gathered from https://www.asthmahandbook.org.au/ -v3.0

Definition of asthma

Core definition

• Chronic inflammatory airway disease
• Defined by both:
  • Variable respiratory symptoms
    • wheeze
    • breathlessness
    • chest tightness
    • cough
  • Variable expiratory airflow limitation
    • reversible (spontaneously or with treatment)
    • fluctuates over time

Key pathophysiology

• Airway inflammation
  • eosinophilic (common), neutrophilic (less common), mixed
• Airway hyperresponsiveness
  • exaggerated bronchoconstriction to triggers
• Airflow obstruction
  • due to:
    • bronchospasm
    • mucosal oedema
    • mucus hypersecretion
• Airway remodelling (chronic disease)
  • subepithelial fibrosis
  • smooth muscle hypertrophy

Asthma is a heterogeneous syndrome

• Not a single disease → multiple phenotypes + endotypes
• Common phenotypes:
  • Allergic (atopic) asthma
    • childhood onset, eczema/allergic rhinitis association
  • Non-allergic asthma
  • Viral-induced wheeze (young children)
  • Exercise-induced bronchoconstriction
  • Late-onset asthma (often eosinophilic)
  • Obesity-related asthma

Diagnostic principles (all ages)

1. Clinical features (essential but not sufficient alone)

• Variable symptoms:
  • fluctuate over time (days, weeks, seasons)
  • vary in intensity
• Typical patterns:
  • worse at night / early morning
  • triggered by:
    • viral infections
    • exercise
    • allergens
    • cold air
    • smoke/irritants
• Symptoms improve with:
  • bronchodilator (SABA)
  • anti-inflammatory therapy (ICS)

2. Objective evidence of variable airflow limitation (≥6 years ideally)

• Spirometry demonstrating:
  • reversibility:
    • ↑ FEV1 ≥12% and ≥200 mL post-bronchodilator
  • variability:
    • peak flow variability >10%
• Alternative:
  • bronchial provocation testing
• Supportive:
  • elevated FeNO (eosinophilic inflammation)

---

Focused history

• Current symptoms:
  • wheeze
  • breathlessness / difficult breathing
  • chest tightness
  • cough
• Severity markers (explain to parents):
  • increased work of breathing
  • tracheal tug
  • subcostal/intercostal recession
• Symptom pattern:
  • frequency (daytime symptoms)
  • nocturnal symptoms / waking at night
  • episodic vs persistent
• Relation to infections:
  • only during viral colds vs also between colds
• Triggers:
  • exercise / playing / laughing
  • cold or dry air
  • allergens (pets, dust, pollen)
  • smoke/vaping exposure
• Functional status:
  • child alertness and activity level
• Environmental factors:
  • pets
  • carpet / dust exposure
  • indoor air pollution
• Smoke exposure:
  • household smoking/vaping
• Atopy history:
  • eczema (atopic dermatitis)
  • allergic rhinitis
  • food allergies
• Infection history:
  • recurrent respiratory infections
  • previous significant illnesses
• Neonatal history:
  • prematurity
  • neonatal respiratory distress
  • NICU admission
• Early life respiratory history:
  • bronchiolitis
  • hospitalisation for LRTI
• Family history:
  • asthma
  • allergies

Examination

• General:
  • vital signs (RR, HR, SpO₂, temperature)
  • overall appearance and distress
• Respiratory:
  • observe breathing effort
  • chest auscultation (wheeze, air entry)
• Growth:
  • height and weight (plot on growth chart)
• Chest inspection:
  • deformity (e.g. pectus)
• Upper airway:
  • allergic rhinitis signs:
    • swollen turbinates
    • transverse nasal crease
    • mouth breathing
    • allergic shiners
• Extremities:
  • finger clubbing (red flag)
• Skin:
  • eczema / atopic dermatitis

---

DIAGNOSIS

1. Core principle

• Clinical diagnosis (no reliable spirometry)
• Based on:
  • Pattern recognition
  • Therapeutic response (salbutamol ± ICS)

2. Entry point: recurrent symptoms

• Recurrent respiratory symptoms
  • Verified wheeze ± cough

3. Required diagnostic features (must have)

A. Typical recurrent symptoms

• Wheeze ± cough
• Episodic breathlessness
• Increased work of breathing (WOB)
  • recession, tracheal tug, tachypnoea

B. Variability (key concept)

• Symptoms:
  • occur over time
  • vary in frequency/severity
• NOT a single isolated episode

C. Exclude alternative diagnoses

• Always consider:
  • bronchiolitis
  • foreign body aspiration
  • structural airway disease
  • infection / other pathology
• Use:
  • history
  • examination
  • red flags (see below)

D. Response to bronchodilator (pivotal step)

• Trial salbutamol (pMDI + spacer)
• Positive response:
  • rapid improvement (within minutes)
  • strongly supports asthma
• No response:
  • asthma unlikely
  • reconsider differentials

4. Red flags → alternative diagnosis

• Persistent (non-variable) symptoms
• Failure to thrive
• Neonatal onset
• Clubbing
• Focal chest signs
• Recurrent infections
• Poor/no response to bronchodilator

→ Investigate + consider specialist referral

5. Supporting features (increase probability)

• Response to ICS trial (8–12 weeks)
• Atopy:
  • eczema
  • allergic rhinitis
  • family history of asthma
• Symptoms outside viral illnesses (strong predictor)
• Frequent or severe episodes

6. Diagnosis reached: Preschool asthma

If:

• typical recurrent symptoms
• variability
• no red flags
• bronchodilator response

→ Diagnosis = Preschool asthma

7. Decide: Is ICS indicated?

Indications for ICS trial

Any of:

• Daytime symptoms >2/week
• Night symptoms >2/month
• Symptoms limiting activity/sleep
• >4 wheezing episodes/year
• ≥1 episode:
  • ED visit OR
  • oral corticosteroids
• Previous PICU admission

8. Management pathways

A. ICS indicated → Trial (8–12 weeks)

• Low-dose ICS + SABA PRN

Reassess:

• Improved:
  • continue
  • stepwise adjustment
  • periodic review (consider remission)
• No improvement:
  • check:
    • adherence
    • inhaler technique
  • reconsider diagnosis

B. Mild, infrequent symptoms

• SABA only (PRN)
• Regular review
• Reassess need for ICS

9. Important negatives (avoid overdiagnosis)

• Do NOT diagnose asthma if:
  • wheeze occurs only during viral URTI
  • no respiratory distress or increased WOB
• Age <12 months:
  • most wheeze = bronchiolitis
  • → do not label asthma
  • → refer if persistent/recurrent

Signs and symptoms that suggest an alternative diagnosis in children

Feature	Consider:
Symptoms present from birth	Cystic fibrosis Structural abnormality Bronchopulmonary dysplasia Primary ciliary dyskinesia
Abnormal voice	Acute viral laryngitis  Vocal cord nodules Structural abnormalities  Inducible laryngeal obstruction
Sudden breathlessness at rest	Panic attacks
Cough
Acute onset	Inhaled foreign body
Dry cough occurring during daytime only	Somatic cough (previously called ‘habit’ cough)
Persistent productive cough	Bronchiectasis Cystic fibrosis Primary ciliary dyskinesia Protracted bacterial bronchitis
Persistent cough	Post-viral cough Allergic rhinitis Primary ciliary dyskinesia Pertussis
🚩Cough with haemoptysis	InfectionInhaled foreign body Congestive heart disease Vascular abnormality Bronchial mass Cystic fibrosis
Upper respiratory tract
Chronic production of sputum	Protracted bacterial bronchitis
Nasal polyps	Cystic fibrosis
Chest sounds
🚩 Unilateral wheeze	Inhaled foreign body
No variation in wheeze	Structural abnormality
Inspiratory wheeze	Inducible laryngeal obstruction
Sudden wheeze at rest	Panic attacks
Exercise-induced wheeze that stops immediately when exertion ceases	Inducible laryngeal obstruction Anxiety
Stridor	CroupInducible laryngeal obstruction
Localised crepitation	Pneumonia
Cardiac murmur	Congenital heart disease
Skin and integument
Finger clubbing	Cystic fibrosis Primary ciliary dyskinesia Bronchiectasis Immunodeficiency
Systemic signs
Weight loss/lack of weight gain	Immunodeficiency
Fevers	Chronic infection
Growth failure	Cystic fibrosis Immunodeficiency
Recurrent or atypical infections	Immunodeficiency

Features suggesting higher or lower probability of asthma in children

Asthma more likely

Asthma less likely

More than one typical asthma symptom: – wheeze – difficulty breathing / breathlessness – chest tightness – cough Symptoms are: – frequent – worse at night or early morning – variable over time – recurrent rather than a single isolated episode Symptoms triggered by: – exercise – pets/allergens – cold air – damp air – emotions – laughing Symptoms occur even when the child does not have a cold. Atopic background: – allergic rhinitis – eczema / atopic dermatitis – food allergies Family history of: – allergies – asthma Examination: – widespread wheeze on auscultation Treatment response: – symptoms improve with reliever trial – symptoms improve with preventer trial if indicated Objective evidence, if age-appropriate: – spirometry improves after rapid-acting bronchodilator – spirometry improves after inhaled corticosteroid treatment trial

Symptom pattern inconsistent with asthma: – symptoms only occur during viral infections (no interval symptoms) – isolated cough without wheeze or dyspnoea – chronic moist/productive cough (→ think bronchiectasis, PBB) Atypical triggers/symptoms: – exercise-induced dyspnoea with noisy inspiration (→ consider inducible laryngeal obstruction) – chest pain (rare in asthma; consider MSK, cardiac, reflux) – dizziness, light-headedness, peripheral tingling (→ hyperventilation, anxiety) Examination findings: – repeatedly normal chest exam when symptomatic – focal/unilateral wheeze (→ foreign body, structural lesion) Objective testing: – normal spirometry when symptomatic no bronchodilator reversibility Treatment response: – no response to appropriate asthma therapy (adequate dose/correct inhaler technique/sufficient duration) Red flags for alternative diagnosis: – persistent wet cough – failure to thrive – recurrent pneumonia – haemoptysis – clubbing – neonatal onset symptoms – aspiration symptoms (choking with feeds)

Additional information

* In preschool children, wheezing that only occurs during viral respiratory infections may not be due to asthma, but this finding does not rule out asthma. Viral respiratory infection is the most common trigger for severe acute asthma exacerbations in children of all ages. 

---

Managing Asthma in Children

Goals of asthma management

Population level

• reduce asthma deaths
• reduce ED presentations
• reduce disease burden

Individual child

• minimise:
  • symptoms
  • sleep disturbance
  • limitation of play/activity
• prevent:
  • exacerbations
  • need for oral steroids
• maintain:
  • normal lung function
• minimise:
  • medication adverse effects
• recognise:
  • possible remission → avoid overtreatment

Core management principles

• confirm and reconfirm diagnosis over time
• assess:
  • symptom control
  • exacerbation risk
• tailor treatment to:
  • symptom pattern
  • triggers
  • risk profile
• Parent/carer education:
  • inhaler technique
  • adherence support
  • written asthma action plan
  • trigger avoidance
• Regular review:
  • step up or down treatment
• manage:
  • exacerbations
  • comorbidities (e.g. allergic rhinitis)
• lifestyle:
  • avoid smoke exposure
  • healthy weight, activity
  • immunisation

---

Treatment step approach (step-up / step-down)

• Aim:
  • maintain good symptom control
  • prevent exacerbations
  • minimise side effects

Treatment levels:

• Level 1:5/
  • SABA (e.g. salbutamol) as needed

• Level 2:
  • Low-dose ICS maintenance + SABA PRN
  • Start low-dose ICS if ANY of:
    • symptoms ≥2 days/week
    • night waking ≥2 times/month
    • ≥1 exacerbation requiring:
      • ED visit
      • systemic corticosteroids

Severity of Exacerbations	Frequency of symptoms
	Less often than once every 3 months	At least once every 3 months but not more than once per month	More than once per month
MildExacerbations quickly* resolve with salbutamol	Not indicated	Consider	Indicated
Moderate–severe≥2 exacerbations required ED or oral corticosteroids in past 12 months	Indicated	Indicated	Indicated
Life-threatening≥1 exacerbation required hospitalisation or PICU	Indicated	Indicated	Indicated

Low and medium/high ICS doses in children 1–5 years:

Active ingredient	Total daily dose (microg)
	Low	Medium/high
Fluticasone propionate	100 (50 twice daily)	200 (100 twice daily)

If poor control on low-dose ICS

👉 Before stepping up — ALWAYS check:

• adherence to ICS
• inhaler technique
• correct diagnosis (is it asthma?)
• ongoing triggers:
  • smoke
  • allergens
  • pollution

• Level 3:
  • Medium-dose ICS + SABA PRN
  • OR (≥4 years):
    • low-dose ICS + LABA (while awaiting specialist advice)

If still uncontrolled on higher treatment

• Recheck:
  • adherence
  • technique
  • triggers
  • diagnosis
• ➜ Refer to specialist
  • paediatrician / respiratory

• Level 4 (specialist):
  • high-dose ICS ± add-on therapy
  • paediatrician / respiratory / immunology input

⬇️ Stepping DOWN treatment

When to step down

• Good control for ≥3 months
• Even during exposure to usual triggers

How to step down

• Reduce treatment intensity gradually:
  • e.g. medium → low-dose ICS
  • consider trial off preventer (selected cases)

Follow-up

• Review in 3–6 weeks:
  • reassess symptoms
  • adjust again if needed

Alternative options (when needed)

• Level 2:
  • montelukast daily + SABA PRN
  • only if ICS declined
  • → switch to ICS when possible
• Level 3:
  • low-dose ICS + montelukast
  • OR (≥4 years): low-dose ICS + LABA
• ⚠️ Montelukast warning (TGA):
  • neuropsychiatric effects (e.g. mood, behaviour, sleep disturbance)
  • → must counsel parents

Before starting treatment

• Assess:
  • current symptom control
  • risk factors for exacerbations
• Confirm:
  • symptoms consistent with asthma
  • response to salbutamol trial
• Exclude alternative diagnoses

Good control	Poor control
Daytime symptoms (e.g. wheeze, difficult breathing, cough) ≤2 days per week Need for salbutamol ≤2 days per week (do not include dose given before exercise) Symptoms last only a few minutes and are rapidly relieved by salbutamol No limitation of activities: child is active, plays without symptoms No symptoms during night or when wakes up (including no coughing during sleep)	Daytime symptoms (e.g. wheeze, difficult breathing, cough) >2 days per week Need for salbutamol >2 days per week (do not include dose given before exercise) Any limitation of activities due to asthma Any symptoms at night (including coughing during sleep) Waking with wheezing or breathing problems

exacerbation history

Clarify flare-ups

• Ask:
  • “Has your child had a flare-up since the last visit?”
• Explain flare-up:
  • worsening breathing symptoms
  • more wheeze/cough
  • needing more reliever than usual
  • reduced activity or sleep disturbance

If YES — explore details

• Triggers:
  • viral infection (most common)
  • allergens
  • stopping preventer
  • smoke exposure
  • exercise
• Management of flare-up:
  • increased salbutamol use
  • GP visit
  • ED presentation
  • oral corticosteroids

Severity markers (high-yield)

• Oral corticosteroid use:
  • ever required?
  • frequency
  • dose/duration
• Hospitalisation:
  • any admission for asthma/wheeze?
  • ICU / oxygen requirement (if severe)

Timing + pattern

• Last flare-up:
  • when?
  • how managed?
• Previous flare-up:
  • interval between episodes
  • increasing frequency?

Healthcare utilisation

• Number of visits:
  • GP visits for asthma
  • ED presentations
  • hospital admissions
• Specify timeframe:
  • last 2 weeks
  • last month
  • last year

Allergy assessment

• Allergic rhinitis (hay fever):
  • sneezing, runny/blocked nose
  • itchy eyes/nose
  • seasonal vs perennial
• Current allergy medications:
  • oral antihistamines
  • intranasal antihistamines
  • intranasal corticosteroids
• Allergen exposure:
  • identified triggers? (dust, pollen, pets, mould)
  • can exposure be reduced/avoided?
• Other allergic conditions:
  • food allergy
  • insect sting allergy
  • history of anaphylaxis
• Adrenaline injector:
  • prescribed (e.g. EpiPen)?
  • knows how/when to use?
• Skin manifestations:
  • eczema / atopic dermatitis
  • urticaria (hives)

Inhaler technique — assessment (high yield)

• Demonstration:
  • ask parent/child:
    • “Can you show me how you use the inhaler?”
• Check key steps (pMDI + spacer):
  • shake inhaler
  • correct assembly with spacer
  • good seal (mask or mouthpiece)
  • actuate 1 puff at a time
  • tidal breathing (young child) or slow deep breaths
  • adequate number of breaths per dose
• Common errors:
  • poor seal
  • multiple puffs at once
  • not shaking inhaler
  • not waiting between puffs

Spacer care

• Ask:
  • “When did you last wash the spacer?”
  • “How do you clean it?”
• Correct method:
  • wash in warm water with detergent
  • do not rinse (reduces static)
  • air dry (no towel drying)

Risk factors for severe asthma exacerbations

Disease-related factors

• Poor asthma symptom control
• History of:
  • ED visit or hospital admission in past 12 months
  • sudden, unpredictable exacerbations
  • previous intubation / PICU admission
• High eosinophil count (if known)

Medication-related factors

• Overuse of salbutamol (SABA)
• Poor adherence to ICS
• Incorrect inhaler technique

Trigger-related factors

• High risk of viral infection:
  • start of daycare/preschool
  • seasonal epidemics
• Exposure to:
  • allergens (dust, pets, pollen)
  • tobacco smoke
  • outdoor air pollution
  • damp/mouldy housing

Allergy-related factors

• Confirmed food allergy
• History of anaphylaxis

Healthcare engagement factors

• Frequent missed appointments
• Poor follow-up

Caregiver / social factors

• Difficulty following asthma action plan
• Carer unable to manage emergencies
• Parental psychological or socioeconomic challenges

Child-related factors

• Obesity

---

Reliever (all children)

• Salbutamol PRN
  • 100 mcg/puff
  • 2 puffs via pMDI + spacer
  • repeat after a few minutes if needed
• Delivery:
  • pMDI + spacer ± mask (preferred)

When to start preventer (ICS)

Start low-dose ICS trial (~3 months) if:

• symptoms ≥2 times/week
• night symptoms ≥2/month
• activity limitation
• ≥2 exacerbations requiring oral steroids

ICS trial — review approach

• After ~3 months:
  • Good response →
    • consider stepping down / trial off
  • Poor response →
    • check:
      • inhaler technique
      • adherence
      • triggers (smoke, dust, mould)
    • reconsider diagnosis

Monitoring reliever use

• Ask parents to track:
  • frequency of use
  • number of inhalers per year
• ⚠️ Red flag:
  • ≥3 SABA canisters/year → poor control + ↑ exacerbation risk

What NOT to use

• ❌ Nebulisers (unless severe acute asthma)
• ❌ Oral salbutamol
• ❌ Theophylline
• ❌ Anti-inflammatory reliever (ICS-formoterol)
  • not TGA-approved in this age group

Systemic steroids

• Avoid routine use
• Only for:
  • moderate–severe exacerbations

Essential non-pharmacological management

• Written asthma action plan
  • give to parents + childcare/school
• Parent education:
  • inhaler technique
  • adherence
  • trigger avoidance

Key clinical principles

• asthma diagnosis evolves → reassess regularly
• step up or down based on control
• avoid overtreatment (possible remission)
• treat comorbidities (e.g. allergic rhinitis)

Asthma inhalers available for children 1–5 years

Class	Medicine	Available inhaler types (brand names)	TGA-approved age group	Notes
SABA	Salbutamol	pMDI with dose counter (Asmol, Ventolin, Zempreon)	No restriction	≤3 years: with small spacer plus mask 4–5 years: with small spacer
		Breath-actuated MDI (Airomir Autohaler)	No restriction	Breath-actuated MDIs not recommended for children 1–5 years
ICS	Fluticasone propionate	pMDI (Axotide Junior, Flixotide Junior)	≥ 1 years	≤3 years: with small spacer plus mask 4–5 years: with small spacer and mouthpiece
		DPI (Axotide Junior Accuhaler, Flixotide Junior Accuhaler)	≥ 5 years	DPIs not recommended for children 1–5 years ⚠ Accuhaler contradicted for children with severe milk-protein allergy
	Fluticasone furoate	DPI (Arnuity Ellipta)	≥ 5 years	DPIs not recommended for children 1–5 years ⚠ Arnuity Ellipta contradicted for children with severe milk-protein allergy
ICS-LABA	Fluticasone propionate-salmeterol	pMDI (Evocair, Pavtide, Seretide)	≥4 years	4–5 years: with small spacer and mouthpiece
		DPI (Pavtide Accuhaler, Seretide Accuhaler)	≥4 years	DPIs not recommended for children 1–5 years ⚠ Accuhaler contradicted for children with severe milk-protein allergy
LABA	Salmeterol	DPI (Serevent Accuhaler)	≥4 years	Salmeterol indicated only in patients also using ICS or oral corticosteroids Separate inhalers for ICS and LABA should be generally avoided to prevent accidental LABA monotherapy DPIs not recommended for children 1–5 years ⚠ Accuhaler contradicted for children with severe milk-protein allergy

Additional information

DPI; dry powder inhaler; 

ICS: inhaled corticosteroid;  

LABA: long-acting  beta₂ agonist; 

MDI: metered-dose inhaler; 

pMDI: pressurised metered-dose inhaler;  

SABA: short-acting beta₂ agonist; 

TGA: Therapeutic Goods Administration

---

Trigger avoidance & lifestyle strategies (children 1–5 yrs with asthma)

🚭 Smoke & vaping (MOST important)

• Ensure completely smoke-free and vape-free environment
  • no smoking inside home or car
  • avoid exposure to:
    • tobacco smoke
    • e-cigarette vapour
• Explain:
  • even third-hand smoke (clothes, furniture) can trigger symptoms

🌫️ Outdoor air pollution

• Avoid exposure when possible:
  • bushfire smoke
  • high pollution days
• Practical advice:
  • stay indoors during poor air quality
  • keep windows closed
  • consider air conditioning/filtration

🏠 Indoor air quality

• Avoid:
  • indoor smoking
  • open fireplaces
• Reduce exposure:
  • ensure good ventilation
    • open windows
    • use exhaust fans
  • ventilate when:
    • cooking (gas stoves)
    • using heaters

🌿 Allergen avoidance (IMPORTANT nuance)

• ❌ Do NOT routinely recommend blanket allergen avoidance
• ✅ Only consider if:
  • proven sensitisation
  • clinically relevant trigger
• Examples (if relevant):
  • dust mite
  • pets
  • mould
• Avoid:
  • expensive/onerous strategies without evidence

💉 Immunisation

• Recommend vaccination against respiratory infections:
  • influenza
  • COVID-19
  • pertussis
  • pneumococcal
  • RSV (if eligible)
• Explain:
  • reduces risk of asthma exacerbations

🏃 Physical activity

• Encourage normal participation
  • asthma should not limit activity
• Reassure:
  • exercise-induced symptoms are manageable
  • use reliever before exercise if needed

⚖️ General lifestyle

• Maintain:
  • healthy weight
  • balanced diet
• Address comorbidities:
  • allergic rhinitis
  • eczema

---

Guide to writing asthma action plans for children 1–5 years

Core education messages

• Asthma is:
  • variable and episodic
  • often triggered (e.g. viruses, allergens)
• Goal:
  • keep child symptom-free and active
  • prevent flare-ups

⚠️ Important safety points

• ❌ Do NOT include parent-initiated oral steroids in action plan Oral steroids:

• only used when prescribed for moderate–severe exacerbation

Provide written asthma action plan

• Ensure parents:
  • understand each step
  • can follow it confidently
• Share with:
  • childcare / preschool

Follow-up & review

• Review:
  • at least yearly
  • after exacerbations
  • when treatment changes
• Recheck:
  • inhaler technique every visit

Current symptom control	Reliever(salbutamol 100 microg/actuation)	Maintenance ICS treatment IF PRESCRIBED
When child well (e.g. almost no symptoms, occasional symptoms mild with no visibly increased work of breathing)	Principle: Use child’s usual dose if symptoms occur	Principle: Daily dose as prescribed
	Sample instruction: When child has symptoms, give 2 puffs, one at a time using puffer and spacer. If symptoms do not improve within 4 minutes, give 2 more puffs. Before exercise, give 2 puffs using puffer and spacer.	Sample instruction (for child using fluticasone propionate 50 microg twice daily):† 1 puff morning and night using puffer and spacer
When child not well (e.g. needing reliever more often than usual, night-time symptoms, waking with symptoms)	Principle: Increase dose taken on each occasion and give only when symptoms occur (not by the clock)	Principle: Short-term increase in ICS not recommended
	Sample instruction: Give 4 puffs, one puff at a time using puffer with spacer. If symptoms do not improve within 2–4 minutes, give 4 more puffs	Sample instruction:Keep giving usual daily dose.
If symptoms* worsening (e.g. needing reliever again within 3 hours, increasing breathing difficulty, e.g. sucking in above, below or around the rib cage, using abdominal muscles to push air out of lungs, breathing fast, shoulders bobbing up and down with breathing )	Principle: Increase dose taken on each occasion and give only when symptoms occur (not by the clock)	Principle: Short-term increase in ICS not recommended
	Sample instruction: Give 6 puffs, one puff at a time using puffer and spacer. if symptoms do not improve within a few minutes, give 6 more puffs and call an ambulance. If difficult breathing recurs within 1 hour, give 6 more puffs and call an ambulance or take child to ED, even if symptoms get better. If difficult breathing recurs within 3 hours, give 6 more puffs and get urgent medical care, even if symptoms get better.	Sample instruction: Keep giving usual daily dose.

Additional information

*Table shows only sample adjustments for reliever and maintenance ICS treatment when asthma symptoms worsening. Asthma action plans also include other usual treatment, such as medicines for comorbid allergic rhinitis, emergency instructions including when to call an ambulance, and instructions according to individual triggers and comorbidity (e.g. when to use adrenaline auto-injector)

†See Medicines guide for range of inhalers and doses

⚠ Asthma action plans for children 1–5 years should not include instructions to start oral corticosteroids. Systemic corticosteroid treatment in this age group is indicated only for exacerbations severe enough to require hospital admission.

---

Sample Asthma Action PLan

Child Details

• Name: __________________________
• DOB: __________________________
• GP: __________________________
• Practice: __________________________
• Date issued: __________________________

Usual (Daily) Asthma Treatment

• Reliever (as needed):
  • Salbutamol 100 mcg inhaler
  • Dose: ___ puffs via spacer
• Preventer (if prescribed):
  • e.g. Fluticasone ____ mcg
  • Dose: ___ puffs twice daily via spacer
• Other treatments (if any):
  • e.g. intranasal steroid / antihistamine

🟢 When child is WELL

(No or mild symptoms, normal play, no increased work of breathing)

• Continue daily preventer (if prescribed)
• Use reliever only if symptoms occur:
  • Give 2 puffs, one at a time via spacer
  • If needed, repeat after 4 minutes
• Before exercise (if needed):
  • Give 2 puffs salbutamol

🟡 When asthma is GETTING WORSE

(More cough/wheeze, waking at night, needing reliever more often)

• Give:
  • 4 puffs salbutamol, one puff at a time via spacer
• If symptoms persist after 2–4 minutes:
  • Give 4 more puffs
• Continue:
  • usual preventer dose (do NOT increase ICS short-term)
• Monitor closely:
  • If needing reliever frequently → seek medical review

🔴 When symptoms are WORSENING / SEVERE

Emergency recognition:

• Breathing difficulty
• fast breathing
• ribs sucking in
• cannot talk/play normally

• Give:
  • 6 puffs salbutamol, one puff at a time via spacer
• If no improvement after a few minutes:
  • Give 6 more puffs
• CALL AMBULANCE (000) if:
  • child struggling to breathe
  • symptoms not improving
  • child becomes drowsy or exhausted
• While waiting:
  • continue 6 puffs every 5–10 minutes

🚨 Asthma Emergency

• Call 000 immediately
• Give:
  • 6 puffs salbutamol via spacer
  • repeat every 5–10 minutes until help arrives

When to seek medical review

• Needing reliever:
  • more often than usual
  • every 3 hours or less
• Night waking due to asthma
• Reliever not lasting
• Any concerns about breathing

Triggers to avoid (if known)

• ☐ Viral infections
• ☐ Smoke/vaping
• ☐ Pets
• ☐ Dust/mould
• ☐ Exercise
• Other: __________________________

Inhaler Technique (important)

• Use puffer + spacer (± mask)
• Give 1 puff at a time
• Key steps:
  • 1 puff at a time
  • good seal
  • multiple breaths per puff (4–5 breaths per puff)
• Clean spacer:
  • wash in warm soapy water
  • air dry (do not rinse or wipe)
• After ICS use:
  • rinse mouth and spit reduces:
    • oral thrush
    • possible dental effects

Emergency Contact Details

• Parent/carer: __________________________
• Phone: __________________________

Doctor Details

• Name: __________________________
• Provider No: __________________________
• Signature: __________________________

Review Plan

• Review at least every 6–12 months
• Or sooner if:
  • symptoms worsen
  • medications changed

Key Education Points for Parents

• Asthma is variable and can flare quickly
• Early reliever use prevents worsening
• Preventer (ICS) reduces inflammation and flare-ups
• Correct inhaler technique is critical
• Always carry reliever