Asthma Management Handbook

Providing information, skills and tools for asthma self-management for adults


Provide or arrange education in asthma self-management, including (all of):

  • self-monitoring of asthma control based on symptoms (and peak expiratory flow monitoring, if used)
  • inhaler technique
  • a written asthma action plan
  • the importance of regular medical review.
How this recommendation was developed


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

  • Gibson et al. 20021
  • Gibson et al. 20022
  • Gibson and Powell, 20043
  • National Asthma Council Australia, 20084
  • Powell and Gibson, 20025

Check the person’s inhaler technique at each encounter:

  • Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
  • Demonstrate correct technique using a placebo device and correct any specific errors identified.
  • Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.


Watch the person use their inhaler – don’t just ask if they think they know how to use it properly.

Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on National Asthma Council Australia’s website.

How this recommendation was developed


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

  • Basheti et al. 20136
  • National Asthma Council Australia, 20084

Advise patients to seek emergency medical care immediately if they experience any of these danger signs:

  • severe breathing problems
  • symptoms get worse very quickly
  • reliever has little or no effect
  • difficulty saying sentences
  • blue lips
  • drowsiness.

The person and their family should know that they must call an ambulance and give asthma first aid if they see any of these danger signs. 

How this recommendation was developed


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

More information

Asthma self-management for adults

Effective self-management requires:

  • adherence to the agreed treatment regimen
  • correct use of inhaler devices for asthma medicines
  • monitoring asthma control (symptoms, with addition of peak expiratory flow for some patients)
  • having an up-to-date written asthma action plan and following it when asthma worsens
  • management of triggers or avoidance (if appropriate)
  • regular medical review.

Self-monitoring of asthma

Self-monitoring by the patient, based on symptoms and/or peak expiratory flow, is an important component of effective asthma self-management.1

For most patients, a daily diary is not necessary. Patients should be trained to take note if their symptoms worsen or their reliever use increases, so they can implement their written asthma action plan and/or get medical care as appropriate.

Internet-based self-management algorithms in which patients adjust their treatment monthly on the basis of control scores have been reported to be more effective than usual care.7 In patients with partly and uncontrolled asthma, weekly self-monitoring and monthly treatment adjustment may improve asthma control.8

Asthma self-management education

Patients need careful asthma education to enable them to manage their asthma effectively.

Education in asthma self-management that involves self-monitoring (by either peak expiratory flow or symptoms), regular medical review and a written action plan improves health outcomes for adults with asthma.1 Training programs that enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.1

Information alone does not appear to improve health outcomes in adults with asthma,  although perceived symptoms may improve.2

Structured group asthma education programs are available in some regions. Contact Asthma Australia in your state or territory for information about available asthma education programs.

Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.9

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from:

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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.3 Written asthma action plans are effective if based on symptoms5 or personal best peak expiratory flow (not on percentage predicted).3

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:

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 plans1011 is available online.

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.1213

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,14, 15, 16, 17, 18 even among regular users.19 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.20

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.14, 21, 19, 22, 23 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.19

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.24, 25

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:20

  • 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:20

  • 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.20 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.26, 14, 27, 28 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.27 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).12, 25

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.24, 14, 15 

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.29

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.30

'Wheeze-detecting' devices

Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio recording and analysis.

There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma control in adults or children, or in distinguishing wheeze from other airway sounds in children.

  • Over-reliance on these devices could result in over- or under-treatment.
Psychosocial factors affecting asthma self-management

Psychosocial factors can affect asthma symptoms and outcomes in children and adults. These can include biological, individual, family and community-level factors, which can have synergistic effects in an individual with asthma.31 Mechanisms may include effects of stress on the immune system31 and effects of life circumstances on patients’ and families’ ability to manage asthma.

Relationships between psychosocial and cultural factors

Important influences on asthma outcomes include the person’s asthma knowledge and beliefs, confidence in ability to self-manage, perceived barriers to healthcare, socioeconomic status, and healthcare system navigation skills, and by the quality of interaction and communication between patient and healthcare provider.32 There is a complex interrelationship between:32

  • patient factors (e.g. health literacy, health beliefs, ethnicity, educational level, social support, cultural beliefs, comorbidities, mental health)
  • healthcare provider factors (e.g. communication skills, teaching abilities, available time, educational resources and skills in working with people from different backgrounds)
  • healthcare system factors (e.g. the complexity of the system, the healthcare delivery model, the degree to which the system is oriented towards chronic disease management or acute care, and the degree to which the system is sensitive to sociocultural needs).

Health literacy

‘Health literacy’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.33 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.32

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.32 Poor health literacy has been associated with poor asthma control,34 poor knowledge of medications,35 and incorrect inhaler technique.35 Aspects of health literacy that have been associated with poorer asthma outcomes in adults include reading skills, listening skills, numeracy skills, and combinations of these.32 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.32 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.32

Australian research suggests that there are probably many Australians with limited health literacy.36 It may be possible to identify some groups of patients more likely to have inadequate health literacy, such as people living in regions with low socioeconomic status, and those with low English literacy (e.g. people with limited education, members of some ethnic minorities, immigrants, and the elderly).32 However, even well-educated patients might have trouble with basic health literacy skills.32

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.32 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.32 Accordingly, all self-management skills need to be explained carefully, simply and repeatedly, and all written material should be clear and easy to read. Special consideration is needed for patients from culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander people.

Psychosocial support and improving health literacy

Psychosocial interventions that include asthma education may improve health-related quality of life for children and adolescents with asthma and their families.37 However, simply providing education might not improve a person’s health literacy, since it also depends on other factors like socioeconomic status, social support, and is influence by the provider and the healthcare system.32

Asthma Australia provides personal support and information for people with asthma and parents of children with asthma through the Asthma Australia Information line by telephone on 1800 Asthma (1800 278 462) or online.



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