Asthma Management Handbook

Providing asthma management education for parents and children

Recommendations

Provide parents (and children, if old enough) with asthma education that includes information about asthma symptoms and signs, asthma medicines, and how to take inhaled medicines correctly.

Table. Childhood asthma education checklist Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/30

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Provide a written asthma action plan for all children with asthma, and train parents (and older children) how to follow it.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Review the child’s written asthma action plan at least yearly and whenever asthma control status changes significantly or medicines are changed or stopped.

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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How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Provide parents of wheezing preschool children with education that includes information on:

  • causes of wheeze
  • when wheezing is clinically significant (i.e. when accompanied by increased work of breathing or severe enough to interrupt eating, play, physical activity or sleep)
  • effective treatment options
  • how to recognise worsening asthma symptoms (a flare-up).
How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Provide training for children and parents on how to use inhaler devices correctly, including inhaler technique and the care and cleaning of devices and spacers. Review technique each time asthma medicines are dispensed or prescribed.

 

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Advise parents that inhaled medications might affect dental health. Advise rinsing and spitting after taking inhaled medicines to minimise local absorption and the risk of oropharyngeal candidiasis (‘thrush’) with inhaled corticosteroids, and possibly reduce the risk of dental caries with inhaled beta2 agonists.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 20101
  • National Asthma Council Australia 20182

Last reviewed version 2.0

Advise parents to ensure children have adequate exposure to sunlight to maintain healthy vitamin D levels, while avoiding excess exposure to UV radiation.

Note: Parents can use the Sunsmart app to determine safe exposure times in their region for different times of year.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Cancer Council Australia3
  • Paxton et al. 20134

Last reviewed version 2.0

More information

Written asthma action plans for children

Every child with asthma should have their own written asthma action plan.

A systematic review found that the use of written asthma action plans significantly reduces the rate of visits to acute care facilities, the number of school days missed and night-time waking, and improves symptoms.5 

For children and adolescents, written asthma action plans that are based on symptoms appear to be more effective than action plans based on peak expiratory flow monitoring.5

A written asthma action plan should include all the following:

  • a list of the child’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on what to do 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)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name and contact details of the child’s emergency contact person (e.g. parent)
  • the name of the person writing the action plan, and the date it was issued.

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)
  • Children’s written asthma action plans.

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans67 is available online.

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Asthma education programs for parents/carers and children

Asthma education for children and/or caregivers reduces the risk of emergency department visit for asthma, compared with usual care.8

However, the most effective components of education have not been clearly identified.89 There have been relatively few Australian controlled trials assessing education programs.9

There is not enough evidence to tell whether asthma education programs in the child’s home are more effective in helping control asthma than asthma education provided somewhere else or standard care,9 or to identify which types of education is more effective.

All age groups

A systematic review10 found that asthma education programs were associated with moderate improvement in lung function and with a small reduction in school absence, restriction of physical activity, and emergency department visits. The greatest effects were in children with more severe asthma.10

Another systematic review found that educational programmes for the self-management of asthma in children and adolescents improved lung function, reduced the number of school days missed and the number of days with restricted activity, reduced the rate of visits to an emergency department, and possibly reduced the number of disturbed nights.11

0-5 years

There is little evidence about the effects of education for parents of preschool-aged children with asthma or wheezing. Most studies have investigated the effects of asthma management education for older children and their parents.12 Limited evidence suggests that:

  • education for parents of preschool children (e.g. written information and review by a health professional, small-group teaching by nurses or education in the family’s home) may help improve asthma control12
  • education programs are more likely to be effective if they involve multiple sessions, each longer than 20 minutes’ duration.12

Opportunistic asthma education

In addition to the types of structured or formal asthma education evaluated in research trials, all health professionals who work with children with asthma and their parents/carers can provide asthma education whenever the opportunity occurs.

Table. Childhood asthma education checklist Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/30

Resources

Education resources are available from the National Asthma Council Australia, Asthma Australia, and the Asthma Foundation in your state or territory.

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Back-to-school asthma care

Each year during February, a few days after the school year starts, there is an annual increase in asthma flare-ups among children with asthma. 

Asthma flare-ups in children, including those resulting in emergency department presentations and hospitalisations, surge during the first month of the school year. 131415, 17 There are smaller increases at the beginning of the other school terms.18 These flare-ups may be due to changes in exposure to virus, allergens, pollution and/or stress during the early days after school return.19

Primary care health professionals can help parents/carers prepare for back-to-school flare-ups by:

  • recommending a full asthma review at the end of the school holidays to check asthma control, adherence to preventer and inhaler technique
  • ensuring that each child has an up-to-date written asthma action plan and the child and/or parents/carers understand how to follow it
  • reminding parents/carers to get their child back into their asthma routine before the school year starts, including taking preventer medications every day, if prescribed

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Increasing the inhaled corticosteroid dose to control flare-ups in children

In children taking regular inhaled corticosteroid-containing preventers, there is conflicting evidence for whether, and by how much, the dose should be increased when symptoms worsen or at the onset of an acute flare-up.

Overall, current evidence from highly controlled randomised controlled trials does not support increasing the dose of inhaled corticosteroid as part of a self-initiated action plan to manage flare-ups in children younger than 12 years.20

There is some evidence that high doses of inhaled steroids used pre-emptively might be effective in preventing severe acute asthma in children aged under 5 years, based on studies in children not taking regular inhaled corticosteroids.21 However, very high pre-emptive doses affect children’s growth22 and are not recommended.

Recent randomised controlled trials reported a lack of effect with a range of dose increases:

  • A five-fold increase in the inhaled corticosteroid dose at early signs of worsening asthma did not reduce the rate of severe acute asthma in children aged 5–11 years with well-controlled asthma while taking maintenance inhaled corticosteroid treatment (with high adherence).23 This strategy was associated with a small reduction in linear growth.23
  • Dose increases of four or eight times usual inhaled corticosteroid maintenance dose at the onset of an acute flare-up in children aged 2–17 years did not reduce requirement for oral corticosteroids, compared with doubling the dose.24

A Cochrane systematic review20 in children and adults reported that increasing the inhaled corticosteroid dose did not prevent severe flare-ups, regardless of how soon the increase was initiated after the onset of symptoms or the magnitude of the dose increase (doubling versus quadrupling). The results did not differ between children under 15 and adults or older adolescents.20 However, there were too few studies in children to make firm conclusions.

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Parent/carer-initiated oral corticosteroids for wheezing and asthma flare-ups
  • Oral corticosteroids are associated with adverse effects on behaviour and bone health. Frequent courses may affect the hypothalamus–pituitary–adrenal axis.

Children aged 1–5 years

Short courses of oral corticosteroids initiated by parents/carers in response to children’s wheezing, or at the first sign of a cold, are not effective in managing symptoms in preschool children.25, 2627

There is inconsistent evidence for the benefits of systemic corticosteroids in preschool children with acute viral-induced wheezing presenting to acute care services.272829 Current evidence does not strongly support their use in this age group.30

The Thoracic Society of Australia and New Zealand position statement on the use of corticosteroids in children1 recommends that oral corticosteroid treatment in preschool children, particularly those with intermittent viral-induced wheezing, should be limited to children with wheeze severe enough to need admission to hospital.

Children aged 6 years and over

A Cochrane systematic review found that there was insufficient evidence supporting the use of parent-initiated courses of oral corticosteroids in school-aged children,31 although some clinical trials have reported benefits.

In a clinical trial in children aged 6–14 years with a history of recurrent episodes of acute asthma, short courses of oral prednisolone (1 mg/kg a day), initiated by parents in response to an asthma flare-ups, reduced asthma symptoms and the number of missed school days.32 Another quasi-experimental study found that home initiation of corticosteroids reduced the rate of emergency department visits among school-aged children with moderate-to-severe persistent asthma, compared with rates pre-intervention.33

The Thoracic Society of Australia and New Zealand position statement on the use of corticosteroids in children1 recommends a short course of systemic corticosteroid therapy for children with moderate-to-severe acute asthma or when there is an incomplete response to beta-agonists, and does not recommend against parent/carer-initiated courses.

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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,34, 35,3636, 37 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.34, 35, 38, 39, 40, 41

Poor asthma symptom control is often due to incorrect inhaler technique.42, 43

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.

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References

  1. van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: https://www.thoracic.org.au/journal-publishing/command/download_file/id/25/filename/The_role_of_corticosteroids_in_the_management_of_childhood_asthma_-_2010.pdf
  2. National Asthma Council Australia,. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. NACA, Melbourne, 2018. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  3. Cancer Council Australia,, Position statement - Sun exposure and vitamin D - risks and benefits. **, . Available from: https://wiki.cancer.org.au/policy/Positionstatement-Risksandbenefitsofsunexposure
  4. Paxton, G. A., Teale, G. R., Nowson, C. A., et al. Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: a position statement. Med J Aust. 2013; 198: 142-3. Available from: https://www.mja.com.au/journal/2013/198/3/vitamin-d-and-health-pregnancy-infants-children-and-adolescents-australia-and
  5. Zemek RL, Bhogal S, Ducharme FM. Systematic Review of Randomized Controlled Trials Examining Written Action Plans in Children - What Is the Plan?. Arch Pediatr Adolesc Med. 2008; 162: 157-63. Available from: http://archpedi.jamanetwork.com/article.aspx?articleid=379087#tab1
  6. Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
  7. Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
  8. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008; 121: 575-86. Available from: http://pediatrics.aappublications.org/content/121/3/575.long
  9. Welsh EJ, Hasan M, Li P. Home-based educational interventions for children with asthma. Cochrane Database Syst Rev. 2011; Issue 10: CD008469. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008469.pub2/full
  10. Wolf F, Guevara JP, Grum CM, et al. Educational interventions for asthma in children. Cochrane Database Syst Rev. 2002; Issue 4: CD000326. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000326/full
  11. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003; 326: 1308-1309. Available from: http://www.bmj.com/content/326/7402/1308
  12. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  13. Johnston NW, Johnston SL, Duncan JM et al. The September epidemic of asthma exacerbations in children: a search for etiology. J Allergy Clin Immunol 2005; 115: 132-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15637559
  14. Sears MR, Johnston NW. Understanding the September asthma epidemic. J Allergy Clin Immunol 2007; 120: 526-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17658590
  15. Eggo RM, Scott JG, Galvani AP, Meyers LA. Respiratory virus transmission dynamics determine timing of asthma exacerbation peaks: Evidence from a population-level model. Proc Natl Acad Sci U S A 2016; 113: 2194-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26858436
  16. Ahmet, A, Kim, H, Spier, S. Adrenal suppression: A practical guide to the screening and management of this under-recognized complication of inhaled corticosteroid therapy. Allergy Asthma Clin Immunol. 2011; 7: 13.
  17. Australian Institute of Health and Welfare. Asthma hospitalisations in Australia 2010-11. Australian Institute of Health and Welfare, Canberra, 2013. Available from: http://www.aihw.gov.au/publication-detail/?id=60129544541
  18. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Asthma series no. 4. Cat. no ACM 22. Australian Institute of Health and Welfare, Canberra, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159
  19. Tovey ER, Rawlinson WD. A modern miasma hypothesis and back-to-school asthma exacerbations. Med Hypotheses 2011; 76: 113-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20869177
  20. Kew KM, Quinn M, Quon BS, Ducharme FM. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev 2016; Issue 6: CD007524. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27272563
  21. Kaiser SV, Huynh T, Bacharier LB et al. Preventing exacerbations in preschoolers with recurrent wheeze: a meta-analysis. Pediatrics 2016; 137: Available from: https://www.ncbi.nlm.nih.gov/pubmed/27230765
  22. Ducharme FM, Lemire C, Noya FJ, et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med. 2009; 360: 339-353. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0808907#t=article
  23. Jackson DJ, Bacharier LB, Mauger DT et al. Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations. N Engl J Med 2018; 378: 891-901. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29504498
  24. Yousef, E., Hossain, J., Mannan, S., et al. Early intervention with high-dose inhaled corticosteroids for control of acute asthma exacerbations at home and improved outcomes: a randomized controlled trial. Allergy Asthma Proc. 2012; 33: 508-13. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23394509
  25. Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing?. J Allergy Clin Immunol. 2013; 131: 1518-1525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23498594
  26. Oommen A, Lambert PC, Grigg J. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet. 2003; 362: 1433-1438. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14685-5/fulltext
  27. Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009; 360: 329-328. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19164186
  28. Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2018; 6: 97-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29373235
  29. Therapeutic guidelines [Electronic book]: Therapeutic Guidelines Limited; 2018 [cited 2018 April].
  30. Castro-Rodriguez JA, Beckhaus AA, Forno E. Efficacy of oral corticosteroids in the treatment of acute wheezing episodes in asthmatic preschoolers: Systematic review with meta-analysis. Pediatric pulmonology 2016; 51: 868-76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27074244
  31. Ganaie MB, Munavvar M, Gordon M et al. Patient- and parent-initiated oral steroids for asthma exacerbations. Cochrane Database Syst Rev 2016; 12: Cd012195. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27943237
  32. Vuillermin P, Robertson CF, Carlin JB, et al. Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial. BMJ. 2010; 340: c843. Available from: http://www.bmj.com/content/340/bmj.c843.long
  33. Sarzynski LM, Turner T, Stukus DR, Allen E. Home supply of emergency oral steroids and reduction in asthma healthcare utilization. Pediatr Pulmonol 2017; 52: 1546-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29034999
  34. 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: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  35. 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
  36. 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: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  37. 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
  38. 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
  39. 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: https://www.ncbi.nlm.nih.gov/pubmed/27098045
  40. 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
  41. 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
  42. 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.
  43. 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: http://www.nature.com/articles/pcrj201088