You are on page 1of 5

How to Treat

www.australiandoctor.com.au

PULL-OUT SECTION

Complete How to Treat quizzes online


www.australiandoctor.com.au/cpd to earn CPD or PDP points.

INSIDE
Diagnosis
Assessment
Principles of
management
Management

Asthma
in adults

the author

Professor Amanda
Barnard
chair, Australian Asthma
Handbook Guidelines Committee,
and associate dean, rural clinical
school and Indigenous health,
Australian National University
Medical School, Canberra, ACT.

Background
ABOUT one in 10 Australian
children and adults has asthma.1
Asthma rates have declined in children and young adults since 2001,
but have remained stable in adults.
Asthma represents a spectrum
of conditions with different pathophysiological mechanisms, but the
clinical and treatment implications

of this fact are not yet well understood.2,3


There is no standardised definition of asthma. Untreated asthma
is usually characterised by chronic
inflammation of the airways, airway
hyper-responsiveness, and intermittent airway narrowing due to a
combination of bronchoconstric-

tion, congestion or oedema of the


bronchial mucosa, and mucus.
In clinical practice, asthma is
defined by the presence of both
excessive variation in lung function (greater variation in expiratory airflow than is seen in healthy
people) and intermittent respiratory
symptoms (eg, wheeze, shortness of

OUT
NOW!
www.australiandoctor.com.au/ebooks

www.australiandoctor.com.au

breath, cough or chest tightness). In


young children, asthma is defined by
variable respiratory symptoms.
This article is the first of a twopart series which will focus on the
current approach to diagnosing
asthma and the management of
asthma in both adults and children.
contd page 29

Copyright 2014
Australian Doctor
All rights reserved. No part of this
publication may be reproduced,
distributed, or transmitted in any
form or by any means without
the prior written permission of
the publisher.
For permission requests, email:
howtotreat@cirrusmedia.com.au

Travel Medicine
FREE ebook available
Helpful advice for preventing and treating
travel-related medical conditions. A collection
of 16 clinical articles written by Professor Nick Zwar.
Easy download for your tablet, e-reader
or desktop computer.

24 October 2014 | Australian Doctor |

27

How To Treat Asthma in adults


Diagnosis
THE diagnosis of asthma is based on
history, physical examination and
lung function testing (eg, spirometry)
in all adults able to perform the test
(figure 1). There are no standardised
diagnostic criteria for asthma.
The current best practice in
asthma diagnosis and management
is shown in figure 1, which is a summary of the core sections of the 2014
edition of the Australian Asthma

Handbook. Table 1 summarises the


updates in this edition.
Respiratory symptoms may be
due to many conditions other than
asthma, so the diagnosis is based on
the probability that symptoms and
clinical findings are due to asthma
(table 2). In some patients, observing a response to treatment may
help confirm the diagnosis, but
lack of response to bronchodilators

or to inhaled corticosteroids does


not rule out asthma. In young children, especially preschoolers, it is
often not possible to be certain of
the diagnosis. Spirometry should be
performed by well-trained operators
with well-maintained and calibrated
equipment, either in general practice
or by an appropriate provider such
as an accredited respiratory function
laboratory.4,5

Table 1: Updates to the Australian Asthma Handbook (2014 edition)


Update

Details

Change in definition of asthma


severity

Asthma severity is now defined by the intensity of treatment required to achieve


optimal control of asthma symptoms, not by symptoms when untreated

Broader indication for regular


inhaled corticosteroids in adults
and adolescents

The indication for regular inhaled corticosteroids in adults and adolescents includes
any patient with asthma symptoms twice or more during the past month, waking due
to asthma symptoms once or more during the past month, or an asthma flare-up
requiring treatment with oral corticosteroids in the previous 12 months

Table 2: Findings that increase or decrease the probability


of asthma in adults
Asthma more likely

Asthma less likely

More than one of main symptoms (wheeze,


breathlessness, chest tightness, cough)
Symptoms recurrent or seasonal
Symptoms worse at night or in the early
morning
History of allergies (eg, allergic rhinitis, atopic
dermatitis)
Symptoms obviously triggered by exercise,
cold air, irritants, medicines (eg, aspirin or beta
blockers), allergies, viral infections, laughter)
Family history of asthma or allergies
Symptoms began in childhood
Widespread wheeze audible on chest
auscultation
FEV1 or PEF lower than predicted, without
other explanation
Eosinophilia or raised blood IgE level, without
other explanation
Symptoms rapidly relieved by a short-acting
beta2 agonist bronchodilator

Dizziness,
lightheadedness,
peripheral tingling
Isolated cough with
no other respiratory
symptoms
Chronic sputum
production
No abnormalities on
physical examination of
chest when symptomatic
(over several visits)
Change in voice
Symptoms only present
during URTIs
Current or past heavy
smoker
Cardiovascular disease
Normal spirometry or
PEF when symptomatic
(despite repeated tests)

PEF = peak expiratory flow rate


Adapted from Therapeutic Guidelines: Respiratory, version 4, 2009.

Figure 1: Diagnosis of asthma in adults.

Guidance on how to confirm the


diagnosis of asthma in adults
Emphasis on reassessment when Stronger emphasis on crucial assessments that should be made before increasing
symptom control is suboptimal
treatment whenever recent symptom control is suboptimal: reconsidering the
diagnosis, confirming that symptoms are due to asthma, assessing adherence to
preventer medicine, and checking inhaler technique
Preference for combinations of
long-acting beta2 agonist and
inhaled corticosteroid in a single
inhaler

It is now recommended to prescribe the combination of long-acting beta2 agonists


(LABA, previously classed as symptom controllers) and inhaled corticosteroid (ICS)
in a single inhaler (combinations now classed as preventers) rather than as separate
prescriptions. LABA should never be prescribed as a monotherapy

Discretion with allergen


avoidance strategies

Allergen avoidance strategies are only recommended if clinically relevant for the
individual (supported by evidence that they are likely to improve asthma control) and
patient or carers are motivated to implement them

Emphasis on asthma control in


pregnancy

Emphasis on maintaining good asthma control during pregnancy, with more


comprehensive information on balancing risks and benefits of medicines

New recommendation for healthy


eating

Healthy eating is recommended, with an emphasis on fruit and vegetables and limiting
processed and takeaway foods

New recommendation for


physical training

Physical training is now recommended as part of overall asthma management for


quality-of-life benefits

Assessment
THE possibility of asthma should
be considered in adults with episodic breathlessness, wheezing,
chest tightness and/or cough. The
history should include a review of
symptoms, risk factors and impact
on the patient (see box, Questions
to include when taking a history
in adults with suspected asthma).
Physical
examination
should
include chest auscultation and
inspection of the upper respiratory
tract for signs of allergic rhinitis.
The absence of abnormalities on
physical examination does not
exclude a diagnosis of asthma.
The differential diagnosis for
asthma-like respiratory symptoms
in adults includes poor cardiopulmonary fitness, bronchiectasis,
COPD, hyperventilation or other
dysfunctional breathing, inhaled
foreign body, large airway stenosis, pleural effusion, pulmonary
fibrosis,
rhinitis/rhinosinusitis,
upper airway dysfunction (also
known as vocal cord dysfunction),
cardiovascular disease (eg, chronic
heart failure, pulmonary hypertension), obesity, gastro-oesophageal
reflux and lung cancer. Chronic

Questions to include when


taking a history in adults
with suspected asthma
Current symptoms (both daytime
and night-time)
Pattern of symptoms (eg, course
over day, week or year)
Precipitating or aggravating factors
(eg, exercise, viral infections,
ingested substances, allergens)
Relieving factors (eg, medicines)
Impact on work and lifestyle
Home and work environment
Smoking history (tobacco or
cannabis, exposure to other
peoples smoke)
Past history of allergies including
atopic dermatitis (eczema) or
allergic rhinitis (hay fever)
Family history of asthma and
allergies

cough is unlikely to indicate


asthma if there are no other symptoms, and should be thoroughly
investigated if there are findings
that might indicate a serious alternative diagnosis.6

Spirometry is necessary to confirm the diagnosis. It can detect


airflow
limitation
(compared
with predicted normal airflow or
with personal best) and determine
whether this is reversible. Spiromwww.australiandoctor.com.au

etry should be performed before,


and 10-15 minutes after, administering a short-acting beta2 agonist
bronchodilator (SABA), eg, four
separate puffs of salbutamol 100g/
actuation via pressurised metered-

dose inhaler and spacer. A reduced


ratio of FEV1 to FVC (forced vital
capacity) indicates airflow limitation. Airflow limitation is reversible if there is a clinically important
bronchodilator response, defined
as an increase in forced expiratory
volume in 1 second (FEV1) of at
least 200mL and an increase of at
least 12%.5 Airflow limitation can
be transient (eg, when recorded
during a severe acute infection of
the respiratory tract), so the diagnosis should be confirmed when
the patient does not have a respiratory tract infection.7
The greater the variation in
lung function, the more certain
is the diagnosis of asthma (see
box, Findings that confirm variable airflow limitation in adults).
However, people with longstanding asthma may develop nonreversible airflow limitation. The
possibility of COPD, as an alternative diagnosis or a coexisting
diagnosis, should be considered in
people with incompletely reversible airflow limitation, especially
in smokers and ex-smokers aged
contd next page
24 October 2014 | Australian Doctor |

29

How To Treat Asthma in adults


from previous page
over 35 and in people over 65.
The evidence for variable airflow limitation must be documented at the time of diagnosis.
This is because reversibility in
airflow limitation may not be
detected if the person is already
taking a long-acting beta2 agonist
or inhaled corticosteroid.
The diagnosis of asthma should
be made if the person has variable
symptoms (especially cough, chest
tightness, wheeze and shortness of
breath), objectively demonstrated
variable airflow limitation, and an
alternative diagnosis is unlikely (table
2). Response should be checked 4-6
weeks after starting treatment.

Findings that confirm variable airflow limitation in adults


A clinically important increase in FEV1 (change in FEV1 of at least 200 mL and
12% from baseline) 1015 minutes after administration of bronchodilator
At least 20% change in FEV1 when measured repeatedly over time
(eg, spirometry on separate visits)
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 exerciseinduced bronchoconstriction)
Increase in FEV1 of at least 200 mL and 12% from baseline after a trial of four
or more weeks of treatment with an inhaled corticosteroid
More than 10% diurnal variability in peak expiratory flow when measured over
time
A clinically important reduction in lung function (1520%, depending on the
test) during a test for airway hyperresponsiveness (exercise challenge test or
bronchial provocation test) measured by a respiratory function laboratory

Referral should be considered if


the diagnosis is uncertain, if signs
and symptoms do not respond to
initial treatment, or if work-related

asthma is suspected (eg, if symptoms


are associated with work activities
and improve when the person is
away from the workplace).

Principles of management
THE overall aims of asthma management are to establish and maintain good asthma control, while
minimising the potential side effects
of treatment. The box (Steps in
asthma management) outlines the
steps in managing asthma.
Asthma management involves
the prompt use of self-administered (or carer-administered)
rapid-acting beta2 bronchodilators
(relievers) to control flare-ups
(times when asthma symptoms are
getting worse over hours or days
or recur within a few hours of taking reliever) and acute symptoms.
Most adults also need regular
treatment with preventers such
as inhaled corticosteroids. Regardless of the type of inhaler device
prescribed, patients need clear
instruction on correct inhalation
technique, including a physical
demonstration. Inhaler technique
must be checked regularly.
Current national guidelines for
asthma management emphasise
stepwise adjustment of treatment
(see figure 2), based on periodic
reassessment of recent symptom
control and regular assessment of
risk factors for asthma flare-ups or
treatment side effects. Whenever
recent symptom control is suboptimal, reconsider the diagnosis
of asthma, confirm that the current symptoms are due to asthma,
assess the persons adherence to
preventer treatment, and check
inhaler technique before adjusting
treatment.

Steps in asthma management

Figure 2: Stepped approach


to adjusting asthma
medication in adults.

Confirm the diagnosis


Assess recent asthma symptom control
In children, assess the pattern of symptoms (including frequency of episodes
and pattern of symptoms between episodes)
Assess asthma triggers
Assess risk factors for asthma flare-ups or treatment side effects
Identify management goals in collaboration with the patient or parents/carers
Choose initial treatment appropriate to the patients age, clinical assessments
and patient or parent/carer preference
Train patients in correct inhaler technique
Provide information and support to maximise adherence to preventer treatment
(if prescribed)
Review and adjust drug treatment periodically
Provide patient or parents/carers with information, skills and tools for selfmanagement
Provide every patient with a written asthma action plan
Provide information about avoiding clinically relevant triggers, where feasible
and appropriate
Manage flare-ups when they occur

Diagnosis

Advise against smoking and support patients and parents to quit

Management

Advise healthy eating, adequate physical activity, healthy weight and


immunisation.

Adherence

30

| Australian Doctor | 24 October 2014

Inhaler devices and technique


Acute asthma
Clinical issues (troubleshooting, allergies, comorbidities, complementary
therapies, COPD, exercise, food, smoking, triggers, work-related asthma)
Populations (adolescents and young adults, pregnant women, older adults,
Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse
communities)
Asthma prevention
Preventive care
*The Australian Asthma Handbook is the national clinical practice guidelines for
asthma management in primary care, published by the National Asthma Council
Australia. The handbook is endorsed by the RACGP, APNA and TSANZ.

Lifestyle factors
Lifestyle modification is relevant to
asthma self-management, just as for
other chronic diseases.
Patients who smoke should be
advised and supported to quit.
Smoking increases the risk of flareups, hastens decline in lung function, and reduces the effectiveness
of inhaled corticosteroids and the
chance of achieving good asthma
control.8-12
Physical training should be recommended for adults with asthma.
Regular, moderately intense physical activity improves cardiopulmonary fitness and quality of life
in people with asthma, and is well
tolerated, although it has no effect
on lung function or asthma symptoms.13
Emerging evidence suggests that
antioxidant-rich fruit and vegetables may help reduce the risk of
asthma flare-ups and improve lung
function.14 High-fat and low-fibre

Topics included in the Australian Asthma Handbook*

Identify and manage comorbid conditions that may affect asthma or respiratory
symptoms

Emerging evidence
suggests that
antioxidant-rich fruit
and vegetables may
help reduce the risk
of asthma flare-ups
and improve lung
function.

diets have been associated with


worse airway inflammation and
lower lung function in people with
asthma.15 Dietary restrictions such
as low-salt diets, or avoiding dairy
foods or food additives, should not
be routinely recommended to manage asthma.
Weight loss may help control

asthma symptoms in people who


are obese or overweight, regardless
of the weight loss intervention.16,17

Clinical issues and special


populations
The Australian Asthma Handbook
(see Online resources and the box,
Topics included in the Australwww.australiandoctor.com.au

ian Asthma Handbook) provides


guidance on a range of clinical
situations commonly encountered
in primary care. This includes
information about troubleshooting, asthma triggers, the relationship between asthma and COPD,
exercise-induced bronchoconstriction, work-related asthma, and
managing allergies and comorbid
conditions that affect asthma care
(eg, rhinosinusitis, gastro-oesophageal reflux disease, depression, anxiety and panic disorders,
chronic infections and obstructive
sleep apnoea).
Special considerations are also
needed when caring for pregnant
women, adolescents and young
adults, older adults, and Aboriginal
and Torres Strait Islander people,
and working with culturally and linguistically diverse communities.
contd page 43

How To Treat Asthma in adults


Management
PEOPLE
with
well-controlled
asthma should not experience any
interference in their life and activities
due to asthma symptoms. Asthma
control refers to the overall degree
to which risks due to the underlying
disease and its treatment have been
reduced or managed. Assessment of
asthma control involves both:
Assessment of recent symptom
control (ie, good, partial or poor),
based on frequency of daytime
asthma symptoms, night-time
symptoms or symptoms on waking, reliever use in response to
symptoms, and on limitation of
activity; and
Assessment of risk factors for
future events (eg, flare-ups, lifethreatening asthma, accelerated
decline in lung function, or adverse
effects of treatment).

Before starting regular


treatment
Before prescribing asthma treatment, the diagnosis should be
confirmed. Reports from around
the world show that 25-35% of
people with a diagnosis of asthma
in primary care may not actually
have asthma.18-21 Confirmation
may include obtaining original
records documenting reversible
airflow limitation or repeating
spirometry.
Before starting treatment, recent
asthma symptom control should
be assessed (table 3), baseline lung
function should be documented,
and any risk factors (for flare-ups,
life-threatening asthma, accelerated decline in lung function,
or adverse effects of treatment)
should be identified. Initial treatment (see table 4) is selected based
on recent asthma symptom control, risk factors and the patients
preference, after discussing the
goals of treatment and taking cost
into consideration.

Inhaled corticosteroids
In addition to a reliever taken as
needed (or before exercise, if indicated), most adults with asthma
also need regular treatment with
an inhaled corticosteroid preventer (beclomethasone, budesonide,
ciclesonide, fluticasone propionate).
An inhaled corticosteroid should be
prescribed for all adults and adolescents who report any of the following: asthma symptoms twice or more
during the past month, waking as a
result of asthma symptoms once or
more during the past month, or an
asthma flare-up requiring treatment
with oral corticosteroids in the past
12 months.
Inhaled corticosteroids reduce
asthma symptoms, improve quality of life, improve lung function,
reduce airway hyper-responsiveness, control airway inflammation, reduce the frequency and
severity of asthma flare-ups, and
reduce the risk of death due to
asthma.22-31 For most adults, the
starting dose should be low (see
table 5). Most of the benefit is
achieved with doses at the upper
limit of the low-dose range.32,33
On average, higher doses provide
relatively little extra benefit but
are associated with a higher risk
of adverse effects. The response to
treatment should be reviewed 6-8

Table 3: Level of recent asthma symptom control in adults


Level of control

Symptom pattern over past four weeks

Good

All of:
Daytime symptoms two days per week
Need for reliever two days per week*
No limitation of activities
No symptoms during night or on waking

Partial

One or two of:


Daytime symptoms >two days per week
Need for reliever >two days per week*
Any limitation of activities
Any symptoms during night or on waking

Poor

Three or more of:


Daytime symptoms >two days per week
Need for reliever >two days per week*
Any limitation of activities
Any symptoms during night or on waking

*Not including short-acting beta2 agonist taken prophylactically before exercise.


Record this separately and take into account when determining management.

Table 4: Initial treatment choices in adults not already using a preventer


Clinical situation

Suggested starting regimen

Symptoms fewer than twice per


month and no flare-up within past
12 months

SABA as needed

Alternative options and notes

Symptoms are mild and occur


twice per month or more often

Regular ICS starting at a low dose


(plus SABA as needed)

Montelukast*
Cromones

Waking due to asthma symptoms


at least once during the past
month

Regular ICS starting at a low dose


(plus SABA as needed)

If patient also has frequent daytime symptoms


consider either of:
mediumhigh dose ICS (plus SABA as
needed)
(private prescription) combination ICS/LABA#

Asthma flare-up within past two


years that required treatment with
oral corticosteroids (even if current
symptoms infrequent)

Regular ICS starting at a low dose


(plus SABA as needed)

Lifetime history of artificial


ventilation or admission to
intensive care unit due to acute
asthma (even if current symptoms
infrequent)

Regular ICS starting at a low dose


(plus SABA as needed)
Monitor frequently

Severely uncontrolled or very


troublesome symptoms (eg,
frequent night waking, low lung
function)

Consider either of:


high-dose ICS (then down-titrate
when symptoms improve)
a short course of oral
corticosteroids in addition to
inhaled corticosteroids

Adjusting treatment

Consider (private prescription) combination


ICS/LABA#

SABA = Short-acting beta2 agonist; LABA = Long-acting beta2 agonist; ICS = inhaled corticosteroid
*Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special authority is available for DVA gold
card holders or white card holders with approval for asthma treatments.

Requires multiple daily doses and daily maintenance of inhaler
#
Inhaled corticosteroids/LABA combination therapy as first-line preventer treatment is not subsidised by the PBS, except for
patients with frequent symptoms while taking oral corticosteroids.

Table 5: Dose levels of inhaled corticosteroid in adults*


Daily dose (g)
Low

Medium

High

Beclomethasone dipropionate

100200

250400

> 400

Budesonide

200400

500800

> 800

Ciclesonide

80160

240320

> 320

Fluticasone propionate

100200

250500

> 500

 ose equivalents for Qvar (CFC-free formulation of beclomethasone dipropionate


D
currently available in Australia).
*T
 he potency of generic formulations may differ from that of original formulations.
Check TGA-approved product information for details.
adapted from Therapeutic Guidelines: Respiratory version 4 (2009).

weeks after initiation and during


this interval if needed.
For most patients, high doses
of inhaled corticosteroids should
be used for short periods only. If
a patient seems to need prolonged
high-dose inhaled corticosteroid
treatment to control asthma, referral for specialist assessment should
be considered.
Hoarseness and candidiasis are
the most common local adverse
effects of inhaled corticosteroids
with both pressurised metered-

dose inhalers and dry-powder


inhalers.34 Long-term use of high
doses has been associated with
lower bone mineral density and
with increased risk of cataracts
and diabetes.35-37
Prescribers should discuss the
potential side-effects of inhaled
corticosteroids with patients and
ask if they have any concerns.
Many people with asthma have
misunderstandings and fears about
using inhaled corticosteroids, such
as risk of weight gain, unwanted
www.australiandoctor.com.au

muscle development, infections,


and that the medicine will become
less effective over time. Safety concerns are a major reason for poor
adherence.38
When taking corticosteroids via
pressurised metered-dose inhalers,
the use of a spacer reduces the risk
of dysphonia and candidiasis.39
Spacers improve delivery of the
medicine to the airways. Rinsing
the mouth with water after inhaling reduces the risk of oropharyngeal candidiasis. Quick mouth
rinsing immediately after inhaling
effectively removes a high proportion of remaining medicine.40

Reports from around


the world show that
25-35% of people
with a diagnosis of
asthma in primary
care may not actually
have asthma.

Treatment should be reviewed and


adjusted periodically (see figure 2).
After starting a new treatment or
adjusting a regimen, the response
should be reviewed in 6-8 weeks.
Before stepping up treatment, the
persons recent asthma symptom
control and risk factors should be
assessed and recorded. To avoid
unnecessary dose escalation, common reasons for apparent treatment failure should be carefully
assessed and ruled out. These
include partial or non-adherence,
incorrect inhaler technique, exposure to avoidable triggers, and
other conditions that could worsen
or mimic asthma symptoms.
Stepping up to a combination
of an inhaled corticosteroid and a
long-acting beta2 agonist (LABA)
should be considered for patients
whose asthma is only partly controlled despite low-dose inhaled
corticosteroids, good adherence
and correct inhaler technique.
Combination treatment reduces
the risk of flare-ups compared with
inhaled corticosteroid alone and
compared with increasing the dose
of corticosteroids.22 Some combinations are available as a single
inhaler: budesonideeformoterol,
fluticasone propionatesalmeterol
and fluticasone propionateeformoterol. LABAs should not be
used without an inhaled corticosteroid in the management of
asthma.41-44
In addition to its use as regular
long-term preventer treatment,
the budesonideeformoterol combination can be used as reliever
for asthma symptoms (instead of
using a short-acting beta2 agonist
reliever). The maintenance-andcontd next page
24 October 2014 | Australian Doctor |

43

How To Treat Asthma in adults


from previous page
reliever regimen involves starting
the combination at a low regular dose, then taking extra doses
as needed in response to asthma
symptoms.45-48

Self-management
To self-manage asthma well, patients
need information, skills and tools.
These include training in correct
inhaler technique, information and
support to maximise adherence, and
information about avoiding triggers,
where appropriate.
A written asthma action plan
should be prepared for every
patient. It should list the persons
usual asthma and allergy medicines. Clear instructions on how
to change medication including
when and how to start a course of
oral corticosteroids and when and
how to get medical care, including
during an emergency should be
provided. The date and the name
of the person preparing the plan
should be recorded each time the
plan is updated.

Monitoring and review


Scheduled asthma visits should

What to check at scheduled asthma visits


Problems or concerns about asthma or medicines
Current symptom control (based on symptoms and reliever use during the past
four weeks)
Flare-ups during the previous 12 months
Lung function (spirometry every 1-2 years for most people more often when
good asthma control has been lost or not achieved, or when the person has a
known risk factor for accelerated loss of lung function)
Other risk factors (eg, smoking, exposure to other triggers)
Comorbid conditions that could affect asthma control or self-management
Current treatment, including adherence to preventer if prescribed
Inhaler technique
The written asthma action plan (check that it is current and whether the
patient knows how to use it)

be planned at least yearly, at


times when the patient does not
have asthma symptoms, so that
lung function can be checked and
asthma management thoroughly
assessed (see box, What to check
at scheduled asthma visits). Partial or poor adherence to preventer
medicines is common, so it cannot be assumed that the patient is
taking the dose most recently prescribed. GPs should ask, in a nonjudgemental way, which asthma
medicines the patient is using.

Managing flare-ups
Flare-ups of asthma can occur
from time to time, even in people with asthma that is generally
well controlled. Flare-ups range
in severity from slight worsening
of asthma control compared with
the persons normal range when
well, or distressing symptoms that
require a change in treatment, to
severe acute asthma that requires
treatment by emergency services.
Each patients written asthma
action plan should include instruc-

tions on how to take extra doses of


reliever during flare-ups and when
to visit emergency services.
For adults taking regular maintenance inhaled corticosteroids or combination corticosteroid/LABA, the
dose can be temporarily increased to
achieve a high dose of corticosteroid
for two weeks unless contraindicated.
For those taking combinations, the
instructions should ensure that the
dose of LABA is adequate but not
excessive (eg, by using a second corticosteroid inhaler).
Short courses of oral prednisone/
prednisolone are used to manage flare-ups that do not resolve
promptly. The recommended dose
for adults is 37.5-50mg each day
for 5-10 days.
Acute asthma emergencies are
managed with inhaled salbutamol,
supplementary oxygen if needed
to maintain oxygen saturation targets of 92-95%. If acute asthma is
not resolved, add-on treatments
include inhaled ipratropium bromide, IV magnesium sulfate, and
(critical care settings only) IV salbutamol. The Australian Asthma
Handbook provides guidance on
managing acute asthma.

Authors case study


A 35-YEAR-old woman presented
in June as a new patient of a general practice in a small rural town.
She had recently moved into town
with her three children, and was
temporarily living at her parents
house while looking for suitable
accommodation.
The purpose of her visit was for
a repeat script of her SSRI prescribed for depression. She also
used inhaled salbutamol as needed,
and mentioned that her asthma
had been playing up recently.
Her history included asthma, seasonal hay fever and depression,
and a past history of smoking (five
pack-years, ceased age 25), and
family history included a sister
with asthma.
The diagnosis was confirmed by
obtaining records from her previous GP, taking a more detailed history and performing spirometry.
Her asthma was first diagnosed
when she was at primary school.
Her usual symptoms then and as
an adult were chest tightness and
wheeze. She tended to have more
symptoms in the spring with hay
fever, and had been prescribed
a preventer in the past. She was
never hospitalised with asthma but
attended the ED 12 years earlier,
where she was given a course of
prednisone. Before moving from
her previous home, she rarely
experienced night-time symptoms,
but in a typical week would have
daytime symptoms at least twice
a week. The notes from her previous practice include pre- and postbronchodilator spirometry from
four years ago showing an increase
on FEV1 of 400mL (15%) postbronchodilator and an obstructive
pattern.
Recent asthma symptom control was assessed by asking about
frequency of daytime symptoms,
frequency of reliever use, limitation of activities and night or
waking symptoms during the past
four weeks. She had been using

44

| Australian Doctor | 24 October 2014

Online resources
Australian Asthma Handbook
www.asthmahandbook.org.au
National Asthma Council
Australia
Spirometry: training, published
guides, video
www.nationalasthma.org.au/
health-professionals/spirometryresources
First aid for asthma: wall charts
and instructions for patients of
all ages
www.nationalasthma.org.au/
first-aid
Asthma action plan library:
templates to print or download
www.nationalasthma.org.au/
health-professionals/asthmaaction-plans/asthma-action-planlibrary
Using your inhaler: how-to video
www.nationalasthma.org.au/howto-videos/using-your-inhaler

Further reading
National Asthma Council Australia.
Inhaler Technique in Adults with
Asthma or COPD. An Information
Paper for Health Professionals.
NAC, Melbourne, 2008.
National Asthma Council Australia.
Intranasal Corticosteroid Spray
Technique for People with Allergic
Rhinitis. Information Paper for
Health Professionals. NAC,
Melbourne, 2010.
National Asthma Council Australia.
Managing Allergic Rhinitis in People
with Asthma. An Information Paper
for Health Professionals. NAC,
Melbourne, 2012.
National Asthma Council Australia.
Asthma and Healthy Living. An
Information Paper for Health
Professionals. NAC, Melbourne,
2013.
Johns DP, Pierce R. Pocket Guide
to Spirometry. 3rd edn. McGraw
Hill, Sydney, 2011.

References

Available on request from


howtotreat@cirrusmedia.com.au

Recent asthma
symptom control was
assessed by asking
about frequency of
daytime symptoms,
frequency of reliever
use, limitation of
activities and night
or waking symptoms
during the past four
weeks.

her reliever most days over the


past four weeks, usually twice a
day as she felt a bit tight in the
chest and wheezy. She had been
having symptoms at night, and so
had been taking her reliever before
bed, and occasionally used it when
she woke during the night. She did
not notice any limitation of her
activities. Recent asthma symptom
control was assessed as poor.
Further enquiry revealed that
her symptoms had been worse
since she moved into her parents
house. Her father was a smoker.
She had been prescribed an
inhaled corticosteroid preventer
two years earlier, but said she did
not like the idea of taking steroids
and always got a funny taste
when she used it. She had been
taking it episodically, when her
symptoms were playing up, and
for a couple of months during
the spring. Her inhaler technique
was assessed to be suboptimal,
and she did not use a spacer to
www.australiandoctor.com.au

take her corticosteroid.


After discussing her concerns
and reassuring her about the purpose and effects of inhaled corticosteroids, she agreed to start
taking a low dose regularly. She
was instructed to use a spacer, and
to rinse her mouth and spit after
taking it. The practice nurse demonstrated correct inhalation technique and provided training and
written instructions for the device
and information about the medicine. Exposure to environmental
smoke in her parents house was
a likely trigger, so she planned
to move to a smoke-free home as
soon as possible.
An appointment was made for
a recheck in four weeks, and a
second review appointment scheduled for late August to reassess
preventer need and allergic rhinitis
medicines during spring. Written
information was provided about
asthma and self-care, including a
written asthma action plan.

contd page 46