Asthma Management Handbook

Diagnosing and assessing asthma in Aboriginal and Torres Strait Islander people

Recommendations

Ask all patients whether they smoke or are exposed to other people’s tobacco smoke.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111

For all Aboriginal and Torres Strait Islander adults and children, take a comprehensive respiratory health history.

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):

  • Chang et al. 20102

For Aboriginal and Torres Strait Islander children and adults, routinely ask about coughing (frequency and type), and carefully observe for cough, even if parents or carers do not mention cough.

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):

  • Morey et al. 20133

When cough is present (especially wet or productive cough), consider the possibility of other chronic lung disease (e.g. bronchiectasis, chronic suppurative lung disease and COPD) as an alternative or coexisting diagnosis in Aboriginal and Torres Strait Islander adults and children with respiratory symptoms.

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):

  • Chang et al. 20034
  • Chang et al. 20085
  • Chang et al. 20126
  • Craven and Everard, 20137

In Aboriginal and Torres Strait Islander adults in whom bronchiectasis cannot be ruled out, arrange high-resolution computed tomography and offer referral to a specialist if possible.

How this recommendation was developed

Adapted from existing guidance

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

  • Chang et al. 20085

In children with symptoms and signs that suggest chronic suppurative lung disease, offer referral to a specialist if possible.

How this recommendation was developed

Adapted from existing guidance

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

  • Chang et al. 20085

Consider and investigate any other comorbid conditions (e.g. diabetes, cardiovascular disease, kidney disease, ear problems).

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):

  • Australian Institute of Health and Welfare, 20138

Include a thorough respiratory check-up when performing a Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715).

How this recommendation was developed

Adapted from existing guidance

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

  • National Aboriginal Community Controlled Health Organisation and Royal Australian College of General Practitioners, 20129

More information

Culturally secure asthma care for Aboriginal and Torres Strait Islander people

Primary care services can aim to deliver healthcare that is culturally secure. However, only the Aboriginal or Torres Strait Islander person themselves can determine whether their care is culturally safe or respectful.10

Making the healthcare system a secure environment for Aboriginal and Torres Strait Islander peoples involves cultural respect, which involves not only respecting cultural difference but recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples.11

Cultural awareness (or ‘cultural sensitivity’) among individual health professionals involves sensitivity to the similarities and differences between different cultures to enable effective communication with members of another cultural group.12

Training in cultural awareness and  ‘cultural safety’ is available for non-Indigenous health professionals who provide healthcare for Aboriginal and Torres Strait Islander people.

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Involvement of Aboriginal and/or Torres Strait Islander health workers and health practitioners in asthma care

Aboriginal and Torres Strait Islander health workers and Aboriginal and Torres Strait Islander health practitioners can provide self-management education for people with asthma and parents of children with asthma. Culture-specific programs may be more appropriate than mainstream programs for Aboriginal and Torres Strait Islander people.13

An education program (three sessions) conducted by Aboriginal and Torres Strait Islander health workers in primary health care in  the Torres Strait region reduced the number of school days missed due to wheezing among school-aged children, and increased carers’ knowledge of asthma, the contents of the child’s written asthma action plan, and where the written asthma action plan was kept.14 However, it did not reduce the rate of asthma flare-ups, compared with children whose families did not participate.14

Aboriginal and Torres Strait Islander health workers and practitioners can provide health care services that are reimbursable through Medicare.1516

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Asthma prevalence in Aboriginal and Torres Strait Islander people

Asthma prevalence is higher among Aboriginal and Torres Strait Islander people than non-Indigenous Australians, based on the findings of various surveys.81718, 19

Based on data from the 2004–2005 National Aboriginal and Torres Strait Islander Health Survey and the Australian Centre for Asthma Monitoring:

  • The estimated overall asthma prevalence in Aboriginal and Torres Strait Islander people is 16.5%, compared with 10.2% among non-Indigenous Australians.19
  • The estimated asthma prevalence in Aboriginal and Torres Strait Islander adults (aged 18 years and over) is 17.5%, compared with 9.8% among non-Indigenous adults. 19
  • The estimated asthma prevalence rates are similar in Aboriginal and Torres Strait Islander children (13.5%) and non-Indigenous children (11.2%).19

Fewer Aboriginal and Torres Strait Islander people living in remote areas (9%) report that they have asthma than those living in non-remote areas (17%).17 Torres Strait Islander people living in the Torres Strait Island region report a relatively low prevalence of asthma (5%).17

The rate of hospitalisation for asthma is approximately twice as high among Aboriginal and Torres Strait Islander people, compared with other Australians.20

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Risk factors for asthma in Aboriginal and Torres Strait Islander people

Compared with the whole Australian population, Aboriginal and Torres Strait Islander people have higher rates of some risk factors for developing asthma or for poor asthma control.

Smoking and smoke

Rates of tobacco smoking are high among Aboriginal and Torres Strait Islander people:8212223

  • Approximately 45% of Aboriginal and Torres Strait Islander people aged 15 years and over smoke daily (more than twice the rate among non-Indigenous Australians).
  • Approximately half of Aboriginal and Torres Strait Islander mothers smoked during pregnancy (3.7 times the rate among non-Indigenous mothers).
  • Approximately 65% of Aboriginal and Torres Strait Islander children live households with someone who smokes daily (approximately twice the rate among non-Indigenous children).

Many Aboriginal people are also frequently exposed to smoke from outdoor vegetation fires and cooking fires, particularly in remote regions.

Allergies

Limited available data suggest that sensitisation to house dust mite is increasing among rural and remote Aboriginal communities, correlating with adoption of urban lifestyles.24

Factors contributing to an increase in allergic disease may include dietary changes and reductions in parasitic infestation and exposure to some bacteria.24

Dietary factors

Low fruit and vegetables intakes are more common among Aboriginal and Torres Strait Islander people than non-Indigenous Australians.8

Increasing intake of pro-inflammatory fats and low intake of antioxidant-rich fruits and vegetables may be contributing to an increase in allergic asthma among Aboriginal and Torres Strait Islander people.24

Obesity

The rate of obesity among Aboriginal and Torres Strait Islander adults (approximately 34%) is almost twice the rate in non-Indigenous adults (approximately 18%).8

Among Aboriginal and Torres Strait Islander people aged 18 years and over living in non-remote areas, rates of overweight and obesity increased between 1995 (51%) and 2004–05 (60%).8

Socioeconomic risk factors

Traditional markers of socioeconomic status (e.g. education, income and employment status) are not strongly associated with asthma risk among Aboriginal and Torres Strait Islander peoples,18 unlike the associations between socioeconomic status and asthma risk in non-Indigenous Australians, and the risk of other chronic diseases such as diabetes and kidney disease in Aboriginal and Torres Strait Islander people.18

In the 2000–2002 Western Australian Aboriginal Child Health Survey, Aboriginal children aged 0–17 years living in areas with highest socioeconomic status were more than nine times more likely to have ever had asthma than those living in the lowest socioeconomic status areas.25 However, when socioeconomic status was measured by parental, family and household indicators rather than by area, it was less strongly association with asthma.25

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Respiratory disease in Aboriginal and Torres Strait Islander peoples

Morbidity and mortality from respiratory diseases among Aboriginal and Torres Strait Islander people is higher than among non-Indigenous Australians across all age groups and regions.26 Among Aboriginal and Torres Strait Islander people living in remote areas, the rate of hospitalisation for respiratory disease is approximately three times the rate among Aboriginal and Torres Strait Islander people living in major cities.17 However, from 1997 to 2010 there was a 39% reduction in deaths due to respiratory disease among Aboriginal and Torres Strait Islander people.8

Detection, diagnosis and management of asthma may be complicated by increased rate of respiratory infections and chronic lung disease in rural remote Aboriginal and Torres Strait Islander communities.

  • Approximately 30% of Aboriginal and Torres Strait Islander people report respiratory problems.5
  • Chronic cough in Aboriginal and Torres Strait Islander children may be under-reported because it is so common that is considered normal by parents and caregivers.3
  • Pneumonia and COPD are the most common causes of hospitalisation for respiratory disease among Aboriginal and Torres Strait Islander people.17 The prevalence of COPD among Aboriginal and Torres Strait Islander people cannot be accurately estimated.27 The rate of death due to COPD among Aboriginal and Torres Strait Islander people is five times the rate among non-Indigenous Australians.28
  • The prevalence of bronchiectasis is disproportionately high in remote Aboriginal communities, particularly in Central Australia, but is underdiagnosed.54 High-resolution computed tomography of the chest is necessary to diagnose bronchiectasis in adults.5 In Aboriginal and Torres Strait Islander adults, it may be difficult to distinguish between asthma, COPD and bronchiectasis.27 Bronchiectasis is associated with relatively rapid decline in lung function.5 
  • Chronic suppurative lung disease is highly prevalent among Aboriginal and Torres Strait Islander children in remote communities.5 The diagnosis of chronic suppurative lung disease is made in children who have symptoms and signs of bronchiectasis without radiographic features of bronchiectasis.5 In Aboriginal and Torres Strait Islander children, it may be difficult to distinguish between asthma and bronchiectasis or chronic suppurative lung disease.27 
  • Protracted bacterial bronchitis is often misdiagnosed as asthma,7, 29 but can also co-occur with asthma.29 Protracted bacterial bronchitis might precede chronic suppurative lung disease, but this is not yet well understood.29 Inadequate treatment of protracted bacterial bronchitis might put Aboriginal and Torres Strait Islander children at risk for chronic suppurative lung disease.29 Recurrent episodes of protracted bacterial bronchitis that does not resolve after treatment (e.g. a 14-day course of antibiotics) require investigation for chronic suppurative lung disease, bronchiectasis and aspiration.29

Notes

† Chronic suppurative lung disease is defined as a clinical syndrome of respiratory symptoms and signs due to chronic endobronchial suppuration, including continuous, wet or productive cough > 8 weeks, with or without other features (e.g. exertional dyspnoea, symptoms of reactive airway disease, recurrent chest infections, growth failure, clubbing, hyperinflation or chest wall deformity).2

‡ Bronchiectasis is diagnosed in patients with both chronic suppurative lung disease and the presence of radiological features on a chest high-resolution computed tomography scan.2

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Non-respiratory comorbidity among Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples have a high burden of chronic diseases that may affect asthma control and management, including:8

  • diabetes
  • cardiovascular disease
  • kidney disease
  • ear disease
  • mental health problems.
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Australian government health initiatives for Aboriginal and Torres Strait Islander people

Asthma Spacer Ordering System

The Asthma Spacer Ordering System provides Aboriginal and Torres Strait Islander health services with access to low cost asthma spacers for their clients.

Health Assessment Medicare items

The MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715) reimburses health professionals for health assessments for (any of):16

  • Aboriginal and Torres Strait Islander children (<15 years)
  • Aboriginal and Torres Strait Islander adults (≥15 years and < 55 years)
  • Aboriginal and Torres Strait Islander older people (≥ 55 years).

This item is linked to follow-on item numbers to support follow-up care by allied health professionals and Aboriginal/Torres Strait health workers and practitioners to manage asthma and comorbid conditions.

The Indigenous Chronic Disease Package

The Indigenous Chronic Disease Package provides a range of supports to Aboriginal and Torres Strait Islander people with chronic disease or at risk of chronic disease. The package includes:30

  • subsidy of PBS medicines (reduced copayments for Aboriginal and Torres Strait Islander people with chronic disease)
  • orientation and training for Aboriginal and Torres Strait Islander Outreach Workers in Aboriginal community-controlled general practices
  • professional development scholarships and clinical placement scholarships for nurses working in Community Controlled Aboriginal/Torres Strait Island Health Services
  • general practitioner registrar training posts for Aboriginal Medical Services
  • Practice Incentives Program Indigenous Health Incentive to support general practices and Indigenous health services to provide care for people with chronic disease
  • increased access to specialist medical and allied health care
  • GPs can access these services to overcome barriers to health care for Aboriginal and Torres Strait Islander people. 

National immunisation program

Additional vaccinations are recommended and reimbursed for Aboriginal and Torres Strait Islander people.  Refer to national guidelines.

Other resources

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Asthma–COPD overlap

Distinguishing between typical allergic asthma (childhood-onset allergic asthma) and typical COPD (emphysema in a heavy smoker) is straightforward.31 However, it can be difficult to distinguish COPD from asthma in adults who have features of both conditions.32, 33These people are described as having asthma–COPD overlap.32, 31, 34

Asthma–COPD overlap is not a single, well-defined disease entity, but includes a range of airway disease phenotypes with different causal mechanisms.32, 35 Features of both asthma and COPD have been described in:34, 36, 37, 38

  • people with current asthma (allergic or non-allergic) who have had significant exposure to tobacco smoke
  • people with longstanding asthma or late-onset asthma who have become persistently short of breath over time
  • people significant smoking history and symptoms consistent with COPD who also have a history of childhood asthma
  • people who present in middle age or later with shortness of breath, with a history of childhood asthma but no or few symptoms in between, and little smoking history.

Figure. Development of asthma, COPD and asthma–COPD overlap Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/108

People with asthma–COPD overlap often have poor disease outcomes, including:32, 38, 39, 40, 41, 42

  • high need for healthcare services
  • worse quality of life, more wheezing, dyspnoea, cough and sputum production, and more frequent and severe respiratory exacerbations and hospitalisations, than people with COPD or asthma alone
  • worse lung function demonstrated by spirometry than those with COPD alone, despite lower average exposure to tobacco smoke.

Features of asthma, COPD and asthma–COPD overlap

If several features of both asthma and COPD are present and neither condition is strongly favoured, respiratory disease should be managed according to recommendations for asthma–COPD overlap.

Table. Features that, when present, favour asthma or COPD

Clinical feature (if measured/relevant)

Asthma more likely

COPD more likely

Age of onset

Before 20 After 40

Pattern of symptoms

Variation in respiratory symptoms:

  • changes over minutes, hours or days
  • worse at night or early morning
  • triggered by exercise, emotions, airborne pollutants or allergens

Persistence of respiratory symptoms despite treatment

Symptoms every day, including exertional dyspnoea

History of chronic cough and sputum unrelated to specific triggers, before onset of dyspnoea

Lung function

Expiratory airflow limitation* is variable#

Lung function normal between symptoms

Expiratory airflow limitation* is persistent

Lung function abnormal between symptoms

History

Previous diagnosis of asthma

Family history of asthma and allergies§ (allergic rhinitis or eczema)

Previous diagnosis of COPD, chronic bronchitis or emphysema

Heavy exposure to tobacco smoke or biomass fuels

Long-term disease trajectory

Seasonal or yearly variation in symptoms

Improvements (spontaneously or in response to medication) last for weeks

Slowly worsens over years

Relief in response to medication is limited and short term

Chest X-ray

Normal Severe hyperinflation

Features that, when present, increase the probability of either typical asthma or typical COPD. None of these features is essential to make the diagnosis of asthma or COPD, with the exception of persistent airflow limitation for making the diagnosis of COPD.

* Expiratory airflow limitation: indicated by a reduced ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) on spirometry (FEV1/FVC less than the lower limit of normal (i.e. less than the 5th percentile of normal population). Typical FEV1/FVC values derived from population studies are > 0.75 in people aged 40–59 years and > 0.70 in people aged 60–80 years.

# Variable expiratory airflow limitation: variation beyond the range seen in healthy populations. It is indicated in adults by any of the following:

  • a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline) 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 increase in lung function (at least 200 mL and 12% from baseline) after ≥ 4 weeks’ treatment trial with an ICS
  • clinically important variation in peak expiratory flow (diurnal variability of more than 10%, calculated over 1–2 weeks as the average of daily amplitude per cent mean)
  • 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 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.

The greater the variations, or the more occasions excess variation is seen, the more confidently the diagnosis of variable expiratory airflow limitation consistent with asthma can be made.

† Persistent expiratory airflow limitation is indicated by reduced post-bronchodilator FEV1/FVC*

§ Lack of history of atopy does not exclude non-allergic asthma.

‡ Chest X-ray may be normal in a patient with COPD

Adapted from

Global Initiative for Asthma, Global Initiative for Obstructive Lung Disease. Diagnosis and initial treatment of asthma, COPD and asthma-COPD overlap. Updated April 2017. Global Initiative for Asthma and Global Initiative for Obstructive Lung Disease; 2017. Available from: http://ginasthma.org/gina-reports

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Table. Spirometry findings in asthma, COPD and asthma–COPD overlap

Finding

Consistent with

Asthma COPD Asthma–COPD overlap

Normal FEV1 /FVC before of after bronchodilator

  Yes   No   No *

Abnormal lung function

(post-bronchodilator reduced FEV1/FVC and FEV1 < lower limit of normal)

  Yes #   Yes   Yes

Airflow limitation with greater bronchodilator reversibility than in healthy population

(post-bronchodilator FEV1 increase ≥ 12% and 200mL from baseline)

  Yes   Yes   Yes

Marked bronchodilator reversibility

(FEV1 increase ≥ 12% and 400mL from baseline)

  Yes   Possible but unusual   Possible §

FEV1/FVC: ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC), either before or after bronchodilator

* Normal FEV1/FVC is not consistent with COPD unless there is other evidence of chronic non-reversible expiratory airflow limitation.

# This finding is consistent with asthma that is poorly controlled or measured during a flare-up, or can be seen in some patients with longstanding asthma.

‡ The greater the variation, and the more times variation is seen, the more likely the diagnosis of asthma. However, some patients with longstanding asthma may develop persistent airflow limitation.

† Marked reversibility strongly favours asthma and is generally inconsistent with COPD, but does not rule out asthma–COPD overlap.

§ This finding may be seen in patients with asthma–COPD overlap, or occasionally in COPD, especially when FEV1 is low.

Sources

Global Initiative for Asthma, Global Initiative for Obstructive Lung Disease. Diagnosis and initial treatment of asthma, COPD and asthma-COPD overlap. Updated April 2017. Global Initiative for Asthma and Global Initiative for Obstructive Lung Disease; 2017. Available from: http://ginasthma.org/gina-reports

Woodruff P, van den Berge M, Boucher R et al. ATS-NHLBI Asthma COPD Overlap (ACO) Workshop Report. Am J Respir Crit Care Med 2017; 196:375-381. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28636425

 

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Treatment for patients with asthma–COPD overlap

Inhaled corticosteroid treatment at low–moderate doses is essential to reduce the risk of potentially life-threatening flare-ups, even if asthma symptoms appear mild or infrequent.32, 43

Most patients also need treatment with a long-acting bronchodilator (either long-acting beta2 agonist or long-acting muscarinic antagonist) in addition to an inhaled corticosteroid. Long-acting beta2 agonists and long-acting muscarinic antagonists should not be used by people with asthma or asthma–COPD overlap unless they are also taking an inhaled corticosteroid (either in combination or separately).

Table. Long-acting bronchodilators for asthma–COPD overlap

Class

Dosing frequency

Agent

Brand name

ICS–LABA combinations

Once daily

Fluticasone furoate + vilanterol

Breo Ellipta#

Twice daily

Budesonide + formoterol

Symbicort Rapihaler

Symbicort Turbuhaler

Twice daily

Fluticasone propionate + formoterol

Flutiform

Twice daily

Fluticasone propionate + salmeterol

Fluticasone and Salmeterol Cipla

Seretide Accuhaler

Seretide MDI

LABAs*

Once daily

Indacaterol

Onbrez Breezhaler

Twice daily Formoterol

Oxis

Foradile

Twice daily Salmeterol

Serevent Accuhaler

LAMAs* Once daily Glycopyrronium

Seebri Breezhaler

Once daily

Tiotropium

Spiriva

Spiriva Respimat

Once daily

Umeclidinium

Incruse Ellipta

Twice daily Aclidinium

Bretaris Genuair

LABA–LAMA combinations*

Once daily

Indacaterol + glycopyrronium

Ultibro Breezhaler

Once daily

Olodaterol + tiotropium

Spiolto Respimat

Once daily

Vilanterol + umeclidinium

Anoro Ellipta

Twice daily

Formoterol + aclidinium

Brimica Genuair

  • * Ensure that patient is also using regular long-term ICS. LABAs and LAMAs should not be used by people with asthma or asthma–COPD overlap unless they are also taking an ICS, in combination or separately)

# Only the 100/25 mcg dose of fluticasone furoate/vilanterol is TGA-approved for treatment of COPD. The higher dose (200/25 mcg) is not TGA-approved for the treatment of COPD, so it should not be used in people with asthma–COPD overlap.

High doses of ICS (alone or in combination) are not recommended in patients with COPD and should therefore be used with caution in patients with asthma-COPD overlap, because of the risk of pneumonia.

Refer to PBS status before prescribing.

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Management should also include smoking cessation, treatment of comorbid conditions, physical activity, pulmonary rehabilitation, vaccinations, self-management (including a regularly updated action plan) and regular follow-up.32

Respiratory tract infections should be monitored carefully because people with asthma–COPD overlap have high morbidity rates and because ICS treatment is associated with increased risk of non-fatal pneumonia in people with COPD.44 Most of the available evidence is from patients treated with fluticasone propionate, particularly at higher doses. Increased pneumonia rates have also been observed in studies of patients with COPD using fluticasone furoate/vilanterol. The higher dose of fluticasone furoate/vilanterol (Breo Ellipta 200/25 mcg) is not approved for patients with COPD, so it should also not be used in patients with asthma–COPD overlap.

Specialist referral should be considered for patients with atypical symptoms or symptoms that suggest an alternative diagnosis, persistent symptoms or flare-ups despite treatment, or complex comorbidities.

For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.45

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References

  1. Zwar N, Richmond R, Borland R, et al. Supporting smoking cessation: a guide for health professionals. Updated 2012. The Royal Australian College of General Practitioners (RACGP), Melbourne, 2011. Available from: http://www.racgp.org.au/your-practice/guidelines/
  2. Chang AB, Bell SC, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. Med J Aust. 2010; 193: 356-65. Available from: https://www.mja.com.au/journal/2010/193/6/chronic-suppurative-lung-disease-and-bronchiectasis-children-and-adults-australia
  3. Morey MJ, Cheng AC, McCallum GB, Chang AB. Accuracy of cough reporting by carers of Indigenous children. J Paediatr Child Health. 2013; 49: E199-203. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23438209
  4. Chang AB, Masel JP, Boyce NC, et al. Non-CF bronchiectasis: clinical and HRCT evaluation. Pediatr Pulmonol. 2003; 35: 477-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12746947
  5. Chang AB, Grimwood K, Maguire G, et al. Management of bronchiectasis and chronic suppurative lung disease in indigenous children and adults from rural and remote Australian communities. Med J Aust. 2008; 189: 386-93. Available from: https://www.mja.com.au/journal/2008/189/7/management-bronchiectasis-and-chronic-suppurative-lung-disease-indigenous
  6. Chang AB, Robertson CF, Van Asperen PP, et al. A multicenter study on chronic cough in children : burden and etiologies based on a standardized management pathway. Chest. 2012; 142: 943-50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22459773
  7. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23175647
  8. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detail analysis. Australian Institute of Health and Welfare, Canberra, 2013. Available from: http://www.aihw.gov.au/publication-detail/?id=60129543821&tab=2
  9. National Aboriginal Community Controlled Health Organisation, Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 2nd edn. Royal Australian College of General Practitioners, Melbourne, 2012. Available from: http://www.naccho.org.au/promote-health/national-guide-to-a-preventive-health-assessment/
  10. National Aboriginal Community Controlled Health Organisation. Creating the NACCHO Cultural Safety Training Standards and Assessment process. A background paper. National Aboriginal Community Controlled Health Organisation, Canberra, 2011. Available from: http://www.naccho.org.au/promote-health/cultural-safety/
  11. Australian Health Ministers' Advisory Council Standing Committee for Aboriginal and Torres Strait Islander Health Working Party. Cultural respect framework for Aboriginal and Torres Strait Islander health, 2004 -2009. Department of Health South Australia, Adelaide, 2004. Available from: http://www.sapo.org.au/pub/pub2142.html
  12. Thomson N. Cultural respect and related concepts: a brief summary of the literature. Australian Indigenous Health Bulletin. 2005; 5: 1-11. Available from: http://archive.healthinfonet.ecu.edu.au/html/htmlbulletin/bull54/reviews/bulletinreviewsthomson.htm
  13. Bailey EJ, Cates CJ, Kruske SG, et al. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev. 2009; Issue 2: CD006580. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006580.pub4/full
  14. Valery PC, Masters IB, Taylor B, et al. An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: a randomised controlled trial. Med J Aust. 2010; 192: 574-9. Available from: https://www.mja.com.au/journal/2010/192/10/education-intervention-childhood-asthma-aboriginal-and-torres-strait-islander
  15. Australian Government Department of Health. Chronic Disease Management (CDM) Medicare Items. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement
  16. Australian Government Department of Health and Ageing. Medicare Health Assessment for Aboriginal and Torres Strait Islander People. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycareATSIMBSitem715
  17. MacRae A, Thomson N, Anomie, et al. Overview of Australian Indigenous health status. Perth, 2012. Available from: http://www.healthinfonet.ecu.edu.au/health-facts/overviews
  18. Cunningham J. Socioeconomic status and self-reported asthma in Indigenous and non-Indigenous Australian adults aged 18-64 years: analysis of national survey data. Int J Equity Health. 2010; 9: 1 - 11. Available from: http://www.equityhealthj.com/content/9/1/18
  19. 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
  20. 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
  21. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, 2008. Cat. no. 4714.0. Australian Bureau of Statistics, Canberra, 2009. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0/
  22. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey 2004-05. Cat. no. 4715.0. Australian Bureau of Statistics, Canberra, 2006. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4715.0
  23. Australian Bureau of Statistics (ABS), Australian Institute of Health and Welfare (AIHW). The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2008. ABS and AIHW, Canberra, 2008. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468085
  24. Walton SF, Weir C. The interplay between diet and emerging allergy: what can we learn from Indigenous Australians?. Int Rev Immunol. 2012; 31: 184-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22587020
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