1st December 2017, Volume 130 Number 1466

Innes Asher, David McNamara, Cheryl Davies, Teresa Demetriou, Theresa Fleming, Matire Harwood, Lorraine Hetaraka-Stevens, Tristram Ingham, John Kristiansen, Jim Reid, Debbie Rickard, Debbie Ryan

Abbreviations:

FEV1

Forced expiratory volume in one second

ICS

Inhaled corticosteroid

LABA

Long-acting beta-agonist

MDI

Metered dose inhaler

PEF

Peak expiratory flow

SABA

Short-acting beta-agonist

SpO2

Oxygen saturation

Inequities in New Zealand

Despite advances in knowledge about asthma and its management, we could be doing better. We believe that all children in New Zealand have the right to achieve the highest standard of asthma outcomes equally. In New Zealand, a large number of children are not faring well with their asthma, especially due to disadvantages that arise from inadequate income for the basics needed for wellbeing, and unhealthy indoor environments (homes which are crowded, cold, damp, mouldy,1 smoke-exposed or with unflued gas heating2). Children aged 13–17 years usually do not have free primary healthcare visits or prescriptions. Māori and Pacific children with asthma are more likely to have severe asthma symptoms and be hospitalised, but are less likely to be prescribed inhaled corticosteroid (ICS), have an action plan or receive adequate education (see “Māori—getting it right for Māori children with asthma” and “Pacific peoples—getting it right for Pacific children with asthma”). Other groups who experience inequities include refugees, people living in remote rural areas and people with low English language proficiency. All health professionals have a role in improving outcomes and reducing inequities, and these guidelines specify the actions required regarding asthma.

New reports to inform us

Three important reports were released by the Asthma and Respiratory Foundation of New Zealand in 2015:The Impact of Respiratory Disease in New Zealand: 2014 Update,3 He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand4 and Te Hā Ora: The National Respiratory Strategy.5 In 2017 The Impact of Respiratory Disease in New Zealand report was updated.These reports describe the context of the growing impact of asthma in New Zealand, especially among children, the inequities suffered by Māori, Pacific peoples and low-income families, and the intersectorial and holistic approaches needed to tackle the issues.

Other guidelines consulted

This guide is a complete update of the outdated Paediatric Society of New Zealand 2005 Management of Asthma in Children aged 1–15 years. The following guidelines were reviewed in the preparation of this document: the National Asthma Council of Australia 2015 Australian Asthma Handbook version 1.1, including the companion Quick Reference Guide,6 the Global Initiative for Asthma 2016 Asthma Management and Prevention, including the companion Pocket Guide,7 the SIGN 2016 British Guidelines on the Management of Asthma, including the Quick Reference Guide,8 and the Asthma and Respiratory Foundation NZ Adult Asthma Guidelines: A Quick Reference Guide.9

A systematic review was not performed, although relevant references were reviewed as required to formulate this guideline, and to clarify differences in recommendations made between guidelines. Readers are referred to the above published guidelines and handbooks for the more comprehensive detail and references that they provide. Additional analyses and reviews on the assessment and management of preschool wheezing were consulted.10–12

Grading

No levels of evidence grades are provided here due to the format of this quick reference guide. Readers are referred to the above published guidelines and handbooks for the level of evidence for the recommendations on which the Child and Adolescent Asthma Guidelines: A Quick Reference Guide are based.

Age

Adolescents

These guidelines apply to children 15 years and below. However, adolescents mature at different rates, and for many who are still maturing and require adult support with their asthma care, these guidelines will usually apply. Once adolescents are largely responsible for their own management, application of the recently published Adult Asthma Guidelines: A Quick Reference Guide, intended for those 16 years and over, becomes more appropriate. Special care is needed to ensure that the adolescent transitions in a developmentally appropriate way as they become more independent, make their own decisions and emerge as adults. Adolescents transitioning from family to self-management may have differing priorities.

Children aged under five years

There are special considerations in young children (1–4 years) who wheeze, as many of them do not go on to develop asthma (see Diagnosis).

Guideline development

The Guideline Development Group included representatives from a range of professions, disciplines and backgrounds relevant to the scope of the guidelines. A Draft for Consultation of this report was peer-reviewed by a wide range of respiratory health experts and key professional organisations (see Appendix C).

The guidelines are primarily presented through lists, tables and figures in an electronic format, which can be used in clinical practice. Key references are provided where necessary to support recommendations that may differ from previous or other guidelines, or standard clinical practice.

Dissemination plan

The guidelines will be translated into tools for practical use by health professionals, and used to update existing consumer resources. They will be published on the Asthma and Respiratory Foundation NZ website, and disseminated widely via a range of publications, training opportunities and other communication channels to health professionals, nursing and medical schools, primary health organisations and district health boards.

Implementation

The implementation of the Child and Adolescent Guidelines: A Quick Reference Guide by organisations will require communication, education and training strategies.

Expiry date

The expiry date of the guide is 2022.

Health professional to 10 actions

These are the top 10 ways health professionals can help (apart from prescribing medicines)

1. Relationships

Encourage the continuity of care with doctors and nurses in your practice and secondary care, and make follow-up appointments—relationships help. Easy access to a trusted nurse and telephone follow-up is recommended.

2. Wellness

Work with families to attain and maintain wellness, and not accept sickness as the norm.

3. Smoke exposure

Ask about smoke exposure, encourage reducing tobacco smoke exposure in the child’s environment (home and car) and recommend smoking cessation. If appropriate, give advice and refer to a local smoking cessation service or Quitline (0800 778 778). Provide Health Sponsorship Council’s pamphlet A Guide to Making Your Home and Car Smokefree (www.healthed.govt.nz/).

4. Housing

A lot of New Zealanders live in unhealthy housing, and conditions are worse in private rental housing. Some families are homeless. Therefore ask about housing and unhealthy features (crowding, cold, damp, mouldy, unflued gas heater). (http://www.asthmafoundation.org.nz/about-us/advocacy/national-respiratory-strategy; http://www.energywise.govt.nz/). Provide the family with information about having a healthy home (“Tips for healthy living” http://www.asthmafoundation.org.nz/your-health/healthy-living) and if relevant, refer for healthy housing assessment if available in your region.

5. Income

Assume that most families struggle with income and ask about it. Inquire about the ability to access the doctor, the pharmacy and paying for prescriptions. Does the child have partly or uncontrolled persistent asthma and meet criteria for Child Disability Allowance?13 (http://www.workandincome.govt.nz/). It is important for all family members to use the same pharmacy because once patients and their families have collected 20 new prescription items in a year, they won’t have to pay any more prescription charges until 1 February the following year (http://www.health.govt.nz/your-health/conditions-and-treatments/treatments-and-surgery/medications/prescription-charges).

6. Health literacy

Assume little health literacy, and use steps described in He Māramatanga Huangō: Asthma Health Literacy for Māori Children in New Zealand. Specifically ask the child and whānau what they understand, what they want to know, and use simple language to explain about asthma. For example, use the term ‘asthma flare-up’ rather than ‘asthma exacerbation’.

7. Adherence

Firstly, assume inhaler device technique is poor and check it. Secondly, assume adherence is imperfect and don’t judge. Ask questions in an open way, such as “Many people take less preventer than the doctor prescribes—about how many times a week do you take your asthma preventer?”14–16

8. Asthma action plan

Develop an appropriate asthma action plan with the child and family and check on each visit. Plans should be made available to schools and child care facilities where appropriate. (http://www.asthmafoundation.org.nz/resources).

9. Access

Help the family to understand how to access care appropriate to asthma severity, and identify any barriers they have. Consider referral to asthma educator, Māori providers or paediatrician where available and appropriate.

10. Ambulance

Ensure the family know when and how to call an ambulance. In some regions this service may incur a charge.

Diagnosis

Goal: All children who have asthma are promptly and correctly diagnosed

Approach to diagnosis

  • The diagnosis of asthma is based on the recognition of a characteristic pattern of symptoms and signs (Table 1) and response to treatment, in the absence of an alternative explanation.
  • Initial diagnosis is probability-based and should always be reconsidered if the patient fails to respond to therapy, or has atypical symptoms or signs.
  • The key to making the diagnosis of asthma is to take a careful clinical history and assess clinical +/- spirometry response to inhaled bronchodilator and/or ICS treatment. There is no reliable single ‘gold standard’ diagnostic test.
  • The diagnosis and monitoring of asthma requires frequent and repeated review. This may require the use of recall or follow-up systems (Figure 2).
  • Algorithms to guide the diagnosis in 1–4 year olds (Figure 1A) and 5–15 year olds (Figure 1B).
Table 1: Clinical features that increase or decrease the probability of asthma in children and adolescents.

c 

*Consider aspiration, bronchiectasis, ciliary dyskinesia, cystic fibrosis, developmental airway anomaly, foreign body aspiration, heart disease, hyperventilation, immunodeficiency, tuberculosis, vocal cord dysfunction.

Figure 1A: Diagnostic pathway for asthma and wheeze in children 1–4 years.6,8

c 

Figure 1B: Diagnostic pathway for asthma and wheeze in children 5–15 years.18,19 

c 

Practice points

  • During a trial of therapy, give the patient a label of ‘suspected asthma’ as a means of communicating with other health professionals.
  • In most children, observing a symptomatic response to treatment may help to confirm the diagnosis, but a limited response to bronchodilator or ICS does not rule out asthma.
  • In children with a high probability of asthma, start a trial of treatment (see Figures 4 and 5) and assess the response to therapy.
  • In children with a low probability of asthma, perform further investigations, such as chest x-ray and/or specialist referral prior to initiating preventer therapy.
  • Spirometry may be helpful in older children (≥12 years or six years and above if paediatric-trained technician).
  • In New Zealand, bronchiectasis should be considered for all children with asthma symptoms at any age. Sometimes bronchiectasis co-exists with asthma, and can be missed on a chest x-ray. Chronic wet cough is a key marker.

Children 1–4 years of age

  • Young children 1–4 years are a special group, as about half of those who wheeze do not have asthma at school age and later.
  • They are managed according to three patterns of symptoms and labelled accordingly to assist making decisions about prescribing ICS.
  • In each of these groups, a bronchodilator should be prescribed as for asthma, according to clinical severity (see Figure 4).

Infrequent preschool wheeze

For those with infrequent symptoms, or who wheeze only with viral illnesses, ICS are not indicated. An alternative term sometimes used is ‘infrequent episodic (viral) wheeze’.

Frequent preschool wheeze

For those with frequent episodes of wheeze (more than every 6–8 weeks), only with viral illnesses, but no symptoms in the interval between—give a trial of ICS for a minimum of eight weeks. If there is a positive response, these children should then be labelled as ‘preschool asthma’, if not, the treatment should be stopped and the child should remain labelled as ‘frequent preschool wheeze’. An alternative term sometimes used is ‘frequent episodic (viral) wheeze’.

Preschool asthma

Those with frequent symptoms typical for asthma during and in the interval between viral illnesses. Treat as for asthma and give a trial of ICS (preferred) or montelukast, and the same treatment is indicated if there are severe attacks (see Figure 6). An alternative term sometimes used for this pattern is ‘multi-trigger wheeze’. This label does NOT mean the child will go on to have asthma at school age or as an adult, which may be reassuring for many families.

Wheezing in children under one year

In children under one year, bronchiolitis is the most common cause of wheezing, and the PREDICT Australasian Bronchiolitis Clinical Practice Guideline17 should be followed. If the illness does not seem to be bronchiolitis, then refer to Table 1 and Figure 1A for guidance.

Assessing asthma severity, control and future risk

Goal: All children with asthma are assessed for their severity, control and future risk

Evaluation of asthma control and severity

  • Evaluation of asthma severity, the level of control and the risk of future events are all-important components of the assessment of children with asthma.
  • Asthma control is defined by the frequency of symptoms, the degree to which symptoms affect sleep and activity, and the need for reliever medication.
  • Poor asthma control is defined as regular symptoms occurring in a usual week that affect the patient’s quality of life, or according to the asthma symptom control measures below.
  • Poor control should trigger a review of adherence, inhaler technique and preventer therapy.
  • If poor control persists, then reconsider the diagnosis.
  • If poor control persists despite above, then consider increasing the asthma treatment step.
  • The level of asthma control should be assessed regularly. Two methods for assessing asthma symptom control are the Asthma Control Test and the GINA Assessment.
1.  Asthma Control Test for children 4–11 years (below; Adult guideline for ≥12 years9).
c

Table 2: GINA assessment of asthma symptom control in people six years and over (1) (See Table 3).

A. Asthma symptom control

Level of asthma symptom control

In the past four weeks, has the patient had:

Well controlled

Partly controlled

Uncontrolled

  • Daytime asthma symptoms more than twice/week?

  • Any night waking due to asthma?

  • Reliever needed for symptoms* more than twice/week?

  • Any activity limitation due to asthma?

Yes
No □

Yes
No □

Yes
No □

Yes
No □

None of these

1–2 of these

3–4 of these

 *Excludes reliever taken before exercise.
(GINA recommends assessment of risk factors as an essential part of the assessment of asthma control).
(Modified with permission of GINA). 

2.  The GINA yes/no questions about the four criteria in Table 2 above, regardless of current treatment regimen.7

Practice points—severity and future risk

  • Assessment of asthma also involves risk of adverse outcomes, including severe exacerbations, deaths and treatment-related adverse effects (Table 3).
  • Severity of asthma is defined by the treatment step (Figures 4 and 5) needed to maintain good control. Work with patient/parent to determine what good control looks like.6
  • For symptomatic children, asthma severity can be determined only after a therapeutic trial of ICS for at least eight weeks (Figures 4 and 5). Start the therapeutic trial and book the follow-up appointment for eight weeks later.
  • The best predictor of future asthma attacks is the number of exacerbations in the last 12 months.
  • Growth (height and weight) should be measured at least annually in children with asthma, and plotted on a percentile chart. Fall-off on percentiles suggests poor asthma control; other causes include malnutrition, frequent oral corticosteroids or after initiation of higher dose ICS.
  • Increase in weight may reflect inappropriate diet and steroid dose.
  • Monitor healthcare use. Children and adolescents with high healthcare use (such as hospital admissions, emergency department visits, emergency doctor visits and unplanned doctor visits) are at high risk for severe or life-threatening asthma.
  • Monitor medicine use. Children and adolescents with high medication requirements or usage (such as courses of oral steroids, frequency of beta-agonist prescriptions and more prescriptions for beta-agonists than ICS) are at high risk for severe or life-threatening asthma.

Table 3: Features associated with increased risk of severe asthma exacerbations and/or death from asthma.20

A.        Asthma

  • Poor asthma control
  • Hospitalisation or emergency department visit for asthma in the last year
  • Extreme inhaled bronchodilator use (>1 canister per month)
  • History of sudden asthma attacks
  • Intensive care admission or intubation (ever)
  • Requirement for long-term oral steroids

B.        Comorbidity

  • Major psychosocial problems
  • Alcohol and drug abuse in family
  • Severe food allergy and anaphylaxis

C.        Other factors

  • Poor inhaler technique
  • Underuse or poor adherence to ICS treatment
  • Tobacco smoke exposure
  • Discontinuous medical care
  • Socioeconomic disadvantage
  • Financial hardship
  • Unhealthy housing
  • Māori and Pacific ethnicity
  • Child protection issues (consider Vulnerable Children Act 2014).          www.legislation.govt.nz/act/public/2014/0040/latest/DLM5501618.html

Management approaches

Identifying management goals with the child & whānau

Goal: The child and family participate in goal-setting

  • Managing asthma requires a partnership between the child, their parents, their whānau and their healthcare team. This will change and develop as children age and involves patient willingness and understanding, agreeing on management goals.
  • Management and partnership are based on a cycle of repeated assessment, adjustment of treatment and review of responses, as outlined in Figure 2.
Figure 2: Asthma management as a continuous cycle of monitoring and reassessment, adapted from GINA (1). 
c
*(patient or parent).

Non-pharmacological measures

Goal: Personal, whānau or environmental factors which may be unsettling asthma are identified and addressed (see Health professional to 10 actions section)

  • To improve asthma outcomes, avoid smoke exposure and known triggers.
  • Avoid triggers which are known to provoke or precipitate asthma attacks (except exercise) or anaphylaxis.
  • Exercise and physical activity should be encouraged, as exercise-induced asthma can be managed. Chlorinated swimming pools may be a trigger for some children.
  • Psychosocial stressors are potent triggers of asthma symptoms. Identification of these triggers and the introduction of very simple strategies, such as slow, relaxed breathing when stressed, may help the patient and whānau in managing symptoms.
  • If anxiety or panic play a part, involve the family to support the patient and consider referral for psychological counselling.
  • Dysfunctional breathing or a breathing pattern disorder can be a contributing factor in the severity of asthma. A physiotherapist can advise on breathing awareness and exercises to help relaxation and improve effectiveness of breathing.
  • Keeping the nose clear will help asthma control, as it filters, warms and humidifies the air to the lungs. Saline drops and frequent blowing are usually adequate.
  • Asthma control may be improved by better insulation and avoiding cold, damp, mouldy or crowded housing.
  • Unflued gas heaters may make asthma symptoms worse (http://www.health.govt.nz/your-health/healthy-living/environmental-health/household-items-and-electronics/unflued-gas-heaters).
  • House dust mite avoidance measures are not effective38 unless the child has symptoms that are clearly triggered on exposure to dust mite allergens.
  • A healthy diet is wise, but other modifications to diet are unlikely to improve asthma control unless food allergy is confirmed.

Self-management

Goal: Effective self/family education and management is achieved

  • Asthma education and improving health literacy and self-efficacy are fundamental in asthma management, and are the responsibility of all health professionals.
  • All patients with asthma and their caregivers should be offered management education, which should include a written personalised asthma action plan. Ask the patient/parent how best to achieve this.6,8
  • Adherence to treatment should be routinely assessed and encouragement provided as part of the self-management education. The health professional should gain an understanding of why the patient/parent is doing anything different7,8
  • Asthma management in all contexts needs attention, including child care and school environments, and support of teachers.

Practice points—enhancing self-management

  • Asthma education should increase health knowledge about asthma, general health literacy and self-efficacy, and should be reinforced every visit.
  • Teach families to recognise when asthma is poorly controlled, know when and how to call emergency services.
  • Asthma education should utilise a variety of media, including printed materials as well as verbal explanations, and printed materials in the first language if possible, eg, www.pamp.co.nz, which produces simple, individualised pictorial asthma medication plans in Te Reo Māori, Samoan, Tongan, Tuvaluan and Chinese.22
  • Education should be delivered in chunks and delivered across multiple visits instead of all at once.
  • Education should be developmentally appropriate. As children mature, offer further information and coach to take increasing responsibility for their care.
  • Inhaler technique should be routinely assessed wherever possible and training provided as part of self-management education.

Asthma action plans

Goal: All children with asthma are provided with an asthma action plan

  • To assist in self-management of childhood asthma, consider all of the child’s regular caregivers and environments in preparing and distributing the action plan.
  • Asthma action plans that are symptom-based, rather than PEF-based, are preferred in children, although some older children may want a PEF-based plan.
  • Child asthma action plans from the Asthma and Respiratory Foundation NZ can be downloaded from http://www.asthmafoundation.org.nz/resources
  • The Child Asthma Action Plan should be written and reviewed with the family/caregivers. It must be individualised for the child and culturally appropriate (see Appendix A).
  • A Child Asthma Symptom Diary may be used to clarify the pattern of symptoms and response to treatment, to guide the Action Plan (see Appendix B).

Practice points—asthma action plans

  • Always involve the child by using developmentally-appropriate language.
  • Ensure the child (in an age appropriate manner) and the family/caregivers understand the plan.
  • Keep a record of the plan and provide copies of the Child Asthma Action Plan for all caregivers—including child care or school.
  • Arrange a formal review, at least annually, of the Child Asthma Action Plan with the family/caregivers. Frequency of reviews will be dependent on family/carer’s confidence and competence with asthma management.
  • Ensure family/caregivers understand the importance of not running out of inhalers and prescribed medication. Check that they know the process for obtaining repeat prescriptions.
  • Ensure enough medications are prescribed and reinforce the need for appropriate regular clinical assessment.

Adolescents: getting it right for adolescents with asthma

Goal: Adolescents with asthma transition smoothly towards emerging adulthood, with good asthma control

  • Children are normally seen accompanied by a caregiver, with caregivers taking responsibility for management, while most adults are seen on their own and assumed to be self-managing. Adolescents require an approach which is inbetween and enables them to take increasing responsibility. Ensure adolescents have a developmentally appropriate understanding of their asthma and treatment. If they have had asthma for a long time, they may not have had updated information since childhood.
  • Assume adolescents are interested in WHY they should control their asthma and HOW it might benefit their own goals, such as by saying, “good asthma control will help you get on with life” , which may be more motivating than saying “Aim for good control”. Assess compliance with open and nuanced questions, such as “When you get wheezy, what do you normally do?” or “Which doses do you find easiest to remember?”
  • Develop a treatment regimen; consider simple regimes. Ensure the young person is aware of what to do if symptoms escalate, and has someone to contact if they have concerns.
  • Offer the chance to ask questions.
  • Arrange follow-up appointments and ensure the adolescent knows how and when to instigate appointments.7,8

Practice points—adolescents

  • Prioritise the relationship, introduce yourself and offer continuity of care.
  • Give adolescents the full consultation time. Consider if a practice nurse could play a coaching role.
  • See adolescents individually first, and then with parents/caregivers as appropriate. Ensure the adolescent knows that as they age they will take more responsibility for their own healthcare and that they can make appointments for themselves.
  • Explain confidentiality, which can be as simple as having health privacy information on the wall and providing a brief verbal outline, such as “Your health information is confidential. We are not allowed to tell other people, like school or family members, unless you agree or unless there are serious safety issues.”
  • Explain risks of sharing inhalers with others (infection, inhaler runs out more quickly).
  • Ask about smoking and e-cigarettes (vaping) and advise.
  • Assume that the young person is likely to have other health issues and questions. Complete a brief HEADSS (Home & Environment, Education & Employment, Activities, Drugs, Sexuality, Suicide/Depression) or holistic psychosocial assessment if practicable. Ask if they have questions about asthma, or about how they are feeling 23–28 (http://www.health.govt.nz/system/files/documents/publications/depression_summary.pdf).
  • Consider these eight key points from this recent systematic review:29

a) Many adolescents have poor knowledge about asthma and treatments.

b) Non-adherence is frequently caused by forgetting to take medication.

c) Adolescents with established routines are better able to self-manage.

d) Some adolescents do not use treatments or use them incorrectly due to erroneous beliefs about their asthma and medication.

e) Asthma self-management is difficult for those with a lack of support at school.

f) Parents play a key role in reminding adolescents to take medication.

g) Many adolescents are embarrassed about having asthma and using medication, particularly around their friends and peers.

h) Many adolescents report difficulties in communicating with their healthcare professional.

Māori—getting it right for Māori children with asthma

Goal: Māori children have asthma outcomes equal to non-Māori and non-Pasifika children

Māori rights in regards to health, recognised in Te Tiriti O Waitangi and other national and international declarations, promote both Māori participation in health-related decision making, as well as equity of health outcomes for all New Zealanders. Currently, Māori with asthma are more likely to be hospitalised or die due to asthma. Despite this, Māori with asthma are less likely to be prescribed ICS, have an asthma action plan or receive adequate education. Major barriers to good asthma management for Māori may include access to care, discontinuity and poor quality care, and poor health literacy. Māori whānau have greater exposure to environmental triggers for asthma, such as smoking and poor housing.9,30

It is recommended that for Māori with asthma:

  • Asthma providers should undertake clinical audit or other similar quality-improvement activities to monitor and improve asthma care and outcomes for Māori.31
  • A systematic approach to health literacy and asthma education for Māori whānau is required. The evidence of the health literacy demands, the barriers and facilitators, and steps to delivering excellent asthma management with Māori, which are described in He Māramatanga Huangō: Asthma Health Literacy for Maori Children in New Zealand (www.health.govt.nz), also apply to adults. Asthma healthcare providers should support staff to develop cultural competency skills for engaging Māori with asthma and their whānau, in line with professional requirements (http://www.health.govt.nz/publication/equity-health-care-maori-framework).
  • Māori leadership is required in the development of asthma management programmes that improve access to asthma care and facilitate ‘wrap-around’ services to address the wider determinants (such as housing or financial factors) for Māori with asthma (http://practice.mvcot.govt.nz/policy/assessment-and-decision-making/resources/working-with-maori.html; http://whatworks.org.nz/kaupapa-maori/).

Pacific peoples—getting it right for Pacific children with asthma

Goal: Pacific children have asthma outcomes equal to non-Pacific & non-Māori children

The Pacific population is diverse and growing fast, with Pacific children numbering one in four babies born in Auckland. Pacific children have great disparities and unequal access to healthcare compared with other New Zealand children, which is well documented.32–37 Changes will come from health workers understanding the drivers for poor health in minority groups, and action at multiple levels of the health and social systems. Central action to improve the health of Pacific children will be a commitment to work with the strengths of the Pacific communities.

The following recommendations for health services and practitioners are based on theory and lessons from good practice:

  • Understand the Pacific population profile, with the majority living in urban areas. Perform an audit on the clinical activities and understand who is registered with the service, and who is registered but does not attend.
  • With over 60% of Pacific children living in families with hardship and 30% in severe hardship, material insecurities will affect the family’s engagement with health providers. Practitioners should explore these insecurities and set up effective pathways to address them.
  • Research shows communication difficulties are a barrier for healthcare. Assess the level of English language proficiency, and use interpreters if necessary. The Health and Disability Commissioner’s Code of Rights (http://www.hdc.org.nz/the-act--code/the-code-of-rights) outline the right to a competent interpreter.

Health systems approaches

Goal: All aspects of the health system will support better asthma care, aiming to decrease inequities and improve outcomes

Good asthma management requires a system approach incorporating information systems to improve quality and service delivery. The following are recommended:

  • Educate clinicians by providing educational outreach visits, such as training visits to GP practices.
  • Computerised decision-support systems, such as web-based systems for self-management. These should incorporate simple tools for the assessment and monitoring of asthma control.
  • School-based asthma interventions, such as education programmes and Asthma Friendly Schools.
  • Pharmacy-based interventions, such as inhaler technique education and the identification of asthma medicine uptake from dispensing history, eg, infrequent preventer dispensing history.
  • Continuity of care between doctors, nurses, pharmacists and patients.

Medicines

Inhaler devices at different ages

Goal: The correct inhaler device is considered and age appropriate

  • Prescibe an inhaler device that is appropriate for the development of the child and that the child and/or caregiver is able to demonstrate they can use well (Table 4).
  • Health professionals who teach patients should ensure they have correct inhaler technique themselves.
  • When teaching inhaler technique, have the child or caregiver demonstrate how they use the device. Use checklists and reminder lists to identify and correct errors.
  • Inhaler technique needs to be taught repeatedly. Check inhaler technique and adherence every visit by asking child or caregiver to demonstrate how they use the device.
  • Advise not to share inhalers.
  • Consider alternative inhaler devices if the patient has persistent difficulty with technique.

Table 4: Inhaler devices recommended by age group.

Inhaler device

<2 years

2–4 years

5–7 years

8–15 years

MDI, small volume spacer & mask

Yes

May transition to no mask

 

 

MDI & spacer No mask

 

Possible

Yes

Yes

MDI (alone)*

 

 

 

Possible, but use with a spacer is preferable

Dry powder device

 

 

Possible

Yes

Breath-activated device

 

 

Possible

Yes

*A spacer should be used with the metered dose inhaler (MDI) for the regular administration of inhaled corticosteroids, and for the administration of short-acting beta agonist (SABA) in the setting of an acute attack. The use of a spacer is always recommended.

Figure 3: Stepwise approach to treatment of children with wheeze 1–4 years.

c 

Figure 4: Stepwise approach to treatment of children with asthma 5–15 years.

c 

Stepwise approach to long-term asthma treatment

Goal: The right step of medicine in the right device is used for the age and symptoms of the child

  • In the stepwise approach to management, children step-up and down therapy as required to achieve and maintain control of their symptoms and reduce the risk of exacerbations.6,8,39
  • Achieving good control requires frequent and repeated assessments. This may require the use of recall or follow-up systems.
  • At each step, check inhaler technique, adherence to treatment, understanding of a self-management plan, and barriers to self-care.6,8,42–46

Practice points—stepwise management

  • Step–up and step-down are determined by asthma control (see section Evaluation of asthma control and severity). Step-up may be required when asthma is partially controlled or uncontrolled. Once asthma has been well-controlled for at least eight weeks, consider step-down and reassess control after at least eight weeks.
  • Many children have intermittent asthma (Step 1) and do not need an asthma preventer.
  • Recommended doses of ICS are lower in children than adults (see Table 5). The usual maximum daily dose in children is also lower than adults, and equivalent to beclomethasone 800 micrograms or fluticasone propionate 500 micrograms. Both these doses are at the top of the dose response curve. If this dose is exceeded there is no therapeutic benefit and there is an increase in adverse medication effects. At Step 5, oral steroids, oral theophylline and even subcutaneous monoclonal antibody therapy (IgE) may be considered as an add-on treatment, if directed by a paediatrician.
  • Alternative therapies, such as sodium cromoglycate, may be considered in some children on the lower steps. Long-acting muscarinic receptor antagonists may be future add-on therapy, such as tiotropium, which is currently licensed for use but not funded for asthma indications in New Zealand.21
  • Remember non-pharmacological approaches to management as well as medicines (see Health Professional Top 10 Actions and Non-pharmacological measures sections).

Table 5: The recommended low and standard daily dose of ICS in children with asthma. “High” doses are double the standard doses (see Tables 4 and 5).

Low dose

 

Standard dose

 

Beclomethasone dipropionate

200mcg/day

Beclomethasone dipropionate

400–500mcg/day

Beclomethasone dipropionate

ultrafine

100mcg/day

Beclomethasone dipropionate

ultrafine

200mcg/day

Budesonide

200mcg/day

Budesonide

400mcg/day

Fluticasone propionate

100mcg/day

Fluticasone propionate

200–250mcg/day

Initial treatment choices (when to add ICS)

Goal: For all children with asthma it should be clear if ICS should be prescribed, and if so, a prescription given and the medicine taken

  • At initial diagnosis, all children with asthma should be provided with a short-acting beta-agonist (SABA) to take as required for relief of symptoms.
  • The key issue is when to start ICS therapy. It is recommended that ICS therapy is introduced if children have symptoms >2 times per week.
  • An exacerbation requiring oral steroids in the previous year is widely regarded as a requirement for regular ICS therapy.

Practice points on ICS

  • The daily doses of ICS in children, which achieve 80–90% of maximum efficacy, are the low doses shown in Table 5. The doses labelled ‘standard’ doses are the same microgram/day ‘standard’ doses in the adult asthma guidelines.
  • ICS should be administered from a MDI with spacer, or from a dry-powder inhaler. The child’s ability to use the inhaler should be checked.6,7,47,48

When to add long-acting beta-agonist (LABA) therapy

Goal: LABAs should never be prescribed without ICS

  • Combination ICS/LABA combined single inhaler treatment should be prescribed at a fixed maintenance dose and patients also prescribed a SABA as a reliever therapy. LABA monotherapy is unsafe.
  • LABAs should not be used in children ≤4 years of age.
  • LABAs (with ICS) should not be initiated when the child is clinically unstable. They should be stopped if they are ineffective or worsen asthma stability.
  • The SMART (Single Maintenance And Reliever Therapy) regimen is an alternative for children 12 years or older. It involves using a low-dose budesonide–formoterol combination powder inhaler. The same inhaler is used for both regular twice-daily maintenance use, and for relief of symptoms, instead of salbutamol.7,45,49,50 A self-management plan prototype is in the Adult Asthma Guidelines.9
  • The LABA should be stopped if the child deteriorates after starting it.
  • The LABA should be stopped after three months if ineffective.

Treatment of acute severe asthma (primary care, after-hours care or ED)

Goal: All children should be managed to avoid life-threatening asthma or death

  • Acute asthma management is based on:
    • Objective measurement of severity.
    • Assessment of the need for referral to hospital and/or hospital admission (Table 5).
    • Administering treatment appropriate for the degree of severity.
    • Repeatedly reassessing the response to treatment.
  • Monitor pulse rate, respiratory rate, accessory muscle use and ability to speak (words/breath).
  • Key priorities include identification of a life-threatening attack requiring urgent admission to intensive care, and a severe asthma attack requiring hospital admission (Table 6 and Figure 6).

Table 6: Criteria for acute referral to hospital and/or hospital admission in children and adolescents.

  • Child with any feature of life-threatening asthma
  • Child with any feature of an acute severe attack persisting after initial treatment
  • Child in whom other considerations suggest that admission may be appropriate:
    •      Still have significant symptoms
    •      Psychosocial problems in child or parent/caregiver
    •      Physical disability or learning difficulties
    •      Previous near fatal or brittle asthma
    •      Exacerbation despite adequate dose of oral steroids pre-presentation
    •      Presentation at night
    •      Remote location or without transportation/communication

Practice points—acute severe asthma

  • A lack of response to initial bronchodilator treatment and/or a requirement for repeat doses two-hourly or more often indicates the need for referral to hospital and/or admission.
  • For most children, initial treatment with beta-agonist via a spacer and oral steroids is likely to be sufficient. Reserve nebulised beta-agonists for those with severe asthma who require continuous oxygen.
  • The standard regimen for a course of prednisone in the situation of severe asthma is 1–2 milligrams/kg (to a maximum of 40 milligrams) daily for 3–5 days.
  • Steroids, such as oral prednisone are not likely to be effective in children <5 years. In this age group, they should be reserved for children admitted to hospital (or who are en route) and who are on oxygen.
  • In hospital consider IV magnesium sulphate, aminophylline or salbutamol according to local protocol.
  • Non-invasive ventilation in life-threatening asthma is not recommended outside of an intensive care setting.
  • For children with acute severe asthma who are treated in primary care or discharged from the after-hours clinic or ED, long-term management should be reviewed and follow-up appointment within the week with their primary healthcare team should be arranged.
  • All children ≥5 years who have presented with acute severe asthma and who are not taking ICS should be prescribed ICS before going home.8,51–57

Figure 5: Algorithm for community management of moderate, severe and life-threatening acute asthma in children and adolescents. (Mild asthma is asthma symptoms not usually requiring medical attention and should be managed according to the asthma action plan.)

c 

Table 7: Pre-discharge considerations in children and adolescents.

  1. Most children presenting with acute exacerbations of asthma should have a course of oral prednisone, 1–2 milligrams/kg (to a maximum of 40 milligrams) daily for 3–5 days.
  2. All children admitted to hospital for asthma should have a structured review assessing control, inhaler technique, asthma education, an action plan and follow-up.
  3. It is recommended that children have prednisone and ICS dispensed prior to discharge to ensure there are no barriers to taking medication.
  4. Before sending a child home, ensure that the child with caregiver:

  • Understands treatment prescribed and the signs of worsening asthma.
  • Can demonstrate inhaler use correctly and has a supply of the medication.
  • Understands how to contact emergency services/seek further advice if symptoms deteriorate (ie, has an action plan).
  • Arranges an early follow-up appointment with their primary healthcare team for review (within a week).
  • Consider referral to asthma educator.
  • Consider housing and social implications, eg, social worker involvement.
  • Encourage notification of hospital admission to school or child care centre.

Checks at follow-up visit after admission

  1. Clinical assessment—resolution of symptoms and signs would be expected.
  2. Consider spirometry in older children.
  3. Understands treatment prescribed and the signs of worsening asthma.
  4. Can demonstrate inhaler use correctly and has a supply of the medication.
  5. Understands how to contact emergency services/seek further advice if symptoms deteriorate.
  6. Check written action plan.
  7. Check housing and social implications.

Appendix A

c 

Appendix B

c 

Appendix C 

List of organisations and individuals consulted for feedback:

All DHBs

All PHOs

Asthma NZ

Australasian College of Emergency Medicine

Authors of adult guidelines

Breathing works

Canterbury Health

Conference delegates

Departments of General Practice for Medical Schools

General Practice NZ

Health Informatics NZ

Health Information Standards Organisation

Ian Town

Internal Medicine Society of Australia and NZ

Julian Crane

Kidz First

Maternal and Child Health Mid-Central District Health

Medtech

Ministry of Education

Ministry of Health NGO

National Health IT Board

Ngā Kaitiakio Te Punao Rongoāo Aotearoa, Māori Pharmacists’ Association

NZ Medical Association

NZ Resuscitation Council

NZ Speech Therapists Association

NZNO & NZNO Respiratory Nurses Section

Paediatric Society

Paediatrics’ Otago Medical School

Pasifika GP Network

Pasifika Medical Association

PHARMAC Pharmaceutical Management Agency

Pharmaceutical Society of NZ

Pharmacy Guild of NZ

Philippa Howden-Chapman

POI Team Public Health South

ProCare Clinical Advisory Committee

Respiratory and Sleep Medicine Auckland University

Royal Australasian College of Physicians

Royal NZ College of GPs

Special Education

St Johns Ambulance

Starship Children’s Health

Te Ora: Māori Medical Practitioners

Te Rūngangao Aotearoa (NZNO Māori)

Thoracic Society of Australia and NZ—NZ Branch

TSANZ Nurses special interest group

Wellington Free Ambulance

Summary

The New Zealand child and adolescent asthma guidelines provide health professionals who deliver asthma care with simple, practical and evidence-based guidance for the diagnosis and treatment of asthma in children of 15 years of age and below. Prior to this project, New Zealand’s child and adolescent asthma guidelines had not been updated since 2005. While medications essentially have remained the same, the way they should be utilised has subtly changed in the last 12 years. The new guidelines align the latest research with specific information for the New Zealand context, including available medications and relevant content for treating Māori and Pacific adults with asthma. The aim of the guidelines is to improve outcomes and reduce inequalities, and discusses factors such as unhealthy indoor environments and inadequate income for the basics needed for wellbeing.

Abstract

The purpose of the New Zealand Child and adolescent asthma guidelines: a quick reference guide is to provide simple, practical, evidence-based recommendations for the diagnosis, assessment and management of asthma in children and adolescents in New Zealand, with the aim of improving outcomes and reducing inequities. The intended users are health professionals responsible for delivering asthma care in the community and hospital emergency department settings, and those responsible for the training of such health professionals.

Author Information

Innes Asher, Paediatrics: Child and Youth Health, University of Auckland, Auckland;
David McNamara, Respiratory Service, Starship Children's Health, Auckland District Health Board, Auckland; Cheryl Davies, Tu Kotahi Māori Trust, Lower Hutt, Wellington;
Teresa Demetriou, Asthma and Respiratory Foundation NZ, Wellington;
Theresa Fleming, Paediatrics: Child and Youth Health & Psychological Medicine, University of Auckland, Auckland; Matire Harwood, Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, Auckland; Lorraine Hetaraka-Stevens, National Hauora Coalition, Auckland;
Tristram Ingham, Medicine, University of Otago, Wellington;
John Kristiansen, Health Quality and Safety Commission, Auckland;
Jim Reid, Dept of the Dean, Dunedin School of Medicine, Dunedin;
Debbie Rickard, Capital and Coast District Health Board, Wellington;
Debbie Ryan, Pacific Perspectives Limited, Wellington.

Correspondence

Professor Innes Asher, Paediatrics: Child and Youth Health, University of Auckland, Private Bag 92019, Auckland 1142.

Correspondence Email

i.asher@auckland.ac.nz

Competing Interests

Dr Harwood reports personal fees from Astra Zeneca Limited outside the submitted work; Dr Reid reports affiliation with Contract Research outside the submitted work; Dr Asher reports one grant from Boehringer Ingelheim New Zealand outside the submitted work; Dr Ingham reports personal fees from Te Hā Ora: The Asthma & Respiratory Foundation of New Zealand, grants from Janssen Research & Development, non-financial support from Astra Zeneca, outside the submitted work; Teresa Demetriou reports grants from REX Medical outside the submitted work.

References

  1. Howden-Chapman P, Baker MG, Bierre S. The Houses children live in. Policies to improve housing quality Policy Quarterly. 2013; 9(2):35–9.
  2. Ministry of Health. Un-flued gas heaters 2016. Available from: http://www.health.govt.nz/your-health/healthy-living/environmental-health/household-items-and-electronics/unflued-gas-heaters
  3. Telfar Barnard L, Baker M, Pierse N, Zhang J. The impact of respiratory disease in New Zealand: 2014 update. Wellington: The Asthma Foundation; 2015.
  4. Jones B, Ingham T. He Māramatanga Huangō: Asthma health literacy for Māori children in New Zealand: Report to the Ministry of Health. Wellington: Asthma Foundation; 2015.
  5. Asthma and Respiratory Foundation of New Zealand. Te Hā Ora (The Breath of Life): National Respiratory Strategy. Wellington: The Asthma Foundation 2015.
  6. National Asthma Council Australia. Australian Asthma Handbook Version 1.1 April 2015 2015 [cited 2016 7 June]. Available from: www.nationalasthma.org.au/handbook
  7. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: www.ginasthma.org
    http://www.sign.ac.uk/
  8. SIGN 153. British guideline on the management of asthma 2016. Available from:
  9. Beasley R, Hancox B, Harwood M, Perrin K, Poot B, Pilcher J, et al. Asthma and Respiratory Foundation NZ Adult Asthma Guidelines: A Quick Reference Guide. New Zealand Medical Journal. 2016; (1445):83–102.
  10. Brand PLP, Caudri D, Eber E, Gaillard EA, Garcia-Marcos L, Hedlin G, et al. Classification and pharmacological treatment of preschool wheezing: changes since 2008. European Respiratory Journal. 2014; 43:1172–7.
  11. Kaiser SV, Huynh T, Bacharier LB, Rosenthal JL, Bakel LA, Parkin PC, et al. Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis. Pediatrics. 2016;e-pub June.
  12. Castro-Rodriguez JA, Custovic A, Ducharme F. Treatment of asthma in young children: evidence-based recommendations. Asthma Research and Practice. 2016; 2:5–11.
  13. Work and Income. Guidance on the severity of disability for child disability allowance. Available from: http://www.workandincome.govt.nz/providers/health-and-disability-practitioners/guides/guidance-on-the-severity-of-disability-for-child-disability-allowance.html
  14. Gardiner and Dvorkin (2006) Promoting medication adherence in children. American Family Physician 74 (5) 793-798
  15. Fleming T, Watson P. Enhancing compliance in adolescents: if only they’d do what they’re told Current Therapeutics, Vol. 43, No. 3, 2002 Mar: 14 <http://search.informit.com.au/documentSummary;dn=526872563101018;res=IELHEA>
  16. Duncan C MJ, Wu YP, Fredericks EM. Practice-based approach to assessing and treating nonadherence in pediatric regimens. Clinical Practice in Pediatric Psychology. 2014; 3(2):322–36.
  17. PREDICT. Bronchiolitis Guideline 2017. Available from: http://www.predict.org.au/2016/project-snapshot-development-of-the-australasian-bronchiolitis-clinical-practice-guideline/
  18. Fingleton J, et al. Bronchodilator responsiveness: interpret with caution. Thorax 2012; 67:667–8.
  19. Jamison JP, McKinley RK. Validity of peak flow rate variability for the diagnosis of asthma. Clin Sci 1993; 85:367–71.
  20. Crane, et al. Markers of risk of asthma death or readmission in the 12 months following a hospital admission for asthma. Int J Epidemiol 1992; 21;737–44.
  21. Kerstjens, et al, Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med 2012; 367:1198–1207.
  22. Kristiansen J, Hetutu E, Manukia M, Jelleyman T. An evaluation of a pictorial asthma medication plan for Pacific children. New Zealand Medical Journal 2012; 125(1354):42–50. http://journal.nzma.org.nz/journal/125-1354/5173/
  23. Neinstein LS, Katzman D, Callahan T, Gordon C, Joffe A, Rickert V. (2016) Adolescent health care: a practical guide Wolters Kluwer 
  24. Tylee, Haller, Graham, et al. Youth-friendly primary-care services: How are we doing and what more needs to be done?Lancet, 369 (2007), pp. 1565–1573.
  25. WHO (2005) Adolescent friendly health services: Making it happen WHO (2005).
  26. Department of Health. ‘You’re Welcome’: Quality criteria for young people friendly health services. 2011: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126813 
  27. Farrant PD. WatsonHealth care delivery: Perspectives of young people with chronic illness and their parents J Paediatr Child Health, 40 (2004), pp. 175–179.
  28. Klein D, Goldenring J, Adelman W. HEEADSSS 3.0: The psychosocial interview for adolescents updated for a new century fueled by media. Contemporary Pediatrics; 2014. Available from: http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/adolescent-medicine/heeadsss-30-psychosocial-interview-adolesce?page=full
  29. Holley S, Morris R, Knibb R, Latter S, Liossi C, Mitchell F, et al. Barriers and Facilitators to Asthma Self-Management in Adolescents: A Systematic Review of Qualitative and Quantitative Studies. Pediatric Pulmonology. 2016; early e-pub.
  30. Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2010, 2nd Edition. Wellington: Ministry of Health; 2010.
  31. Ministry of Health. 2014. Equity of Health Care for Māori: A framework. Wellington: Ministry of Health. http://www.health.govt.nz/publication/equity-health-care-maori-framework
  32. Simpson J, Oben G, Craig E, Adams J, Wicken A, Duncanson M, et al. The Determinants of Health for Pacific Children and Young People in New Zealand (2014): New Zealand Child and Youth Epidemiology Service; 2016. Available from: http://hdl.handle.net/10523/6747
  33. Craig E, Reddington A, Adams J, Dell R, Jack S, Oben G, et al. The Health of Pacific Children and Young People with Chronic Conditions and Disabilities in New Zealand (2013): New Zealand Child and Youth Epidemiology Service; 2016. Available from: http://hdl.handle.net/10523/6746
  34. Craig E, Adams J, Oben G, Reddington A, Wicken A, Simpson J. The Health Status of Pacific Children and Young People in New Zealand: New Zealand Child and Youth Epidemiology Service; 2012. Available from: http://hdl.handle.net/10523/6131
  35. Davis P, Suaalii-Sauni T, Lay-Yee R, Pearson J. Pacific Patterns in Primary Health Care: A comparison of Pacific and all patient visits to doctors: The National Primary Medical Care Survey (NatMedCa): 2001/02. Wellington: Ministry of Health; 2005. 
  36. Health Mo. Tupu Ola Moui Pacific Health Chart Book 2012. Wellington: Ministry of Health; 2012.
  37. Gray B. The use of interpreters In: St George IM, editor. Cole’s medical practice in New Zealand. 12th ed. Wellington: Medical Council of New Zealand; 2013.
  38. Gotzsche PC, Johansen HK. House dust mite control measures for asthma. The Cochrane Collaboration 2008.
  39. Holt S, et al. The use of the self-management plan system of care in adult asthma. Prim Care Resp J 2004; 13:19–27.
  40. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004; 59:94–9.
  41. Robson B, Harris R. Hauora: Māori Standards of Health IV. A study of the years 2000–2005. 2007. Tatau Kahukura: Māori Health Chart Book 2015, 3rd edition. Accessed http://www.health.govt.nz/publication/tatau-kahukura-maori-health-chart-book-2015-3rd-edition
  42. D’Souza W, et al. Asthma morbidity 6 yrs after an effective asthma self-management programme in a Māori community. Eur Respir J 2000; 15:464–9.
  43. Pilcher J, et al. Combination budesonide/formoterol inhaler as maintenance and reliever therapy in Māori with asthma. Respirology 2014; 19:842–51.
  44. Asthma and Respiratory Foundation of New Zealand 2015. Te Hā Ora (The Breath of Life): National Respiratory Strategy. Wellington: The Asthma Foundation.
  45. Powell H, Gibson P. High dose versus low dose inhaled corticosteroids as initial starting dose for asthma in adults and children. The Cochrane Collaboration. The Cochrane Library 2008, Issue 4.
  46. Holt S, et al. Dose-response relation of inhaled fluticasone propionate in adolescents and adults with asthma: meta-analysis. BMJ 2001;323:253.
  47. Patel M, et al. Efficacy and safety of maintenance and reliever combination budesonide-formoterol inhaler in patients with asthma at risk of severe exacerbations: a randomised controlled trial. Lancet Respir Med 2013; 1:32–42.
  48. Beasley R, et al. Call for withdrawal of LABA single-therapy inhaler in asthma. Lancet 2010; 376:750–1.
  49. Aldington S, Beasley R. Asthma exacerbations. 5: Assessment and management of severe asthma in adult in hospital. Thorax 2007; 62:447–58.
  50. Llewellin P, et al. The relationship between FEV1 and PEF in the assessment of the severity of airways obstruction. Respirology 2002; 7:333–7.
  51. Rowe BH, et al. Corticosteroids for preventing relapse following acute exacerbations of asthma (Review). The Cochrane Collaboration. The Cochrane Library 2007, Issue.
  52. Bowler SD, et al. Corticosteroids in acute severe asthma: effectiveness of low doses. Thorax 1992; 47:584–7.
  53. Camargo CA, et al. Continuous versus intermittent beta-agonists for acute asthma. The Cochrane Collaboration. The Cochrane Library 2003.
  54. Cates CJ, et al. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma (Review). The Cochrane Collaboration. The Cochrane Library 2013, Issue 9.
  55. Emerman CL, et al. Comparison of 2.5 vs 7.5 mg of inhaled Albuterol in the treatment of acute asthma. Chest 1999; 115:92–6.