Asthma Management Handbook
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Table. Comparison between Asthma Management Handbook 2006 and Australian Asthma Handbook 2014

Section or topic 6th edition, 2006 7th edition, 2014

General

Recommendations and factual statements are interwoven. Lists of key recommendations include factual statements.

Recommendations now explicit and separate from all supporting information.

All recommendations have been revised and updated based on available evidence.

Definition of asthma

Current at time of publication Revised and updated

Diagnosis (adults)

Recommendation:
Assess the severity of underlying asthma at the initial visit in a patient with newly diagnosed asthma, then reassess severity classification and/or asthma control at subsequent reviews.

Assessment of severity of asthma (‘underlying disease’) is no longer a priority.
Instead, continual assessment of asthma control is high priority.

We no longer recommend assessment of ‘asthma severity’ at the time of diagnosis; severity can only be assessed after treatment has started, because severity is now defined by the type and intensity of treatment needed to achieve good asthma control.

Confirming the diagnosis of asthma

No specific advice about how to confirm the diagnosis of asthma in patients already taking preventer treatment Specific advice provided for a range of clinical situations

Classification of asthma (adults)

Recommendation:
Assessment of asthma pattern and severity is essential in patients with newly diagnosed asthma to guide initial doses of medications and the frequency of subsequent medical review.

Assessment of pattern of asthma (intermittent, mild persistent, moderate persistent, severe persistent) is no longer recommended in adults, because it is not the best guide to treatment.

Initial treatment for asthma in adults is no longer based on distinguishing between intermittent and persistent asthma when person is not taking preventer.

Instead, we recommend initial assessment of recent control and of risk factors for flare-ups and medication-related adverse effects

Indications for preventer treatment (adults)

Recommendation:
Treatment with a preventer medication is recommended for patients who have asthma symptoms more than three times per week or use [short-acting beta2 agonist] more than three times per week.

We now recommend regular treatment with an inhaled corticosteroid-based preventer for most adults (all except those with symptoms less than twice per month and no flare-up within previous 12 months).

This is because recent evidence from clinical trials has shown that inhaled corticosteroid-based preventers also achieve benefits for people with ‘milder’ asthma (e.g. less frequent symptoms).

Indications for preventer treatment (children)

Recommendation:
In children with frequent intermittent and mild persistent asthma, use inhaled cromones, oral LTRAs or low-dose ICS.
For children with moderate-to-severe persistent asthma, an ICS is the preferred option.

 
Recommendations are based on age group as well as pattern of symptoms.

Stepping down (‘back-titrating’) treatment

No specific advice about how to step down preventer treatment Specific advice provided on how to step down preventer treatment with various treatment regimens

Acute asthma management

Emphasis on initial assessments before treatment, and on immediate spirometry to assess treatment response

More practical and evidence-based guidance:

  • We provide instructions for immediate simple, practical assessment and treatment to ensure that effective treatment is not delayed
  • We recommend comprehensive assessment only after initial treatment has started
  • We do not recommend early spirometry to assess baseline status, because this is impractical, distressing to patient and is not the best guide to treatment. Instead, we recommend spirometry as part of a comprehensive reassessment of response 1 hour after starting treatment.

The recommended initial assessments can be done by health professionals in any type of clinical setting (not just well-resourced emergency departments).

Acute asthma management: Drug treatments and oxygen therapy

Reflected consensus at time of publication

All recommendations have been revised are based on best available evidence. Now includes:

  • explicit instructions for oxygen supplementation in adults and children
  • a time sequence and priority order for the use of add-on treatments.

Acute asthma management: anaphylaxis

Adrenaline included in tables for treatment of severe asthma, but key recommendations did not explicitly discuss relationship between asthma and anaphylaxis

We now recommend that clinicians consider the possibility of anaphylaxis for all patients, not just those with the most severe acute asthma.

We recommend to give adrenaline if anaphylaxis is suspected or cannot be excluded.

Acute asthma management: oxygen targets

Recommendation (adults): 
Flow rate adjusted to achieve SaO2 > 90%. Frequent measurement of arterial blood gases is indicated in severe asthma and those not responding to treatment.
 
Recommendation (children):
Monitor oxygen saturation using oximetry. Supplemental oxygen may be required.

We now give specific indications and thresholds in adults and children, with more instructions and supporting information about targets.

Main recommendation: 
Start oxygen therapy if patient shows respiratory distress or oxygen saturation <95% on pulse oximetry. Titrate oxygen saturation to target of 92–95% for adults and at least 95% for children.

In adults, avoid over-oxygenation, because this increases the risk of hypercapnoea

For children, consider whether humidification of oxygen is indicated

Diet

Emphasis on food allergies and intolerance

New recommendations on healthy eating for asthma.

Recent evidence suggests healthy eating may contribute to asthma management as part of holistic care.

New section on lifestyle factors in asthma management, including health eating and physical activity.

Asthma prevention

Recommendation:
Exclusive breastfeeding for the first 6 months of life should be encouraged for all infants.

We now recommend breastfeeding where possible for its health benefits, but do not advise prolonged exclusive breastfeeding (i.e. delayed introduction of complementary foods beyond 4–6 months) specifically for the purpose of reducing the child’s risk of developing asthma.

Earlier evidence suggested that the risk of asthma may be reduced by exclusive breastfeeding in the first months of life, but more recent evidence did not show this. The Australasian Society of Clinical Immunology and Allergy (ASCIA) recommends introduction of foods at 4–6 months while child is still breastfeeding.

Medicines: general

Current at time of publication

The new edition incorporates changes in the use of medicines:

  • New medicines have become available.
  • TGA-approved indications for some medicines has changed.
  • PBS subsidisation criteria for some medicines have changed.

Medicines: TGA-approved indications PBS subsidisation criteria

Occasional recommendations for prescribing outside TGA-approved indications

PBS subsidisation criteria not flagged

Our prescribing recommendations generally follow TGA-approved indications and PBS criteria.

All exceptions (based on evidence for benefit) are flagged with notes.

Medicines: classes of asthma medicines

Main classes:
  • Relievers
  • Preventers
  • Symptom controllers

[Combination therapy (inhaled corticosteroid plus long-acting beta2 agonist) also included in longer list of classes]

We now recognise only two (not three) main classes of asthma treatment: relievers and preventers.

We no longer use the category name ‘symptom controllers’ for long-acting beta2 agonists.

This change was made for two main reasons:

  • to avoid confusion, because doctors in other countries used the term ‘controllers’ to mean something different (preventers in general, e.g. inhaled corticosteroids)
  • long-acting beta2 agonists should not be used without an inhaled corticosteroid, so it is simpler to consider the combination of both medicines as a preventer.

Medicines: long-acting beta2 agonists

Discussed use of long-acting beta2 agonists in single-agent inhalers As a safety consideration, we recommend against prescribing long-acting beta2 agonists in single-agent inhalers, where possible, to prevent patients accidentally or intentionally using a long-acting beta2 agonist without also taking an inhaled corticosteroid.

 

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