Asthma Management Handbook
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Table. Australian Asthma Handbook sections fully revised at Version 2.0

Managing acute asthma in clinical settings

Managing asthma in children

Management challenges

Severe asthma in adults and adolescents

Primary prevention of asthma

 

Section: Managing acute asthma in clinical settings

Topic

Change

Rationale

Key differences from V1.3

Infants < 12 months

New advice: Wheezing infants younger than 12 months old should not be treated for acute asthma. Acute wheezing in this age group is most commonly due to acute viral bronchiolitis.

Replaces V1.3 statement: In children under 12 months old, asthma is less likely to be the cause of wheezing than other conditions (e.g. bronchiolitis, pneumonia)

New recommendation: Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant.

Replacement of age category 0–5 years with 1–5 years.

To avoid potential harm due to inappropriate treatment in infants under 12 months

Ipratropium bromide

New recommendation for routine use of ipratropium in addition to salbutamol for patients with severe or life-threatening acute asthma

Supported by current clinical evidence

Prednisolone in children

Loading doses no longer recommended. Recommended dose: 1 mg/kg (maximum 50 mg) orally each morning for 3 days

Replaces V1.3 recommendation of a single starting dose of 2 mg/kg (maximum 50 mg) orally, then 1 mg/kg each morning for 2 days (total 3 days)

To reduce systemic corticosteroid exposure in children; conventional loading doses not well supported by current clinical evidence

Oral dexamethasone

New recommendation for oral dexamethasone as an alternative to oral prednisolone in adults and children.

Supported by current clinical evidence, well tolerated and can avoid need to dispense corticosteroids

Parenteral systemic corticosteroid doses

Loading doses no longer recommended for hydrocortisone and methylprednisolone in children. Recommended doses:

  • hydrocortisone IV 4 mg/kg (maximum 100 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone
  • methylprednisolone IV 1 mg/kg (maximum 60 mg) every 6 hours on day 1 then reduce (every 12 hours on day 2, once daily on day 3 and, if needed, once daily on days 4–5) or switch to oral prednisolone.

Replaces V1.3 recommendation for hydrocortisone IV initial dose 8–10 mg/kg (maximum 300 mg) or methylprednisolone IV initial dose 2 mg/kg (maximum 60 mg)

To reduce systemic corticosteroid exposure in children; conventional loading doses not well supported by current clinical evidence

Hospital admission

Revision of criteria for admission to include risk factors for poor outcomes (in addition to clinical status at assessment after treatment): 

  • hypoxia at presentation
  • a history of ICU admission for asthma
  • presentation for acute asthma within the past 4 weeks
  • frequent presentations for acute asthma (e.g. several over previous year)
  • high recent use of beta2 agonists
  • patient cannot be monitored adequately at home or cannot easily return to hospital if needed
  • confirmed food allergy [children]
  • other risk factors for adverse outcomes [list provided]

To encourage more comprehensive risk assessment and reduce risk of life-threatening relapse within days after discharge

Other changes (selected)

Anaphylaxis

Addition of specific recommendation on identifying and managing anaphylaxis:

Identify anaphylaxis and manage it according to national guidelines or your organisation’s protocols.

Anaphylaxis should be suspected in a patient with sudden-onset asthma-like symptoms and either of the following:

  • features of anaphylaxis (e.g. urticaria or angioedema)
  • a history of allergy to food, insects or medicines.

If anaphylaxis is suspected or cannot be excluded, give adrenaline.

If adrenaline is indicated, administer before salbutamol.

Note: Anaphylaxis is defined as (either of):

  • Any acute onset illness with typical skin features (urticarial rash or erythema/flushing and/or angioedema) plus involvement of respiratory symptoms and/or cardiovascular symptoms and/or persistent severe gastrointestinal symptoms
  • Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible (even if typical skin features not present).

Expanded from V1.3 recommendation:

Identify and manage anaphylaxis according to national guidelines or your organisation’s protocols. Give adrenaline if anaphylaxis is suspected or cannot be excluded.

To prompt clinicians to consider anaphylaxis and to provide explicit clinical advice aligned with ASCIA guidance

Adrenaline

Addition of recommendation to consider immediate use if patient is unresponsive, cannot inhale bronchodilators, or is considered to be peri-arrest, with advice on routes of delivery and doses

To clarify role of adrenaline and acknowledge the need for guidance in pre-hospital emergencies

Inhaled corticosteroids

Expansion of recommendation to prescribe inhaled corticosteroids at discharge (if indicated) to reduce future risk of flare-ups:

At discharge, check if the patient has a preventer that contains an inhaled corticosteroid:

  • If the person is already using (or has been prescribed) inhaled corticosteroids, check adherence and inhaler technique, and instruct the patient or parent/carer to continue their inhaled corticosteroid.
  • For adults and older adolescents with asthma who have not been prescribed inhaled corticosteroids, prescribe an inhaled corticosteroid at a low dose, demonstrate correct inhaler technique, and arrange review of treatment at comprehensive follow-up.
  • For children younger than 12 years with asthma who are not currently taking a preventer, consider whether preventer treatment is indicated and arrange review of treatment at comprehensive follow-up.

Note: Regular low-dose inhaled corticosteroid treatment is indicated for all adults and adolescents over 12 years who have had an asthma flare-up in the previous 12 months.

Expanded from V1.3 recommendations:

For adults who have not been prescribed inhaled corticosteroids, prescribe inhaled corticosteroid and arrange comprehensive assessment in 2–4 weeks to review the treatment regimen (e.g. refer to person’s GP or arrange specialist assessment)

For children not currently taking a preventer, consider whether preventer treatment is indicated. Arrange a follow-up appointment in 2–4 weeks to review the treatment regimen (e.g. refer to child’s GP or arrange specialist assessment)

To emphasise role of inhaled corticosteroids and promote opportunistic longer-term risk reduction

Discharge checklist

Revision of discharge recommendations, with addition of comprehensive checklist that includes advising patient or carer to make an appointment with their usual GP within 3 days for post-acute assessment and a second appointment for review of asthma at 2–4 weeks

Replaces V1.3 recommendation to advise patient or carer to make an appointment with their usual GP within 2–4 weeks (or earlier if necessary)

To promote effective transition to primary care, reduce risk of relapse and reduce risk of future severe flare-ups

Discharge checklist

Addition of templates for discharge plans (interim asthma action plans) for children and adults

To support acute care staff to provide adequate instructions at discharge to reduce risk of relapse

 

Section: Managing asthma in children

Topic

Change

Rationale

Key differences from V1.3

Infants < 12 months

New advice: Wheezing infants aged less than 12 months old should not be treated for asthma. Wheezing in this age group is most commonly due to acute viral bronchiolitis or to small and/or floppy airways.

Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant under 12 months. Children with clinically significant wheezing that necessitates hospitalisation or occurs frequently (e.g. more than once per 6 weeks) should be referred to a paediatric respiratory physician or paediatrician.

Removal of treatment recommendations for children under 12 months, with clarification that diagnosis and management of asthma in infants is not recommended within primary care. Recommendation against use of short-acting beta2 agonists in infants under 6 months extended to all children under 12 months

Replacement of age category 0–5 years with 1–5 years.

To avoid potential harm due to inappropriate treatment and encourage referral to specialists for this age group

For consistency with current bronchiolitis management guidelines

Symptom patterns in children 1–5 years

Term ‘multiple-trigger wheeze’ no longer used

A single classification system based on frequency of symptoms and severity of flare-ups (Classification of preschool wheeze and indications for preventer treatment in children aged 1–5) replaces previous separate classification systems for (1) wheezing patterns children aged 0–5 years not taking regular preventer (where asthma diagnosis uncertain) and (2) asthma patterns in children aged 0–5 years not taking regular preventer

To simplify terminology and integrate assessment with treatment to make clinical guidance easier to follow

Prednisolone for flare-ups in children

Loading doses no longer recommended

Recommended dose: 1 mg/kg (maximum 50 mg) orally each morning for 3 days

Replaces V1.3 recommendation of a single starting dose of 2 mg/kg (maximum 50 mg) orally, then 1 mg/kg each morning for 2 days (total 3 days)

To reduce systemic corticosteroid exposure in children; conventional loading doses not well supported by current clinical evidence

Other changes (selected)

Risk-factors for flare-ups

Addition of new table: Risk factors for life-threatening asthma flare-ups in children

To promote comprehensive risk assessment

Stepping down (when to consider)

Addition of recommendation against attempt to step down regular preventer treatment at the start of the preschool year or during the child’s peak asthma season

Recommendation to consider stepping down when asthma symptoms have been well controlled for at least 6 months (increase from 3 months in V1.3)

To minimise risk of flare-ups

Stepping  down (options)

Simplification of recommendations for stepping down when current regimen is inhaled corticosteroid plus long-acting beta2 agonist

Current recommendation: halve dose or replace with low-dose inhaled corticosteroid only

Revised from V1.3 recommendation with three additional options (low-dose inhaled corticosteroid plus montelukast, montelukast, a cromone)

Based on updated evidence and simplified for easier implementation

Cromones

Removal of sodium cromoglycate and nedocromil from main recommendations for preventer therapy (retained as options)

To reflect reduced practical role in current practice

Montelukast

Update of evidence for efficacy, update of evidence for behavioural and/or neuropsychiatric adverse effects.

Update

Tiotropium

Addition of information on tiotropium following TGA approval for use in children aged 6 years and over

To acknowledge regulatory update

Inhaled corticosteroids

Update of evidence for efficacy of increasing the dose at the onset of flare-ups, adverse effects

Update

Inhaled corticosteroid–long-acting beta2 agonist combinations

Update of evidence for efficacy and adverse effects in children up to age 12

Update

Oral corticosteroids

Update of evidence on short courses of oral corticosteroids to manage flare-ups at home or primary care (as distinct from use in acute care settings)

Update

Back-to-school care

Addition of advice on asthma management at the beginning of the school year

To provide practical advice

 

Section: Management challenges

Topic

Change

Rationale

Key differences from V1.3

Structure

Replaces former Troubleshooting section with revised structure

To integrate better with new section on Severe asthma in adults and adolescents

Patient/person-centred care

Revision of whole section to emphasise a patient-centred approach to caring for a child or adult with asthma that is not well controlled despite preventer treatment

To promote person-centred care

Living with asthma

Addition of evidence on lived experience of asthma

To foster empathy with patients

Other changes (selected)

Cost of asthma medicines

Addition of information about costs of asthma medicines and strategies for minimising costs to patients

To provide practical advice to reduce financial burden on patients

 

Section: Severe asthma in adults and adolescents

Topic

Change

Rationale

Key differences from V1.3

Definition

Severe asthma defined as: asthma that remains uncontrolled despite regular treatment with high-dose inhaled corticosteroids plus long-acting beta2 agonist or with maintenance oral corticosteroids, or asthma that requires this level of treatment (Step 4) to prevent it becoming uncontrolled

Revised from V1.3 definition: Good control requires (or cannot be achieved despite) regular high dose of inhaled corticosteroid plus long-acting beta2 agonist

To align more precisely with international consensus

Scope of guidance

Replacement of single web page (Managing severe, high-risk and difficult-to-control asthma in adults) with more detailed guidance on each aspect:

  • Identifying severe asthma in adults and adolescents
  • Non-pharmacological strategies and general care
  • Add-on treatments
  • Monoclonal antibody therapy

Significantly expanded breadth and depth of guidance from primary care perspective

Identifying severe asthma

Addition of detailed information on steps for identifying severe asthma in adults and adolescents, including:

  • ruling out common problems (including poor inhaler technique and suboptimal adherence
  • reviewing the diagnosis
  • considering contribution of comorbidity to symptoms/asthma control
  • establishing level of short-acting beta2 agonist use
  • considering triggers
  • considering aspirin-exacerbated respiratory disease
  • optimising treatment

To delineate difficult-to-treat asthma and severe asthma and promote comprehensive, systematic assessment

Monoclonal antibody therapy

Advice on providing ongoing care during monoclonal antibody therapy, with update of evidence on efficacy, including newly introduce benralizumab

To update for TGA-approved indications and PBS listings revised 1 December 2018 and provide guidance for primary care staff who administer maintenance doses

Other changes (selected)

Differential diagnosis

Addition of table: Differential diagnosis of severe asthma in adults listing alternative diagnoses according to prominent clinical feature

To provide more specific information on potential alternative diagnoses for severe asthma as distinct from initial differential diagnosis covered in the Diagnosis section

Investigations for severe asthma

Update on tests required for PBS subsidy, and utility of tests for predicting response to therapy

To promote rational use of investigations within the constraints of current evidence

Non-pharmacological strategies

Addition of advice on non-pharmacological strategies and general care in the management of severe asthma, including:

  • evidence and information on active Cycle of Breathing technique
  • more detailed information and advice on monitoring and managing adverse effects of oral corticosteroids
  • addition of evidence on air temperature control
  • update of evidence for bronchial thermoplasty

To reduce risk associate with systemic corticosteroids by dose minimising requirement

Add-on treatment

Addition of advice on add-on treatments in the management of severe asthma, with update of evidence for efficacy of various treatment options including:

  • tiotropium
  • oral corticosteroids
  • azithromycin
  • monoclonal antibody therapy

To promote rational prescribing, give and overview of available treatments, and clarify the roles of primary care prescribers and specialists

Lived experience of severe asthma

Addition of evidence from Australian research on lived experience of severe asthma

To foster empathy with patients

Resources

Addition of links to Centre of Excellence in Severe Asthma’s Severe asthma toolkit

To link primary care providers to the national centre

 

Section: Primary prevention of asthma

Topic

Change

Rationale

Key differences from V1.3

Prenatal antibiotics

New recommendation:

Prescribe antibiotics for pregnant women as indicated and where a clinical benefit is likely, but avoid unnecessary use.

To reflect emerging evidence for importance of microbial diversity in immune system development

Prenatal diet

New recommendation:

Advise pregnant and breastfeeding women to aim for a healthy, balanced diet rich in fibre, vegetables and fruit, for general benefits and possible protection against wheeze in children, although healthy eating is not proven to prevent asthma and allergies in children.

To reflect evidence for protective effects of fruits and vegetables against wheezing

Prenatal vitamin D

Revision of recommendation:

Advise pregnant women and women planning pregnancy to follow current national guidelines for Vitamin D supplementation.

Note: Current RANZCOG guidelines for vitamin and mineral supplementation during pregnancy recommend vitamin D supplementation for all pregnant women and blood level testing is recommended for those who may be vitamin D-deficient.

Revised from V1.3 recommendation against vitamin D supplementation as a strategy for reducing asthma risk in offspring

To reflect evidence for possible protective effect of adequate vitamin D and acknowledge national guidelines

Antibiotics, proton pump inhibitors and antacids

New recommendation:

Prescribe antibiotics, proton pump inhibitors or antacids for children as indicated and where a clinical benefit is likely, but avoid unnecessary use.

To reflect evidence of possible association with increased risk of developing asthma

Specific allergen immunotherapy

New recommendation:

Consider specific allergen immunotherapy in children with allergic rhinitis who have a history of proven, clinically important sensitisation to a particular allergen that cannot feasibly be avoided and for which for specific allergen immunotherapy is available.

To reflect evidence for possible short-term reductions in the risk developing asthma and possible longer-term control of asthma symptoms

Work-related asthma

New recommendation:

If a patient who is exposed to occupational sensitisers or irritants develops new-onset rhinitis and/or respiratory symptoms, offer urgent referral to a specialist (e.g. respiratory physician, occupational physician or allergist) with experience in investigating and managing work-related asthma.

To emphasise the need for specialist assessment for work-related asthma

Other changes (selected)

Risk and protective factrs

Addition of table: Risk and protective factors for developing asthma

Update of all evidence

To provide easy-to-read summary

Update

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