People with asthma have sensitive airways. Asthma is a medical condition that affects the airways (the breathing tubes that carry air into our lungs) where they narrow and swell and may produce extra mucus. From time to time, people with asthma find it harder to breathe in and out, because the airways in their lungs become narrower – like trying to breathe through a thin straw. This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you breathe out and shortness of breath. At other times their breathing is normal. Some people develop asthma as a child, others as adults. Some people have symptoms often, some only for a shorter period. There is no cure for asthma, but it can usually be well controlled. Most people with asthma can stay active and have a healthy life.

1.1.1 Symptoms

Asthma symptoms vary from person to person. You may have infrequent asthma attacks, have symptoms only at certain times — such as when exercising — or have symptoms all the time. The most common symptoms are:

Breathlessness
Wheezing when exhaling
Tight feeling in the chest
Continuing persistent cough

For some people, asthma signs and symptoms flare up in certain situations:

Exercise-induced asthma, which may be worse when the air is cold and dry
Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust
Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores, cockroach waste, or particles of skin and dried saliva shed by pets (pet dander)

1.1.2 Prevalence - Who gets asthma?

Over 2.5 million (about 1 in 9) Australians have asthma, including children and adults. Asthma is more common in families with asthma or allergies, but not everyone with asthma has allergies. Asthma is common in children, but it can also start later in life.

Asthma often starts as wheezing at preschool age. Not all wheezing is asthma – many preschool children who wheeze do not have asthma by primary school age.

Adults of any age can develop asthma, even if they did not have asthma as a child.

1.2 Causes

The exact causes of asthma are not known. The risk of getting asthma partly depends on genetics. Asthma can run in families.
Asthma can be allergic or non-allergic. Allergic asthma is more common in families with asthma and allergies like eczema and hay fever.

Children’s risk of getting asthma seems to be increased by mothers smoking while pregnant, people smoking around babies or young children, air pollution from traffic or industry, mouldy houses, and being born premature or with a low birth weight.

Adults can develop asthma over time from indoor air pollution at work or home (for example, by breathing fumes that irritate the lungs, or breathing in dusts that they are allergic to).

Athletes can develop asthma after very intensive training over several years, especially while breathing air that is polluted, cold or dry.

Researchers have found many other things that could help explain why asthma is so common, but we don’t yet know exactly why some people get asthma and others don’t.

1.2.1 Triggers

Triggers can cause the airways to become narrow and inflamed, leading to asthma symptoms. Avoiding triggers, if possible, can help to control asthma. Anything that causes a reaction can set off your asthma symptoms.

These triggers differ between individuals. Over time, you will get to know which circumstances can make your asthma get worse. Some can be avoided altogether, while others you will need to plan for:

Colds, flu and other respiratory infections
Allergy related triggers, airborne allergens, such as pollen, dust mites, mold spores, pet dander or particles of cockroach waste
Exercise and physical activity
Weather e.g. cold air, change in temperature, thunderstorms
Work-related triggers e.g. wood dust, chemicals, metal salts
Irritating substances breathed in the air, such as bushfire smoke
Certain medicines, e.g. aspirin, some blood pressure drugs
Stress and high emotions, such as crying
Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat

1.3 Complications

Badly controlled asthma can have an adverse effect on your quality of life. The condition can result in:

Fatigue
Signs and symptoms that interfere with sleep, work and other activities
Underperformance or absence from work or school
Inability to exercise, leading to other health problems such as high blood pressure or weight gain
Permanent narrowing of the tubes that carry air to and from your lungs
Repeated visits to the emergency department or hospital stays
Psychological problems including stress, anxiety and depression
Learning problems in children
Side effects from long-term use of some medications used to stabilize severe asthma (such as prednisolone).

If you feel that your asthma is seriously affecting your quality of life, contact your doctor. Your personal asthma action plan may need to be reviewed to better control the condition. In rare cases, asthma can lead to a number of serious respiratory complications, including:

Pneumonia (infection of the lungs)
Collapse of part or all of the lung
Respiratory failure, where the levels of oxygen in the blood become dangerously low, or the levels of carbon dioxide become dangerously high
Status asthmaticus (severe asthma attacks that do not respond to treatment)

1.4 Prevention

While there's no way to prevent asthma, you and your doctor can design a step-by-step plan for living with your condition and preventing asthma attacks.

Follow your asthma action plan. With your doctor and health care team, write a detailed plan for taking medications and managing an asthma attack. Then be sure to follow your plan. Asthma is an ongoing condition that needs regular monitoring and treatment. Taking control of your treatment can make you feel more in control of your life.
Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups.
Identify and avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to cold air and air pollution — can trigger asthma attacks. Find out what causes or worsens your asthma, and take steps to avoid those triggers.
Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or shortness of breath. But because your lung function may decrease before you notice any signs or symptoms, regularly measure and record your peak airflow with a home peak flow meter. A peak flow meter measures how hard you can breathe out. Your doctor can show you how to monitor your peak flow at home.
Identify and treat attacks early. If you act quickly, you're less likely to have a severe attack. You also won't need as much medication to control your symptoms. When your peak flow measurements decrease and alert you to an oncoming attack, take your medication as instructed. Also, immediately stop any activity that may have triggered the attack. If your symptoms don't improve, seek medical help as directed in your action plan.
Take your medication as prescribed. Don't change your medications without first talking to your doctor, even if your asthma seems to be improving. It's a good idea to bring your medications with you to each doctor visit. Your doctor can make sure you're using your medications correctly and taking the right dose.
Pay attention to increasing quick-relief inhaler use. If you find yourself relying on your quick-relief inhaler, such as albuterol, your asthma isn't under control. See your doctor about adjusting your treatment.

2 Management - Diagnosis and Treatment

2.1 Diagnosis

There is no single test for asthma. Doctors make the diagnosis of asthma when a person has breathing symptoms typical of asthma that come and go, and there is also evidence that sometimes air does not flow in and out of their lungs normally. Your doctor will perform a physical exam to rule out other possible conditions, such as a respiratory infection or chronic obstructive pulmonary disease (COPD). Your doctor will also ask you questions about your signs and symptoms and about any other health problems. If you have eczema or hay fever, or have close relatives with allergies or asthma, a diagnosis is more likely. Asthma is also more likely to be diagnosed if your symptoms:

keep coming back, or happen at the same time each year
are worse at night or in the early morning
are clearly triggered by exercise, allergies or infections, or have a seasonal pattern
improve quickly with reliever medication

2.1.1 Classification of Asthma

For some people, asthma signs and symptoms flare up in certain situations:

Exercise-induced asthma, which may be worse when the air is cold and dry
Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust
Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores, cockroach waste, or particles of skin and dried saliva shed by pets (pet dander)

Asthma is classified into four categories based upon frequency of symptoms and objective measures, such as peak flow measurements and/or spirometry results. These categories are:

Classification of Asthma	Signs, Symptoms and Criteria
Mild Intermittent	Mild symptoms up to two days a week and up to two nights a month
Mild Persistent	Symptoms more than twice a week, but no more than once in a single day
Moderate Persistent	Symptoms once a day and more than one night a week
Severe Persistent	Symptoms throughout the day on most days and frequently at night

2.1.2 Preschool children

It’s often difficult to diagnose asthma in children under 5, especially as they find breathing tests difficult. Your doctor will assess the symptoms and your explanation of your child’s symptoms and may give your child asthma medicine to measure its effect – this is called a ‘treatment trial’. Your doctor will monitor the effect this medicine has on your child and will use the results as part of their diagnostic process.

2.1.3 School-aged children

As well as asking about symptoms and doing a physical examination, your doctor will arrange a spirometry test. A spirometer machine measures how hard and fast a child can breathe out into a mouthpiece attached to a tube. Most of the time you will be asked to take your reliever medicine in the middle of the test. This will show what effect the medication has on your lungs. Many people may have allergy tests as part of their diagnosis. These tests can be skin prick tests or blood tests and they detect allergen sensitivities.

2.1.4 Adults and Adolescents

Same as School-aged children

2.2 Treatment

Prevention and long-term control are key to stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid triggers and tracking your breathing to make sure your medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler. Influenza and pneumococcal vaccinations should be considered in all patients with asthma.³

2.2.1 Goals

The main aims of asthma treatment are:

to keep lungs as healthy as possible
to keep symptoms under control
to stop asthma from interfering with school, work or play
to prevent flare-ups or ‘attacks’.

2.2.2 Good Asthma Control

Good asthma control means having all of the following:

No night-time asthma symptoms
No asthma symptoms on waking
No need for reliever medication
No restriction of day-to-day activities
No days off school or work due to asthma
No asthma attacks or flare-ups

2.2.3 Asthma Action Plan

Different asthma action plans suit different people, but all plans should have the same essential features. The plan should:

be in a written format
be individually prescribed, rather than a general example
contain information that allows the patient and/or their carer to recognise exacerbations (flare-ups)
contain information on what action to take in response to those exacerbations.

Basic details should include the date, the patient’s name, and their doctor’s contact details. Some also include contact details for the patient’s carer or emergency contact person. Many plans follow a traffic light system for assessing the severity of exacerbations, moving from green for ‘under control’ to red for ‘emergency’. Whichever system is used, the response plan needs to cover:

Maintenance/preventer therapy: doses and frequencies of regular medications

Treating exacerbations: how to adjust treatment in response to particular signs and symptoms

Managing increased severity: when to start oral corticosteroids and seek medical advice

Danger signs: when and how to seek urgent medical help

2.2.4 Adults and adolescents

Most adults with asthma need to take a low dose of an ‘inhaled corticosteroid’ preventer medicine every day, as well as taking their reliever when they have symptoms. An inhaled corticosteroid medicine is usually prescribed for an adult who:

has had asthma symptoms twice or more in the past month, or
is sometimes woken by asthma symptoms, or
has had a flare-up severe enough to need an urgent visit to their GP or hospital emergency department within the previous 12 months.

Inhaled corticosteroids include several different medicines and brands. This type of preventer medicine reduces inflammation in the airways and reduces a person’s risk of a severe asthma flare-up. Most adults can achieve good control of asthma symptoms with a low dose.

Preventers sometimes include a second medicine as well as the inhaled corticosteroid. These are called ‘combination’ therapies.

If you have been prescribed a preventer, you should take it every day even when you have no symptoms and also during colds and asthma flare-ups.

2.2.5 Children

Some children with asthma need to take regular preventer treatment every day, as well as taking their reliever when they have symptoms.

Children aged 6 years and over may need regular preventer treatment if they need to take their reliever more than twice a week. Also, if they have flare-ups more often than every six weeks. The best type of medicine depends on their symptoms and age. If your child has been prescribed a preventer, you should make sure they take it every day (even during colds and asthma flare-ups) and keep taking it unless your doctor decides it is safe to stop.

Most preschool children do not need preventer treatment. Your child may need preventer treatment if wheezing occurs often and it is hard work to breathe when wheezing (e.g. your child’s chest sucks in while breathing in), if wheezing is severe enough to interrupt eating, play, exercise or sleep, or if your child has been hospitalised because of breathing problems.

2.2.6 Pregnancy

It is most important to keep asthma well controlled during pregnancy. Treatment of asthma is less risky for the mother and fetus than poorly controlled asthma or severe asthma attacks. Review asthma regularly (eg monthly) and intervene early during exacerbations to minimise risk of fetal hypoxia.

2.2.7 Exercise-induced bronchoconstriction

SABAs (inhaled 15 minutes before exercise) are first-line treatment. However, tolerance (decreasing duration and degree of protection) may develop with regular use; if this occurs or if SABA is required most days, start regular low-dose ICS treatment. Maximum effect of ICS usually occurs within 2–4 weeks (but could take up to 12 weeks), after which pre-exercise SABA may no longer be required.

Montelukast may be used instead of, or in addition to, low-dose ICS; it is generally less effective than SABAs or ICS, but tolerance does not develop.

Cromoglycate and nedocromil offer some protection but are less effective than SABAs.

LABAs although as effective as SABAs, are not appropriate alone (use with ICS); tolerance may develop.

3 Medicines

3.1 Relievers (SABA)

Using a spacer with inhaled asthma medication improves asthma control, and reduces the risk of side effects associated with inhaled corticosteroids.

Relievers (Short Acting 𝛽2-Agonists or SABA) are fast-acting medications that reduce the symptoms of asthma. They act to relax the muscles around the airways and open them up, allowing more air flow. Relievers work within minutes and their effects last for up to four hours.

Everyone who has asthma needs a reliever (e.g. a ‘puffer’) to use when they have asthma symptoms.

Airomir	Asmol	Bricanyl	Ventolin
Salbutamol	Salbutamol	Terbutaline	Salbutamol
How to use 1	How to use 1 How to use 2 How to use 3	How to use 1 How to use 2	How to use 1 How to use 2 How to use 3

3.2 Preventers

3.2.1 Types

Inhaled Corticosteroids (ICS)
Long Acting Beta Agonists (LABA)
Long Acting Muscarinic Antagonists (LAMA)
Non Steroidal Preventers

3.2.2 Single Preventer Inhalers (ICS)

Inhaled Corticosteroid (ICS) are the most common preventers. They all contain a medicine called corticosteroid, delivered by an inhaler device.

It is recommended that all puffers (MDI) should be used with a spacer.⁶

Name	Ingredient	Device & Strength
Alvesco	Ciclesonide	MDI 80µg 160µg
Flixotide	Fluticasone	MDI 50µg 125µg 250µg
Flixotide	Fluticasone	Accuhaler 100µg 250µg 500µg
Fluticasone Cipla	Fluticasone	MDI 125µg 250µg
Pulmicort	Budesonide	Turbuhaler 100µg 200µg 400µg
Qvar	Beclomethasone	MDI 50µg 100µg
Qvar	Beclomethasone	Autohaler 50µg 100µg

3.2.3 Combination Preventer Medicines (ICS + LABA)

It is recommended that all puffers (MDI) should be used with a spacer.⁶

Name	Ingredient	Device & Strength
Breo	Fluticasone Furoate + Vilanterol	Ellipta 100/25 200/25
Flutiform	Fluticasone + Formoterol	MDI 50/5 125/5 250/10
Fluticasone + Salmeterol Cipla	Fluticasone + Salmeterol	MDI 125/25 250/25
Seretide	Fluticasone + Salmeterol	MDI 50/25 125/25 250/25
Seretide	Fluticasone + Salmeterol	Accuhaler 100/50 250/50 500/50
Symbicort	Budesonide + Formoterol	Rapihaler 50/3 100/3 200/6
Symbicort	Budesonide + Formoterol	Turbuhaler 100/6 200/6 400/12
DuoResp Spiromax	Budesonide + Formoterol	Spiromax 200/6 400/12
Trelegy	Fluticasone Furoate + Umeclidinium + Vilanterol	Ellipta 100/62.5/25

3.2.4 Asthma medications for adults

Usual Choice	Comments
Initially
SABA when required for symptom relief add low-dose ICS when: symptoms >twice a month or waking due to asthma in previous month or exacerbation requiring systemic corticosteroids in the previous year	cromones or montelukast are less effective than low-dose ICS if symptoms are severe, consider: adding a short course of oral corticosteroid or using medium-dose ICS initially (reduce later) or starting at the next step
If still symptomatic
low-dose ICS + LABA for maintenance SABA when required for symptom relief	adding montelukast to low-dose ICS is less effective than adding a LABA
If still symptomatic
medium-dose ICS + LABA for maintenance SABA when required for symptom relief	consider referral to specialist
If still symptomatic
high-dose ICS + LABA for maintenance SABA when required for symptom relief	refer to specialist

3.2.5 Asthma medications for children

Usual Choice	Comments
Initially
1-2 years
SABA when required for symptom relief	consider low-dose ICS if symptoms disrupt sleep or play, or if exacerbations are frequent or severe
1-2 years
SABA when required for symptom relief add low-dose ICS for persistent asthma, if exacerbations are frequent or severe, or when atopy or raised blood eosinophils are present	consider montelukast as an alternative if unable to use ICS or if allergic rhinitis is present consider stopping ICS if good control for >6 months, particularly if aged <6 years
If still symptomatic
< 6 years
if already on ICS, increase the dose, or add montelukast SABA when required for symptom relief	refer to specialist
> 6 years
if already on ICS, increase the dose, or add montelukast or LABA (use in fixed-dose combination with ICS if possible) SABA when required for symptom relief	montelukast may be more effective for exercise-induced bronchoconstriction consider referral to specialist

3.2.6 Other Preventer Medications

Montelukast (Tablets)
Sodium cromoglycate (Inhaler)
Nedocromil sodium (Inhaler)

3.3 Correct Use of Inhalers

3.3.1 Using Spacers

Spacers should be washed before first use, and once a month:

wash in warm water and dish-washing detergent. Do not rinse
allow to air dry (do not dry with a cloth as this can make medication stick to the spacer making it less effective)
check for cracks and ensure that the valve is functioning.

Spacers are recommended for:

children (use a small-volume spacer for children <5 years, with a face mask if necessary)
adults with poor hand–breath coordination
acute asthma attacks
patients using inhaled corticosteroids, particularly at higher doses
reducing oropharyngeal adverse effects (candidiasis, dysphonia, frequent cough reflex).

3.3.2 Educational Videos on Correct Use of Inhalers

Type	Image	Links
Spacer Recommended for all ages		Video 1 Video 2 Video 3
Metered Dose Inhaler (MDI or Puffer) Use a spacer.		Video 1 Video 2 Video 3 Video 4
Autohaler		Video 1 Video 2 Video 3
Turbuhaler		Video 1 Video 2 Video 3
Accuhaler (Diskus)		Video 1 Video 2 Video 3
Ellipta DO NOT SHAKE		Video 1 Video 2
Respimat		Video 1
Breezehaler		Video 1 Video 2
Spiromax DO NOT SHAKE		Video 1 Video 2

4 Resources

4.1 Support

4.1.1 Asthma Educators

4.1.2 Information and Support Centre - Lung Foundation Australia

This free and confidential service is available Monday to Friday 8am – 4.30pm (AEST) (excl. public holidays). Freecall 1800 654 301 or email enquiries@lungfoundation.com.au

4.1.3 Asthma Control Test

https://asthma.org.au/about-asthma/understanding-asthma/asthma-control-test/

4.2 Information

4.2.1 Asthma in Numbers

One in every nine Australians have asthma – around 2.7 million of us.
It’s more common in males younger than 14 years. However, for people aged 15 years and over, it is more common in females.
The rate of asthma among Aboriginal and Torres Strait Islanders is almost twice as high as that of non-Aboriginal Australians. This is even more marked in the older adult age group.
Asthma is more common in people living in socioeconomically disadvantaged areas.
The prevalence is significantly higher in people living in outer regional and remote areas compared to people living in major cities.
More than one in every two children who are younger than 15 years (57 per cent) have a written Asthma Action Plan (AAP).
But fewer than one in every five people who are aged over 15 years have a written AAP. This is lowest for people aged 25-44 (16.5%).

4.2.2 The Cost of Asthma

The cost of asthma is measured by the long-term impact it has on the ability of people with asthma to participate in everyday life.

The estimated cost of asthma in Australia in 2015 was $28 billion or $11,740 per person with asthma. The cost of asthma includes:

$24.7 billion attributed to disability and premature death
$1.2 billion on healthcare costs (including medication, hospital and out-of-hospital costs
$1.1 billion in loss of productivity
$72.9 million in loss of wages for carers
$289.4 million in income support for carers of people with asthma

4.2.3 Impact of Asthma

Asthma has a major impact on individuals, their carers and Australia’s health system.

In 2017-2018 there were 38,792 hospitalisations in where asthma was the main diagnosis. Almost half (44%) of these were for children aged younger than 14 years old. Children under 15 were more likely to be hospitalised with asthma (442 per 100,000 population) than those aged 15 and over (98 per 100,000).

The previous year there were 70,034 Emergency Department presentations for asthma.

People with asthma are more likely to report a poor quality of life, especially those with severe or poorly controlled asthma. Asthma is the leading burdensome disease for children up to 15 years and in the top ten overall (AIHW Burden of Disease report).

There were 441 deaths due to asthma in 2016. The rate of all deaths due to asthma has remained stable since 2011.

Although there has been a long-term declining trend in deaths due to asthma over this time, Asthma Australia is working to reinvigorate new asthma management and controls so fewer people die.

Asthma mortality rates are higher for people living in remote or lower socioeconomic areas, and for Aboriginal and Torres Strait Islanders. From 2010-2014, the mortality rate for asthma among Aboriginal and Torres Strait Islanders was twice that of non-Aboriginal Australians.

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Asthma

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1. Understanding Asthma

1.1 What is asthma?