffs twice daily during worsening asthma. An extra fluticasone propionate inhaler may also be prescribed for 1–2 weeks so that the inhaled corticosteroid component can be increased while the salmeterol dose remains at 100 mcg/day.

How this recommendation was developed

Consensus

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

To increase the preventer dose during a flare-up in patients taking budesonide/formoterol as maintenance-and-reliever regimen using a dry-powder inhaler, advise the person to:

  • take one extra inhalation of their budesonide/formoterol combination inhaler when they need relief from asthma symptoms (up to a maximum of 12 inhalations per day in total, including maintenance doses)
  • take action (e.g. contact GP or start a course of oral corticosteroids) if they need more than 6 reliever inhalations of their budesonide/formoterol combination inhaler per day for more than 2–3 days (or as instructed in their written asthma action plan)
  • go to the emergency department or GP if they need more than 12 reliever inhalations of their budesonide/formoterol combination inhaler in one day (keep taking as needed while waiting).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • AstraZeneca Pty Ltd 201014

To increase the preventer dose during a flare-up in patients taking budesonide/formoterol as maintenance-and-reliever regimen using a pressurised metered-dose inhaler, advise the person to:

  • take two extra inhalations of their budesonide/formoterol combination inhaler when they need relief from asthma symptoms (up to a maximum of 24 inhalations per day in total, including maintenance doses)
  • take action (e.g. contact GP or start a course of oral corticosteroids) if they need more than 12 reliever inhalations of their budesonide/formoterol combination inhaler per day for more than 2–3 days (or as instructed in their written asthma action plan)
  • go to the emergency department or GP if they need more than 24 reliever inhalations of their budesonide/formoterol combination inhaler in one day (keep taking as needed while waiting).
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • AstraZeneca Pty Ltd 201215

Advise patients when to reduce their preventer medication back to normal (e.g. after 2 weeks), and to reduce reliever use once symptoms have improved.

How this recommendation was developed

Consensus

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

Make the decision to prescribe antibiotics or not during respiratory tract infections in people with asthma according to the same considerations for people without asthma.

How this recommendation was developed

Consensus

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

More information

Definition and recognition of flare-ups (exacerbations)

An asthma flare-up is a worsening (exacerbation) of asthma symptoms and lung function, compared with the person’s previous status (i.e. outside the patient’s usual range of day-to-day variation).16

The onset of asthma flare-ups varies widely. Flare-ups are usually progressive (over days or weeks), but in some adults acute asthma can occur suddenly over a few hours.1617, 1819

The patient's experience of symptoms may be a more sensitive indicator of the onset of a flare-up than peak expiratory flow monitoring, because symptoms usually increase before deterioration in lung function is detected.20 However, some people perceive symptoms poorly and may have a clinically significant decline in lung function without a marked change in symptoms.17

Patients need clear instructions in their written asthma action plan about how to monitor symptoms and how to recognise a flare-up (e.g. worsening symptoms and increasing reliever use). For most patients, a daily diary is not needed to monitor asthma, but current status (including symptom frequency, frequency of reliever use, limitation of activity) should be documented at every doctor visit so that the clinician can recognise any change.

Table. Severity classification for flare-ups (exacerbations)

Severity Definition Example/s
Mild Worsening of asthma control that is only just outside the normal range of variation for the individual (documented when patient is well)

More symptoms than usual, needing reliever more than usual (e.g. >3 times within a week for a person who normally needs their reliever less often), waking up with asthma, asthma is interfering with usual activities

A gradual reduction in PEF† over several days

Moderate

Events that are (all of):

  • troublesome or distressing to the patient
  • require a change in treatment
  • not life-threatening
  • do not require hospitalisation.
More symptoms than usual, increasing difficulty breathing, waking often at night with asthma symptoms
Severe Events that require urgent action by the patient (or carers) and health professionals to prevent a serious outcome such as hospitalisation or death from asthma Needing reliever again within 3 hours, difficulty with normal activity

† Applies to patients who monitor their asthma using a peak expiratory flow meter (single PEF measurements in clinic not recommended for assessing severity of flare-ups).

Note: the ATS/ERS Task Force recommended that severe exacerbations should be defined in clinical trials as the use of oral corticosteroids for 3 or more days. However, this definition is not applicable to clinical practice.

Source: Reddel H, Taylor D, Bateman E et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009; 180: 59-99. Available at: http://www.thoracic.org/statements

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Managing flare-ups in adults: self-management

Moderate flare-ups (e.g. nocturnal wakening, increased need for reliever, PEF reduction <20% from best) can usually be managed without a hospital visit.17

Patients should be able to manage most flare-ups using their written asthma action plan. Asthma action plans that include instructions both for increasing the dose of inhaled corticosteroid and for starting oral corticosteroids (in addition to reliever as needed) during flare-ups are effective in reducing the risk of needing Emergency Department visits or hospital admissions.21

Written asthma action plans based on symptoms and those based on peak expiratory flow are equally effective.21

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Managing flare-ups in adults: oral corticosteroids

The use of oral corticosteroids is accepted as part of the management of severe asthma flare-ups, including in most asthma clinical trials.

Most clinical trials that have specifically evaluated the use of oral corticosteroids to manage flare-ups have been conducted in patients attending emergency departments. Oral corticosteroids courses of 5–10 days are effective in regaining control of asthma after an acute flare-up.34567 A 5-day course of prednisolone 40 mg per day may be as effective as a 10-day course in adults.5

Abruptly ceasing oral prednisolone after a short course appears to be equally effective as tapering over a longer period. Tapering the dose does not reduce the risk of suppression of adrenal function.36 The dose should be tapered if oral corticosteroids have been taken for more than 2 weeks.

Action plans for worsening asthma that include instructions for the use of oral corticosteroids as well as instructions to increase the dose of inhaled corticosteroid, are effective in improving lung function and reducing hospital admissions.21

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Managing flare-ups in adults: adjusting inhaled corticosteroid dose

Several randomised clinical trials have assessed whether increasing the inhaled corticosteroid dose is an effective strategy in avoiding the need for oral corticosteroids or acute medical care during flare-ups in adults with asthma taking daily maintenance inhaled corticosteroid or daily maintenance inhaled corticosteroid/long-acting beta2 agonist combination treatment.

There is some evidence that quadrupling the maintenance dose of inhaled corticosteroids,10 or treating with a high dose of inhaled corticosteroids,8913 reduces the severity of asthma flare-ups. For patients taking inhaled corticosteroid/long-acting beta2 agonist combinations, this can be achieved by adding a separate high-dose inhaled corticosteroid inhaler to the patient’s usual maintenance treatment for 7–14 days. This strategy may be useful for patients who experience clinically important side-effects with oral corticosteroids, but may not be suitable for patients who cannot afford the extra medicine or who experience hoarseness with high dose inhaled corticosteroid.

However, overall evidence from randomised clinical trials does not support the use of inhaled corticosteroids as a substitute for oral corticosteroids during most flare-ups in adults:

  • A self-initiated increase (e.g. increasing the dose by a factor of two to five) after asthma worsened did not reduce the overall risk of flare-ups requiring rescue oral corticosteroids in a meta-analysis of randomised controlled clinical trials mainly in adults.11
  • Doubling the dose in response to specific criteria for worsening lung function (with or without worsening asthma symptoms) did not reduce the proportion of people who needed oral corticosteroids.12 However, in two of the three clinical trials that evaluated the efficacy of doubling the dose, patients did not begin taking the higher dose (active or placebo) until approximately one week after asthma began to worsen. Therefore, there is insufficient evidence to judge the effectiveness of doubling the dose of inhaled corticosteroid at the first sign of worsening symptoms.
  • In another clinical trial,10 patients taking a range of inhaled corticosteroid-based regimens at baseline were randomised to one of two treatment strategies when any of the following occurred: when peak expiratory flow rate fell (by 15% or more on 2 consecutive days, or by 30% or more on 1 day), when they believed their asthma was worsening, or they developed a cold. Treatment strategies were (1) increasing the dose of inhaled corticosteroid to four times higher than the maintenance dose, regardless of baseline regimen, or (2) continuing usual dose. Overall, the group randomised to the increased dose strategy did not have a reduced risk of flare-ups that required oral corticosteroid treatment.10 However, fewer than one quarter of patients started the study inhaler. Among those patients who did begin taking the high-dose (or placebo) inhaler due to perceived worsening asthma, quadrupling the dose was associated with a significant (almost halving) reduction in the rate of severe flare-up.10
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Managing flare-ups in adults: adjusting budesonide/formoterol maintenance-and-reliever treatment

When asthma symptoms worsen, patients taking budesonide/formoterol 100/6 mcg or 200/6 mcg as maintenance-and-reliever treatment can increase as-needed inhalations:

  • for budesonide/formoterol 100/6 mcg or 200/6 mcg via dry-powder inhaler, up to a maximum of 12 actuations per day (total of maintenance and reliever inhalations) 14
  • for budesonide/formoterol 50/3 mcg or 100/3 mcg via pressurised metered-dose inhaler, up to a maximum of 24 actuations per day (total of maintenance and reliever inhalations).15

A written asthma action plan template developed by Australian clinicians for adults using budesonide/formoterol maintenance and reliever regimen suggests that the patient should commence oral corticosteroids and/or see a doctor after 2–3 days if asthma is worsening, or symptoms are not improving, despite taking 6 reliever inhalations of budesonide/formoterol per day in addition to maintenance doses.

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Self-monitoring in adults using peak expiratory flow

Peak flow monitoring is no longer routinely used in Australia, but is recommended for patients with severe asthma, a history of frequent flare-ups, or poor perception of airflow limitation.

Peak expiratory flow can be monitored at home using a mechanical or electronic peak flow meter, either regularly every day or when symptoms are worse. For patients who are willing to measure peak flow regularly, morning and evening readings can be plotted on a graph or recorded in a diary.

When peak flow monitoring results are recorded on a graph, the same chart should be used consistently so that patterns can be recognised. Flare-ups are easier to detect when the chart or image has a low ratio of width to height (aspect ratio), i.e. is compressed horizontally.22

When a person’s written asthma action plan is based on peak expiratory flow, instructions should be based on personal best, rather than predicted values. Personal best can be determined as the highest reading over the previous 2 weeks. When a person begins high-dose inhaled corticosteroid treatment, personal best peak expiratory flow reaches a plateau within a few weeks with twice daily monitoring.23

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Acute respiratory tract infections

Although people with asthma are no more likely to experience viral upper respiratory tract infection than people without asthma, they are more likely to experience symptoms of lower respiratory tract infection.24

In patients with asthma, respiratory tract infections often lead to asthma flare-ups.

During viral infections, inhaled short-acting beta2 agonists may have reduced effectiveness and there may be a reduced bronchodilator response in lung function.25

Worsening asthma may be misdiagnosed as a respiratory tract infection, and respiratory tract infections may be misdiagnosed as asthma, because acute bronchitis in patients with no evidence of asthma may be associated with a short-term reduction in lung function.

  • If spirometry during a respiratory tract infection shows reduced FEV1 and lack of acute response to bronchodilator in a person with suspected asthma, spirometry should be repeated after the person recovers. Apparent non-reversible airflow limitation may be due to viral infection.

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Antibiotics and asthma management

Most respiratory tract infections are due to viruses rather than bacteria. The decision about whether or not to use antibiotics for treatment of respiratory tract infections in people with asthma should be made on the same basis as in people without asthma.

Long-term therapy with macrolides may have an anti-inflammatory effect, but there is not enough evidence to recommend this routinely for managing asthma.262728

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References

  1. Hall GL, Annese T, Looi K, Devadason SG. Usage of spacers in respiratory laboratories and the delivered salbutamol dose of spacers available in Australia and New Zealand. Respirology. 2011; 16: 639-44. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1843.2011.01928.x/full
  2. Lipworth BJ, Clark DJ. Early lung absorption profile of non-CFC salbutamol via small and large volume plastic spacer devices. Br J Clin Pharmacol. 1998; 46: 45-48. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873975/
  3. Cydulka RK, Emerman CL. A pilot study of steroid therapy after emergency department treatment of acute asthma: is a taper needed?. J Emerg Med. 1998; 16: 15-19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9472754
  4. Hasegawa T, Ishihara K, Takakura S, et al. Duration of systemic corticosteroids in the treatment of asthma exacerbation; a randomized study. Intern Med. 2000; 39: 794-797. Available from: https://www.jstage.jst.go.jp/article/internalmedicine1992/39/10/3910794/_article
  5. Jones AM, Munavvar M, Vail A, et al. Prospective, placebo-controlled trial of 5 vs 10 days of oral prednisolone in acute adult asthma. Respir Med. 2002; 96: 950-954. Available from: http://www.resmedjournal.com/article/S0954-6111(02)91369-7/abstract
  6. O'Driscoll BR, Kalra S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma. Lancet. 1993; 341: 324-327. Available from: http://www.sciencedirect.com/science/article/pii/0140673693901343
  7. Rowe BH, Spooner C, Ducharme F, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007; Issue 3: CD000195. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000195.pub2/full
  8. FitzGerald JM, Shragge D, Haddon J, et al. A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J. 2000; 7: 61-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10700672
  9. Levy ML, Stevenson C, Maslen T. Comparison of short courses of oral prednisolone and fluticasone propionate in the treatment of adults with acute exacerbations of asthma in primary care. Thorax. 1996; 51: 1087-1082. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1090518/
  10. Oborne J, Mortimer K, Hubbard RB, et al. Quadrupling the dose of inhaled corticosteroid to prevent asthma exacerbations: a randomized, double-blind, placebo-controlled, parallel-group clinical trial. Am J Respir Crit Care Med. 2009; 180: 598-602. Available from: http://ajrccm.atsjournals.org/content/180/7/598.full
  11. Quon BS, FitzGerald,JM, Lemière C, et al. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev. 2010; Issue 12: CD007524. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007524.pub3/full
  12. Reddel HK, Barnes DJ. Pharmacological strategies for self-management of asthma exacerbations. Eur Respir J. 2006; 28: 182-199. Available from: http://erj.ersjournals.com/content/28/1/182.long
  13. Rodrigo GJ. Rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation. Chest. 2006; 130: 1301-11. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1084773
  14. AstraZeneca Pty Ltd. Product Information: Symbicort (budesonide and eformoterol fumarate dihydrate) Turbuhaler. Therapeutic Goods Administration, Canberra, 2010. Available from: https://www.ebs.tga.gov.au/
  15. AstraZeneca Pty Ltd. Product Information: Symbicort (budesonide and eformoterol fumarate dihydrate) Rapihaler. Therapeutic Goods Administration, Canberra, 2012. Available from: https://www.ebs.tga.gov.au/
  16. Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. 2009; 180: 59-99. Available from: http://ajrccm.atsjournals.org/content/180/1/59.long
  17. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
  18. James AL, Elliot JG, Abramson MJ, Walters EH. Time to death, airway wall inflammation and remodelling in fatal asthma. Eur Respir J. 2005; 26: 429-34. Available from: http://erj.ersjournals.com/content/26/3/429.long
  19. Sur S, Crotty TB, Kephart GM, et al. Sudden-onset fatal asthma. A distinct entity with few eosinophils and relatively more neutrophils in the airway submucosa?. Am Rev Respir Dis. 1993; 148: 713-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8368644
  20. Chan-Yeung M, Chang JH, Manfreda J, et al. Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma. Am J Respir Crit Care Med. 1996; 154: 889-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8887581
  21. 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
  22. Jansen J, McCaffery KJ, Hayen A, et al. Impact of graphic format on perception of change in biological data: implications for health monitoring in conditions such as asthma. Prim Care Respir J. 2012; 21: 94-100. Available from: http://www.nature.com/articles/pcrj20124
  23. Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans?. Thorax. 2004; 59: 922-4. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746886/
  24. Corne JM, Marshall C, Smith S, et al. Frequency, severity, and duration of rhinovirus infections in asthmatic and non-asthmatic individuals: a longitudinal cohort study. Lancet. 2002; 359: 831-834. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)07953-9/fulltext
  25. Reddel H, Ware S, Marks G, et al. Differences between asthma exacerbations and poor asthma control. Lancet. 1999; 353: 364-369. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9950442
  26. Crosbie PA, Woodhead MA. Long-term macrolide therapy in chronic inflammatory airway diseases. Eur Respir J. 2009; 33: 171-181. Available from: http://erj.ersjournals.com/content/33/1/171.full
  27. Black PN. Antibiotics for the treatment of asthma. Curr Opin Pharmacol. 2007; 7: 266-71. Available from: http://www.sciencedirect.com/science/article/pii/S1471489207000616
  28. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext