Topics in RED Box are relevant to KFP
Quick reference guide
Topics in RED Box are relevant to KFP asthmahandbook.org.au
version 1.0
(WEB CORRECTED)
ENDORSEMENT The Australian Asthma Handbook
The Royal Australian College of General Practitioners (RACGP)
National Asthma Council Australia ABN 61 058 044 634 Suite 104, Level 1, 153-161 Park Street South Melbourne, VIC 3205, Australia Tel: 03 9929 4333 Fax: 03 9929 4300 Email: nac@nationalasthma.org.au Website: nationalasthma.org.au
Topics in RED Box are relevant to KFP The Australian Primary Health Care Nurses Association (APNA)
RECOMMENDED CITATION National Asthma Council Australia. Australian Asthma Handbook – Quick Reference Guide, Version 1.0. National Asthma Council Australia, Melbourne, 2014. Available from: http://www.asthmahandbook.org.au The Thoracic Society of Australia and New Zealand (TSANZ)
National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. National Asthma Council Australia, Melbourne, 2014. Website. Available from: http://www.asthmahandbook.org.au ISSN 2203-4722 Š National Asthma Council Australia Ltd, 2014
DISCLAIMER The Australian Asthma Handbook practitioners, pharmacists, asthma educators, nurses and other health professionals and healthcare students. The information and treatment protocols contained in the Australian Asthma Handbook are based on current evidence and medical knowledge and practice as at the date of publication and to the best of our knowledge. Although reasonable care has been taken in the preparation of the Australian Asthma Handbook, the National contents.
The information and treatment protocols contained in the Australian Asthma Handbook are intended as a general guide individual examination and assessment of appropriate courses
use of the Australian Asthma Handbook or from treating asthma according to the guidelines therein.
Quick reference guide
Contents Complete online version of the Australian Asthma Handbook available at: asthmahandbook.org.au About the Handbook Website features
Abbreviations Diagnosis
Management
Acute asthma Clinical issues
Populations Preventing asthma Medicines guide
asthmahandbook.org.au
1 2 4 4 4 5 6 6 8 11 11 16 21 23 31 31 32 33 35 36 36 37 38
Key tables 5 5 6 8 10 10 11 13 13 14 15 16 18 18 19 19 20 20 21 22 23 28 29 30 31 32 33 34 36 37 38
7 9 12 17 24 26 35
Australian Asthma Handbook - Quick Reference Guide
About the Handbook Quick Reference Guide
Users
Australian Asthma Handbook Version 1.0, Australian Asthma Handbook
Visit asthmahandbook.org.au
OBJECTIVE
Development Australian Asthma Handbook Asthma Management Handbook. Australian Asthma Handbook
Australian Asthma Handbook
Scope Website Handbook
Australian Asthma
settings.
asthmahandbook.org.au
1
Website features Australian Asthma Handbook
about/methodology
asthmahandbook.org.au/
Recommendation showing methodology and evidence information plus hover-over reference information including a link through to the source.
2
Australian Asthma Handbook - Quick Reference Guide
More information
asthmahandbook.org.au/resources
topic including an embedded table that can be clicked to access content and hover-over glossary tool tip.
asthmahandbook.org.au
3
DEFINITIONS
A working definition of asthma Notes
•
•
• • 3
• •
1 1
Sources 1.
Global strategy for asthma management and prevention
2. Lancet 3. Eur Respir J 2
Topics in RED Box are relevant to KFP abbreviations CFC COPD ED EIB FEV1 FVC ICS ICU IgE
4
IV intravenous LABA NSAIDs OCS PBS PEF pMDI SABA TGA
2
2
Australian Asthma Handbook - Quick Reference Guide
Definition of variable airflow limitation Notes
•
1
1
FEV1
1, 2
• 1
• 1
2
• 3,4
•
Sources 1.
• Prim Care Respir J 2. Eur Respir J 3. Am Rev Respir Dis 4. Eur Respir J
Low
Medium
Low
High
High
>400 Budesonide
>800 >320 >500
Budesonide
Qvar
Qvar
Source
Source Respiratory, Version 4. Australian Asthma Handbook asset ID: 22
asthmahandbook.org.au
Therapeutic Guidelines:
management of childhood asthma 2010.
The role of corticosteroids in the
Australian Asthma Handbook asset ID: 21
5
Topics in RED Box are relevant to KFP
Diagnosis Diagnosing asthma in adults • • • •
• • • •
FEV1
Adapted from: Therapeutic Guidelines: Respiratory, Version 4 British Guideline on the Management of Asthma. A national clinical guideline. Australian Asthma Handbook asset ID: 2
6
Australian Asthma Handbook - Quick Reference Guide
VARIABLE RESPIRATORY SYMPTOMS THAT SUGGEST ASTHMA
HISTORY AND PHYSICAL EXAMINATION
NO
Table C. Findings that increase or decrease the probability of asthma in adults
INVESTIGATIONS FOR SPECIFIC ALTERNATIVE DIAGNOSIS
YES
ALTERNATIVE DIAGNOSIS
Alternative diagnosis confirmed?
Supports asthma diagnosis? YES
NO
SPIROMETRY FEV1 before and 10-15 mins after bronchodilator Reversible airflow limitation? (FEV1
FURTHER INVESTIGATIONS NO
Tests as indicated Consider bronchial provocation test Supports asthma diagnosis?
YES
CONSIDER REFERRAL NO
YES
asthma
Start asthma treatment and review response
Australian Asthma Handbook asset ID: 4
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7
Diagnosing asthma in children
• •
• •
•
• • •
A diagnosis of asthma should not be made if cough is the only or predominant respiratory symptom and there are no
• • • • AND • • • • • • • • •
• • • • • • • •
• •
Sources British Guideline on the management of Asthma. A national clinical guideline. Therapeutic Guidelines: Respiratory, Version 4 Australian Asthma Handbook asset ID: 12
8
Australian Asthma Handbook - Quick Reference Guide
wheezing disorder
episodic respiratory Symptoms that suggest asthma
HISTORY AND PHYSICAL EXAMINATION Table D. Findings that increase or decrease the probability of asthma in children
YES
Supports asthma diagnosis?
YES
NO
NO
YES
NO
INVESTIGATIONS FOR SPECIFIC ALTERNATIVE DIAGNOSIS Table E: Findings that require investigation in children Table F: Conditions that can be confused with asthma in children Alternative diagnosis confirmed?
NO
FURTHER INVESTIGATIONS Consider bronchial provocation test, cardiopulmonary exercise test and other tests as indicated Supports asthma diagnosis?
YES
Start asthma treatment and review response
asthma
YES
Reversible airflow limitation? (FEV1 baseline)
FEV1 before and 10-15 mins after bronchodilator
SPIROMETRY
Child able to perform spirometry? NO
treatment trial Seek specialist advice if child under 6 months old Clear response to treatment?
NO
Asthma not confirmed Monitor signs and symptoms and consider referral
Consider options (treatment trial or further investigations) according to individual circumstances, including child’s ability to do bronchial provocation test or cardiopulmonary exercise test. Australian Asthma Handbook asset ID: 17
*
YES
NO
ALTERNATIVE DIAGNOSIS
consider alternative diagnoses and referral
asthmahandbook.org.au 9
Notes
Australian Asthma Handbook asset ID: 59
Source
Australian Asthma Handbook asset ID: 11
10
Australian Asthma Handbook - Quick Reference Guide
Management
Managing asthma in adults
• •
and recent asthma symptom control in adults
• • • adjusting asthma medication in adults • • • • • • • •
•
•
•
•
•
•
•
•
•
•
•
waking
waking
•
waking
Source Global strategy for asthma management and prevention Australian Asthma Handbook asset ID: 33
asthmahandbook.org.au
11
Referral
FEW patients
Higher dose regular preventer ICS/LABA combination (moderate-high dose)
Consider referral
SOME patients
Stepped up regular preventer
ICS/LABA combination (low dose)â€
See:
most patients Regular preventer ICS (low dose)
See:
All patients As-needed reliever
SABA*
§
R See:
2
Note Australian Asthma Handbook asset ID: 31
12
Australian Asthma Handbook - Quick Reference Guide
• •
troublesome • •
Australian Asthma Handbook asset ID: 32
• • •
Australian Asthma Handbook asset ID: 5
asthmahandbook.org.au
13
disease
Alternaria
2
Sources
Global strategy for asthma management and prevention BMJ Open Chest Prim Care Respir J Australian Asthma Handbook asset ID: 40
14
Australian Asthma Handbook - Quick Reference Guide
month
Alternaria
Australian Asthma Handbook asset ID: 41
asthmahandbook.org.au
15
Managing asthma in children
• • • assessing triggers • • • adjusting asthma medication in children
symptom control in children
• • • • • • • •
•
•
•
• •
• •
•
•
• 2
Adapted from: Australian Asthma Handbook asset ID: 23
16
Australian Asthma Handbook - Quick Reference Guide
Referral
FEW CHILDREN
Stepped up regular preventer
ICS (high dose) or ICS (low dose) plus montelukast or ICS /LABA combination (low dose) See: Table Q. Reviewing and adjusting preventer treatment for children aged 0–5 years Table R. Reviewing and adjusting preventer treatment for children aged 6 years and over
some CHILDREN Regular preventer
ICS (low dose) or montelukast or cromone See: Table O. Initial preventer treatment for children 0-5 years Table P. Initial preventer treatment for children 6 years and over
All CHILDREN As-needed reliever
SABA*
Review recent control and risk regularly§ See:
Note Australian Asthma Handbook asset ID: 18
asthmahandbook.org.au
17
Persistent asthma
Mild
Moderate
• • • • • • • • •
Australian Asthma Handbook asset ID: 14
Persistent asthma
Mild
Moderate
FEV1 • • • FEV1 • • • • FEV1 • • • •
Australian Asthma Handbook asset ID: 15
18
Australian Asthma Handbook - Quick Reference Guide
Intermittent asthma
Intermittent asthma
Infrequent intermittent asthma
Frequent intermittent asthma Mild persistent asthma weeks
Moderate–severe persistent asthma
2
Australian Asthma Handbook asset ID: 20
Note
Note
2
Australian Asthma Handbook asset ID: 16
asthmahandbook.org.au
19
Treatment response
No treatment response †
4 weeks
reviewing in 4 weeks
Australian Asthma Handbook asset ID: 25
(symptoms well controlled)
No or partial treatment response †
Set review date
4 weeks Set review date
•
• • 2
Australian Asthma Handbook asset ID: 26
20
Australian Asthma Handbook - Quick Reference Guide
Inhaler devices and technique
• •
Adherence Australian Asthma Handbook
•
Haleraid
Source Australian Asthma Handbook asset ID: 76
asthmahandbook.org.au
21
Brand name Relievers Airomir Asmol Ventolin Rapihaler Preventers Alvesco Flixotide Flutiform Intal Intal Forte Qvar Rapihaler Tilade Autohaler
Relievers Airomir Preventers Qvar
Accuhaler
Preventers Flixotide Other Foradile
Turbuhaler
Relievers Bricanyl
Preventers Pulmicort Other Oxis Australian Asthma Handbook asset ID: 75
22
Australian Asthma Handbook - Quick Reference Guide
acute asthma
Managing acute asthma in clinical settings
Notes
• • • • •
•
•
•
• • • • •
• • Notes
Australian Asthma Handbook asset ID: 74
asthmahandbook.org.au
23
24
Figure E. Managing acute asthma in adults
IMMEDIATELY
Assess severity and start bronchodilator Table U. Rapid primary assessment of acute asthma in adults and children
Australian Asthma Handbook - Quick Reference Guide
Mild/Moderate
Severe
Life-threatening
Can walk and speak whole sentences in one breath
Any of: unable to speak in sentences, visibly breathless, increased work of breathing, oxygen saturation 90-94%
Any of: drowsy, collapsed, exhausted, cyanotic, poor respiratory effort, oxygen saturation less than 90%
Give 4–12 puffs salbutamol (100 mcg per actuation) via pMDI plus spacer
Give 12 puffs salbutamol (100 mcg per actuation) via pMDI plus spacer or Use intermittent nebulisation if patient cannot breathe through spacer. Give 5 mg nebule salbutamol. Drive nebuliser with air unless oxygen needed Start oxygen (if oxygen saturation less than 95%) Titrate to target oxygen saturation of 92–95%
Give 2 x 5 mg nebules salbutamol via continuous nebulisation Start oxygen (if oxygen saturation less than 95%) Titrate to target oxygen saturation of 92–95% ARRANGE IMMEDIATE TRANSFER TO HIGHER LEVEL CARE
Notify senior staff Ventilate if required (NPPV or intubate and ventilate) Transfer to ICU if no improvement
within mINUTES
reAssess severity
Table V. Secondary severity assessment of acute asthma in adults and children aged 6 years and over
Continue Bronchodilator
Continue Bronchodilator
Repeat dose every 20–30 mins for first hour if needed (or sooner as needed)
Repeat dose every 20 minutes for first hour (3 doses) or sooner as needed
If poor response, add ipratropium bromide Repeat every 4–6 hours as needed
Continue Bronchodilator Continuous nebulisation until dyspnoea improves. Then consider changing to pMDI plus spacer or intermittent nebuliser (doses as for Severe)
Give 8 puffs (160 mcg) via pMDI (21 mcg/actuation) every 20 minutes for first hour OR Give 500 mcg nebule via nebuliser added to nebulised salbutamol every 20 minutes for first hour
consider other add-on treatment options Table X. Add-on treatment options for acute asthma
asthmahandbook.org.au
within first hour
1
hour
AFTER 1-hour CHECK
start systemic corticosteroids
Oral prednisolone 37.5–50 mg then continue 5–10 days OR, if oral route not possible Hydrocortisone 100 mg IV every 6 hours
reAssess response to treatment (1 hour after starting bronchodilator)
Perform spirometry (if patient capable) Repeat pulse oximetry Check for dyspnoea while supine
Dyspnoea resolved
observe
for more than 1 hour after dyspnoea resolves
PROVIDE POST-ACUTE CARE Ensure person (or carer) is able to monitor and manage asthma at home Provide oral prednisolone for 5–10 days Ensure person has regular inhaled preventer Check and coach in correct inhaler technique Provide spacer if needed Provide interim asthma action plan Advise/arrange follow-up review
Australian Asthma Handbook asset ID: 65
Dyspnoea persists
Persisting mild/moderate acute asthma
Arrange hospital admission continue bronchodilator and add-on treatment Table X. Add-on treatment options for acute asthma
Persisting severe or life-threatening acute asthma
Transfer to ICU or discuss transfer/retrieval with senior medical staff
25
26
Figure F. Managing acute asthma in children IMMEDIATELY
Assess severity and start bronchodilator Table U. Rapid primary assessment of acute asthma in adults and children
Australian Asthma Handbook - Quick Reference Guide
Mild/Moderate
Severe
Life-threatening
Can walk and speak whole sentences in one breath (Young children: can move about and speak in phrases)
Any of: unable to speak in sentences, visibly breathless, increased work of breathing, oxygen saturation 90-94%
Any of: drowsy, collapsed, exhausted, cyanotic, poor respiratory effort, oxygen saturation less than 90%
Give salbutamol (100 mcg per actuation) via pMDI plus spacer (plus mask for younger children) 6 years and over: 4–12 puffs 0–5 years: 2–6 puffs
Give salbutamol (100 mcg per actuation) via pMDI plus spacer (plus mask for younger children) 6 years and over: 12 puffs 0–5 years: 6 puffs or If patient cannot breathe through spacer and mask, give salbutamol via intermittent nebulisation driven by oxygen: 6 years and over: 5 mg nebule 0–5 years: 2.5 mg nebule Start oxygen if oxygen saturation less than 95% Titrate to target oxygen saturation of at least 95%
Asthma is less likely to be the cause of wheezing in infants less than 12 months old. Monitor closely. If symptoms do not respond, reconsider the diagnosis and contact a paediatrician.
within mINUTES
Give salbutamol via continuous nebulisation driven by oxygen 6 years and over: use 2 x 5 mg nebules 0–5 years: use 2 x 2.5 mg nebules Start oxygen if oxygen saturation less than 95% Titrate to target oxygen saturation of at least 95% ARRANGE IMMEDIATE TRANSFER TO HIGHER LEVEL CARE
Notify senior staff Ventilate if required (NPPV or intubate and ventilate) Transfer to ICU if no improvement
reAssess severity Table V. Secondary severity assessment of acute asthma in adults and children 6 years and over Table W. Secondary severity assessment of acute asthma in children 0-5 years
Continue Bronchodilator
Continue Bronchodilator
Repeat dose every 20–30 mins for first hour if needed (or sooner as needed)
Repeat dose every 20 minutes for first hour (3 doses) or sooner as needed
If poor response, add ipratropium bromide
Continue Bronchodilator Continuous nebulisation until breathing difficulty improves. Then consider changing to pMDI plus spacer or intermittent nebuliser (doses as for Severe)
6 years and over: 8 puffs (160 mcg) via pMDI (21 mcg/actuation) every 20 minutes for first hour 0–5 years: 4 puffs (80 mcg) via pMDI (21 mcg/actuation) every 20 minutes for first hour. OR Give via nebuliser added to nebulised salbutamol 6 years and over: 500 mcg nebule 0–5 years: 250 mcg nebule
Repeat every 4–6 hours as needed
consider other add-on treatment options Table X. Add-on treatment options for acute asthma
asthmahandbook.org.au
Table X. Add-on treatment options for acute asthma
within first hour
start systemic corticosteroids
Oral prednisolone 2 mg/kg oral (maximum 50 mg) then 1 mg/kg on days 2 and 3 OR, if oral route not possible Hydrocortisone IV initial dose 8–10 mg/kg (max 300 mg), then 4–5 mg/kg/dose every 6 hours on day 1, then every 12 hours on day 2, then once on day 3 OR Methylprednisolone IV initial dose 2 mg/kg (max 60 mg), then 1 mg/kg every 6 hours on day 1, then every 12 hours on day 2, then once on day 3 For children 0–5 years, avoid systemic corticosteroids if mild/moderate wheezing responds to initial bronchodilator treatment
1
hour
AFTER 1-hour CHECK
reAssess response to treatment (1 hour after starting bronchodilator)
No breathing difficulty
Perform spirometry (if child capable)
Breathing difficulty persists
Arrange hospital admission Continue bronchodilator and add-on treatment Table X. Add-on treatment options for acute asthma
observe
for more than 1 hour after dyspnoea resolves
reassess
PROVIDE POST-ACUTE CARE Ensure parents are able to monitor and manage asthma at home Provide oral prednisolone for 3–5 days Ensure child has regular inhaled preventer if indicated
No breathing difficulty for more than one hour
Breathing difficulty persists
Persisting severe or life-threatening acute asthma
Check and coach in correct inhaler technique Provide spacer if needed Provide interim asthma action plan Advise/arrange follow-up review
Australian Asthma Handbook asset ID: 67
Transfer to ICU or discuss transfer/retrieval with senior medical staff
27
Note: If features of more than one severity category are present, record the higher category as overall severity level
Posture
or
or
or
† †
Heart rate or
† or
or
or
2 2 2 2
2
2
Australian Asthma Handbook asset ID: 63
28
Australian Asthma Handbook - Quick Reference Guide
Note: If features of more than one severity category are present, record the higher category as overall severity level
† Posture or
or
or
† †
Heart rate or
† or
or
or
Australian Asthma Handbook asset ID: 64
Normal respiratory and heart rates in children Heart rate
Source Advanced paediatric life support: the practical approach.
asthmahandbook.org.au
29
Notes
asthma Adults Children 6 years and over
bromide
Children 0–5 years
Adults
Children 2 years and over
Adults and children
to tire or signs of
Australian Asthma Handbook asset ID: 61
30
Australian Asthma Handbook - Quick Reference Guide
Clinical issues Troubleshooting
Other clinical issues Australian Asthma Handbook website • • • •
• • • •
Allergies and asthma Comorbid conditions and asthma Complementary therapies and asthma Chronic obstructive pulmonary disease (COPD) and asthma • Food and asthma •
Australian Asthma Handbook asset ID: 58
asthmahandbook.org.au
31
Asthma triggers
Cigarette smoke
Exercise Laughter
Allergens (if person is sensitised)
Respiratory tract infections
•
Certain medicines
•
•
•
•
•
•
•
Comorbid medical conditions
•
•
•
•
Airborne/environmental irritants
•
•
•
•
•
•
Physiological and psychological changes
•
•
•
•
•
•
•
•
• • • Certain medicines • • • Dietary triggers • •
Australian Asthma Handbook asset ID: 52
32
Australian Asthma Handbook - Quick Reference Guide
Exercise and asthma
Notes
Exercise symptoms on most or all days is assessed as
Exercise symptoms some days
• • • •
* See
** See Australian Asthma Handbook asset ID: 85
asthmahandbook.org.au
33
Notes
Exercise symptoms most or all days is assessed as Exercise symptoms some days but not every day
• • •
•
* See § See
and
** See Notes
Australian Asthma Handbook asset ID: 84
34
Australian Asthma Handbook - Quick Reference Guide
SMOKING AND ASTHMA
• • • • •
a
Mean FEV1
b
Source
Am J Respir Crit Care Med
Australian Asthma Handbook asset ID: 7
asthmahandbook.org.au
35
Populations
Asthma in pregnant women
Other populations Australian Asthma Handbook website babies at risk.
• •
• Adolescents and young adults • Older adults • • Culturally and linguistically diverse communities
• •
Primary prevention of asthma Australian Asthma Handbook
02 6244 3333
Queensland
Western Australia
Australian Asthma Handbook asset ID: 71
36
Australian Asthma Handbook - Quick Reference Guide
Preventing asthma
Nutrition • • • • Physical activity
Obesity
vaccination
Pneumococcal vaccination General health
Comorbidities • • • • Mental health
Complementary medicines
Australian Asthma Handbook asset ID: 86
asthmahandbook.org.au
37
Medicines guide
2
agonist
2
antagonists.
Duration
Role Relievers
2
beta2 term medicines (symptomatic and acute asthma treatment)
Preventers
2
medicines
asthmahandbook.org.au/resources/medicines-guide
Australian Asthma Handbook. Notes: Australian Asthma Handbook asset ID: 79
38
Australian Asthma Handbook - Quick Reference Guide
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AUSTRALIAN ASTHMA HANDBOOK - QUICK REFERENCE GUIDE
Australia's National Guidelines for Asthma Management