Section 4 - Management of diagnosed conditions

1. What is asthma? ^2–4

• A chronic inflammatory disorder of the airways triggered by a range of factors
• A variation in lung function (especially expiratory airflow) and episodic respiratory symptoms such as wheezing, shortness of breath, cough and tight chest
• Episodes are usually associated with airflow obstruction that is often reversible either spontaneously or with treatment
• Airflow obstruction is due to airway wall inflammation causing oedema and mucus production
• Asthma is associated with allergies such as eczema and hay fever
• More common in women than in men
• More common among Aboriginal and Torres Strait Islander Australians

2. Diagnosis of asthma in adults and children > 12 ^2–4

• Based on a history, physical examination, consideration of other diagnoses and documented changes in airflow (spirometry). See Resources 1.
• If spirometry is unavailable, PEF before and after a therapeutic trial with as-needed SABA and regular ICS, often with a 1 week course of oral corticosteroids, helps to confirm a diagnosis of asthma prior to long-term treatment
• Airflow limitation demonstrated on spirometry and other respiratory symptoms does not always mean a person has asthma. Differential diagnoses include:
  • Rheumatic heart disease Chronic obstructive pulmonary disease, Heart failure, Bronchiectasis,  chronic upper airway cough syndrome, vocal cord dysfunction, hyperventilation and dysfunctional breathing, cystic fibrosis, inhaled foreign body, adverse drug reactions, lung disease, pulmonary embolism, central airway obstruction or congenital heart disease
• Asthma can be over or under diagnosed
• Table 1. outlines findings that increase or decrease the likelihood of asthma

• Flowchart 1. illustrates the steps to confirm an asthma diagnosis

Flowchart 1. Steps to diagnosing asthma in adults and children > 12

Adapted with permission from the Australian Asthma Handbook, Version 2.2. © 2022 National Asthma Council Australia

3. Management of adults and children > 12 with asthma ^2–5

• The goals of managing asthma are to:
  • engage the patient to identify asthma management goals
  • minimise impact of asthma on quality of life
  • optimise asthma symptom control with minimal medicines
  • minimise risk of exacerbations and loss of lung function
  • minimise adverse effects of treatment
  • identify and address comorbid conditions including:
    • hay fever
    • rhinosinusitis
    • GORD
    • Depression and Anxiety disorders
    • chronic infections
    • OSA

1. Support patient self-management ^2,3
   • Provide culturally appropriate asthma resources and support service details. See Resource 2.
   • In partnership develop an asthma action plan (Resource 3.) identifying:
     • asthma triggers. See Table 2.
     • symptoms that indicate asthma is worsening
     • actions to take when symptoms worsen
     • when and how to use medicines and correct use of inhaler. See Resource 4.
     • doses and frequencies of regular medicines
     • how to adjust treatment in response to particular signs and symptoms
     • when to start oral corticosteroids
     • when and how to seek urgent medical help
   • At each visit the asthma action plan should be reviewed and adjusted as required
   • Patients who accept their asthma symptoms as normal, require added support to show that symptoms and quality of life will improve with correct medicine use, lifestyle modification and regular monitoring. See Resource 2.
   • Encourage the patient to identify barriers to adequate lifestyle modification and
     medical adherence and create goals to overcome those barriers. See Engaging our patients
2. Social-emotional support ^2–4
   • Depression and Anxiety disorders are more common in people with asthma, attributing to a patient’s asthma symptom perception and medicine adherence
   • See Social-emotional wellbeing
3. Smoking cessation ^2–5
   • Review recent asthma symptom control every 3 months in those who smoke, due to increased risk of exacerbations and lung function decline over time
   • Regularly encourage the patient to Smoking cessation
   • Offer the patient Quitline details. See Resource 5.
4. Obesity ^1–5
   • Asthma is more difficult to control in obese patients (BMI ≥ 30 kg/m²)
   • Overweight and obesity (adult) and Overweight and obesity (child) is associated with an increased prevalence of asthma via mechanical, inflammatory and genetic/developmental factors
   • 5–10% weight loss can lead to improved asthma control and quality of life
   • The risk of asthma exacerbations is reduced in those who have a diet high in fresh fruit and vegetables and oily fish
   • A diet high in processed foods and soft drink increases the risk of developing asthma
   • See Diet and nutrition

5. Sleep hygiene ^2–5
   • OSA is high among people with asthma and is associated with upper and lower airway inflammation
   • Medicines, difficulty breathing, anxiety and depression may prevent people with asthma from sleeping well at night
   • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 6.
6. Asthma control ^2–4

• Ascertain the patient’s recent level of asthma symptom control using Table 3.
• Recent asthma symptom control is based on symptoms over the previous 4 weeks
• When counting the times a patient uses their reliever puffer, do not include times taken before exercise (dose counters are now available on inhalers)

4. Medicines for adults and children > 12 with asthma

• Use Flowchart 2. to assist with the steps to determine practical management and optimal medicine use for the patient with asthma

1. Correct medicine use ^2–4
   • Monitor medicine adherence and correct inhaler technique according to product instructions. See Resource 4.

• SABA should only be used at the lowest dose and frequency when asthma symptoms occur or if prescribed for use before exercise

2. Medicine precautions in asthma ^2–4
   • Any newly obtained medicines (prescriptions, over the counter or complimentary) should be checked for asthma trigger risk. See Table 2.
   • Sedatives are contraindicated during an acute asthma episode

Flowchart 2. Intervention flowchart to achieve asthma control ^2,3,6

3. Medicine review ^2,3,6

• Patients should be reviewed:
  • 2–4 weeks after an exacerbation OR
  • 1–3 months after an initial visit with preference given to 3 months to ascertain the effectiveness of the medicine to control the asthma OR
  • every 3 months
• If patient’s asthma is poorly controlled after 1–3 months, step up treatment
• See Flowchart 3.
• If good control is achieved for 2–3 months, step down treatment to the least medicine required to maintain control
• Monitor frequently once good control is achieved so that adjustments can be made in response to worsening symptoms or episodes of exacerbations

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. The Spirometry Handbook
2. Asthma resources
3. Asthma action plan and the First Aid for Asthma chart
4. Inhaler use videos and printable instructions
5. Quitline website with resources
6. The Epworth Sleepiness Scale and STOP-Bang questionnaire