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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Is it asthma, COPD or both?

The main symptoms of chronic obstructive pulmonary disease (COPD) are breathlessness, cough and sputum production. Chest tightness, wheezing and airway irritability are also common. Patients often attribute breathlessness to ageing or poor cardiopulmonary fitness.28

The definitions of asthma and COPD overlap, and asthma and COPD frequently coexist in people aged 65 years and over.31 Comorbid COPD is often misdiagnosed as asthma in older people,31  and vice versa.

For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.32

The Global Initiative for Asthma (GINA) and Global Initiative Obstructive Lung Disease (GOLD) recommend the following stepwise approach for adults presenting with respiratory symptoms:33

  1. Identify whether the patient has clinical features of, or is at risk of, chronic airway disease. This may be suggested by the clinical history and physical examination.
  2. Identify features that favour a diagnosis of typical asthma or typical COPD. If several features of both are present, asthma-COPD overlap is likely.
  3. Perform spirometry to confirm airflow limitation.
  4. Start treatment, selected according to whether the assessment favoured the single diagnosis of asthma, the single diagnosis of COPD, or asthma-COPD overlap.
  5. Refer for specialist assessment and other investigations, if necessary.

 

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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
  25. Shepherd CC, Li J, Zubrick SR. Socioeconomic disparities in physical health among Aboriginal and Torres Strait Islander children in Western Australia. Ethn Health. 2012; 17: 439-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22292856
  26. O'Grady KA, Revell A, Maguire GP, et al. Lung health care for Aboriginal and Torres Strait Islander Queenslanders: breathing easy is not so easy. Aust Health Rev. 2011; 35: 512-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22126958
  27. O’Grady KF, Revell A, Maguire G, et al. Lung Health Services for Aboriginal and Torres Strait Islander Peoples in Queensland. Queensland Health, Brisbane, 2010. Available from: http://www.lungfoundation.com.au/professional-resources/publications/
  28. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  29. Chang AB, Redding GJ, Everard ML. Chronic wet cough: Protracted bronchitis, chronic suppurative lung disease and bronchiectasis. Pediatr Pulmonol. 2008; 43: 519-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18435475
  30. Australian Government Department of Health. Closing the Gap: Tackling Indigenous Chronic Disease Package. Australian Government, Canberra, 2012. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/work-ab-gap
  31. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816547
  32. Abramson M, Frith P, Yang I, et al. COPD-X Concise Guide for Primary Care. Lung Foundation Australia, Brisbane, 2016. Available from: http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/
  33. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2016. Available from: http://ginasthma.org/