Asthma Management in Australia (2025)

Key 2025 Paradigm Shift

• SABA alone is now considered inadequate - even for mild, infrequent symptoms
• SABA overuse (3+ canisters/year) significantly increases exacerbation risk
• Using 12+ SABA canisters annually increases asthma death risk 32-fold
• AIR therapy reduces severe exacerbations requiring oral corticosteroids by 55% vs SABA alone

Diagnosis

Objective Testing (Adults & Adolescents)

1. History and clinical assessment - symptoms, triggers, family history, atopy
2. Spirometry - demonstrate variable airflow obstruction (FEV1/FVC <70% + significant bronchodilator reversibility: ≥12% and ≥200 mL increase in FEV1)
3. FeNO (fractional exhaled nitric oxide) - identifies Type 2 eosinophilic airway inflammation; supports diagnosis when spirometry is normal
4. Blood eosinophil count - not reliable as a standalone diagnostic test (AAH position), but used for phenotyping and biologic eligibility
5. Bronchial provocation test (methacholine or mannitol) - most sensitive test; arranged if diagnosis remains uncertain; rules out asthma if negative

Note: Over- and under-diagnosis of asthma are both common. Objective confirmation before treatment is important.

Chronic Management: Stepped Care (Adults & Adolescents ≥12 years)

Track 1 (Preferred): ICS-Formoterol as Controller AND Reliever

Why Only Formoterol-Containing Combinations?

PBS Availability (Australia)

Track 2 (Alternative Pathway)

• ICS remains the controller
• SABA is still used as the reliever in this pathway
• This pathway is described in the AAH but is no longer preferred

Management in Children

Children 6-11 years

• Stepped approach using ICS as controller
• SABA (salbutamol) remains the reliever - ICS-formoterol combinations are not TGA-approved for this age group as AIR therapy
• Step up to ICS-LABA if uncontrolled on low-medium dose ICS

Children 1-5 years (preschool wheeze/asthma)

• ICS-formoterol not TGA-approved for this age group
• Salbutamol via spacer remains the reliever
• Low-dose ICS (e.g., budesonide via spacer) as a controller reduces exacerbations
• Future AAH guidance may change if ongoing clinical trials support AIR in this age group

Infants

• Diagnosis is clinical (wheeze, family history)
• Intermittent salbutamol for episodes; consider preventer ICS if frequent

Severe Asthma

Pathway to Biologic Therapy (2025 AAH)

1. Confirm adherence and correct inhaler technique
2. Eliminate/minimise avoidable triggers and comorbidities (e.g., rhinosinusitis, GERD, obesity)
3. Arrange spirometry + blood eosinophil count (key biomarker)
4. Refer to respiratory physician, clinical immunologist, or allergist
5. While awaiting referral: continue optimised inhaled therapy; consider trial of LAMA add-on

PBS-Listed Biologics in Australia (Step 5)

Acute Exacerbations

Severity Assessment

• Mild-Moderate: SpO2 ≥94%, speaks in sentences, PEF >50% predicted - manage in primary care or ED
• Severe: SpO2 <90%, unable to complete sentences, PEF <40% - refer to ED immediately
• Life-threatening: Silent chest, cyanosis, bradycardia, altered consciousness - ICU

Acute Treatment

1. Inhaled SABA (salbutamol): 4-8 puffs via spacer every 20 minutes (or continuous nebulisation in severe cases); salbutamol remains the acute bronchodilator of choice even in 2025 guidelines
2. Ipratropium bromide: add to SABA for moderate-severe exacerbations (reduces hospitalisations)
3. Systemic corticosteroids: oral prednisolone (1 mg/kg up to 50 mg/day for 3-5 days, or IV methylprednisolone for severe cases) - start early; reduces hospitalisation
4. Oxygen: titrated to SpO2 93-95% (94-98% in children); avoid excessive O2
5. IV magnesium sulphate: 2 g IV over 20 minutes for severe exacerbations failing initial treatment - smooth muscle relaxant; reduces hospital admission rates
6. Heliox: consider for severe exacerbations not responding to initial treatment
7. NIV (non-invasive ventilation): consider for alert, cooperative patients with severe exacerbation not requiring immediate intubation
8. Intubation/mechanical ventilation: for respiratory arrest or impending arrest - use "permissive hypercapnia" strategy (low tidal volume 6-8 mL/kg, low RR 12-14/min, extended expiratory time, minimal PEEP)

Discharge Criteria & Post-Exacerbation Care

• SpO2 ≥94% on room air, PEF >70%, symptoms resolved
• Start or step up ICS-formoterol before discharge
• Provide written Asthma Action Plan
• Follow-up within 48 hours (GP) and again at 4-6 weeks
• Review and address triggers; assess adherence and technique

Non-Pharmacological Management

• Smoking cessation and avoiding vaping (vaping is now a recognised asthma trigger)
• Allergen reduction (dust mite covers, mould remediation, pet avoidance if sensitised)
• Weight loss in obese patients (reduces symptom burden and OCS need)
• Exercise and physical activity encouraged with pre-treatment if needed
• Breathing exercises (Buteyko, Papworth) - evidence-based adjuncts for symptom quality
• Allergen immunotherapy (sublingual HDM): consider for patients with HDM sensitisation and uncontrolled asthma (but stable)
• Vaccinations: annual influenza vaccine; pneumococcal vaccine for severe asthma or on long-term OCS

Asthma Action Plan

• Maintenance medications and doses
• How to recognise worsening (symptom- or PEF-based zones)
• What to do in yellow/red/emergency zones
• When to seek emergency care

Summary of Key 2025 Changes