National Guide

Chapter 14 | Respiratory health

Asthma







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      1. Asthma

Respiratory health | Asthma

Prof Anne B Chang, A/Prof Julie M Marchant, A/Prof Andre Schultz

Key messages

  • The most important and modifiable risk factor to prevent asthma is reducing both in utero and childhood environmental tobacco smoke (ETS) exposure.1
  • Asthma is more common among Aboriginal and Torres Strait Islander people and they have poorer outcomes compared with other Australians.2,3
  • The initial step in primary care is to establish whether the patient has asthma, another respiratory condition or both because management is specific to each condition.4
  • Whenever possible, the diagnosis of asthma should be objectively confirmed by lung function tests.1
  • Effective asthma management resulting in good asthma control supports health and wellbeing and reduces exacerbations, hospitalisations and death (secondary prevention).1,5
  • Effective management, using age-appropriate clinical practice guidelines, includes effective education, an asthma management plan and a stepwise approach in the use of classes, devices and doses of asthma medications.
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 6 months and older Recommend influenza vaccination Yearly Strong International guideline1 Influenza vaccinations reduce the risk of influenza infection and hence likely asthma exacerbations
All people aged 5 years and over Recommend COVID-19 vaccination As per Australian Technical Advisory Group on Immunisation guidelines Strong International guideline1 COVID-19 vaccination reduce the risk of severe illness COVID from COVID-19 infection
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Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Do not routinely screen for asthma
Early detection strategies should be considered, especially in people with allergy and eczema		 As clinically indicated Good practice point International guideline1 There are no data to support routine screening for asthma, although screening tools are available
Workers in high-risk workplaces, where exposure to occupational dusts and chemicals are likely Ask about respiratory symptoms

Discuss health implications of occupational exposure and, if necessary, seek advice from occupational health physician

Recommend avoiding exposure to the occupational hazard and the use of appropriate respiratory protective equipment		 Opportunistically and as part of occupational and annual health checks Strong International guideline1
Review articles6,7		 Occupational asthma is increasingly recognised and can be prevented. Early recognition is important
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Pregnant women Do not recommend maternal dietary restrictions during breastfeeding or pregnancy for the prevention of asthma N/A Good practice point International guideline1 Because there are inconsistent data on whether maternal dietary manipulation prevents asthma, dietary changes are not currently recommended

Although maternal obesity and high gestational weight gain is associated with increased asthma risk in the off-spring, there are no specific recommendations because weight loss in pregnancy may pose other problems
Lactating mothers and children commencing solids Encourage breastfeeding and do not delay the introduction of solids Opportunistically Good practice point International guideline1 Although data on breastfeeding and asthma prevention are conflicting, breastfeeding should be encouraged because of its many other beneficial effects1

There is no evidence that delaying the introduction of solids prevents asthma
Mothers and babies Do not recommend dietary supplements for the prevention of asthma N/A Good practice point International guideline1 Data on the effectiveness of vitamin D, probiotics, fish oil and long-chain polyunsaturated fatty acid dietary supplements for the prevention of childhood asthma are inconsistent
Adults with psychosocial stress Address psychosocial stress Opportunistically, as clinically indicated Good practice point International guideline1 Increased psychosocial stress is associated with the development and severity of asthma
People with overweight and obesity Advise weight loss as per clinical guidelines (see Chapter 15: Overweight and obesity) Opportunistically, as clinically indicated Strong International guideline1 Overweight and obesity are associated with increased risks of developing asthma and having severe asthma

Obesity may need to be intensively managed, including gastric surgery if appropriate
Pregnant women and all people who smoke Advise and assist pregnant women to avoid smoking and second-hand smoke exposure (see Chapter 5: Preconception and pregnancy care)

Advise parents/carers who smoke about the harms of ETS and the need to avoid childhood exposure, particularly in confined spaces (eg homes and motor vehicles; see Chapter 2: Healthy living and health risks, Smoking)		 Opportunistically, as clinically indicated Strong International guideline1
Systematic review8		 Maternal smoking while pregnant and early childhood exposure to second-hand smoke are associated with the development of asthma, including more severe asthma (requiring emergency department (ED) visits and hospitalisation)
People with or at risk of asthma who are current smokers Provide smoking cessation advice to smokers (see Chapter 2: Healthy living and health risks, Smoking) Opportunistically Strong International guideline1 Exposure to tobacco smoke is associated with the development of asthma, as well as more severe asthma (necessitating ED visits and hospitalisation)
Type of preventive activity - Medications
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children at risk of asthma (see Box 1) Do not prescribe immunotherapy or inhaled corticosteroids for the primary prevention of asthma N/A Strong International guideline1
National guideline5
Randomised controlled trials (RCTs)9,10		 Using immunotherapy in those at risk of asthma does not prevent asthma
Children and adults with asthma, including pregnant women Assess whether asthma therapies are indicated and optimise asthma control (see Clinical guidelines in Useful resources)

Check asthma devices and techniques, the availability of an asthma management plan and culturally appropriate health education		 Opportunistically Strong International guideline1
National guideline5		 Effective asthma management resulting in good asthma control reduces exacerbations, hospitalisations and death1,5
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children and adults at risk of exposure to second-hand tobacco smoke Recommend strategies to promote a smoke-free environment Opportunistically Strong International guideline1
Aboriginal and Torres Strait islander-specific studies3,11		 Exposure to tobacco smoke is associated with the development of asthma, including  more severe asthma necessitating ED visits and hospitalisation
People with or at risk of asthma Advise families that interventions to reduce exposure to air-borne allergens (eg house dust mites) or pets do not prevent asthma or improve outcomes for people with asthma Opportunistically Strong International guideline1 Although observational studies have shown the association between inhaled allergens and asthma, RCTs on reducing exposure to single allergens have not been shown to prevent asthma
Health services and practices in settings where environmental and living conditions have strong contributions (environmental attribution) to communicable disease transmission and other conditions such as asthma Know about diseases with a high environmental attribution

Develop a safe clinical relationship in order to ask sensitively about housing and living conditions (inadequate housing facilities; access to affordable and reliable energy supply for refrigeration and air conditioning; access to health hardware, such as working plumbing for clean drinking water and washing facilities; access to hygiene; and sanitation supplies)

Know about local arrangements for environmental health referral
Offer an environmental health referral according to local arrangements, ensuring consent is obtained when a home visit is involved

Advocate with Aboriginal and Torres Strait Islander leaders for adequate housing, an affordable and clean energy supply, facilities for washing and general living conditions

Provide community-based health promotion about environmentally attributable diseases

Check local guidelines		 Opportunistically, in response to any diagnosis or condition with an environmental attribution and as part of general healthcare Good practice point International and Aboriginal and Torres Strait Islander-specific narrative reviews12,13 Household crowding and the quality of housing and environments exacerbate conditions promoting communicable disease transmission, including COVID-19, Group A Streptococcus (Strep A) infections, otitis media, trachoma, tuberculosis and other respiratory tract infections

Aboriginal and Torres Strait Islander peoples have long recognised the links between human health, animal health and the environment. General practitioners can better support their leadership in housing equity
 
 
Box 1. Risk factors for asthma1,7,14,15
  • Family history (particularly maternal) of asthma and allergies
  • Past history of atopy and food allergies in early life
  • Obesity
  • Low birth weight
  • In utero tobacco exposure, tobacco smoking, environmental tobacco smoke
  • Environmental pollution
  • Work-related exposures
  • Establish recall and reminder systems to support the follow-up of those with asthma.
  • Use asthma action plans to support an organised approach to asthma management.
  • Check asthma control using an asthma control questionnaire.(refer to Useful resources)
  • Check medication adherence, puffer and spacer techniques and environmental exposure.
  • Implement clinical audit (eg people with an asthma action plan, smoking status documented for people with asthma).
  • Ensure the availability of spirometry and trained personnel.

Clinical guidelines

  • National Asthma Council: section specific to  
  • Lung Foundation Australia:

Tools

  •  

Patient resources

  •  
  • 16

Background

Definition

Asthma is a chronic inflammatory disease of the airways characterised by variable and recurring symptoms of airway obstruction and bronchial hyper-responsiveness.1 The dominant features of the clinical history are recurrent episodic symptoms of wheeze, chest tightness, difficulty in breathing and shortness of breath, with or without cough.1,5 Asthma is a heterogeneous disorder, with various phenotypes and underlying components (eg dominant cellular type [eosinophilic or neutrophilic] and low or high T helper 2 cell involvement) and variations at different ages (child versus adult) and in severity (mild to severe).1,17

Prevalence

Among Aboriginal and Torres Strait Islander people, 29% report having a chronic respiratory disease, one of the four major diseases that account for over half (54%) the difference in total disease burden between Aboriginal and Torres Strait Islander people and non-Indigenous Australians.18 Of these respiratory illnesses, asthma is the most common by age-standardised proportion.18 Data from 2018–19 show that 16% of Aboriginal and Torres Strait Islander people have asthma, with prevalence and mortality being 1.6- and 2.2-fold higher, respectively, than in non-Indigenous Australians.2 The asthma burden is unequally distributed across the ages and regions. Asthma is the second largest contributor to the total burden of disease of Aboriginal and Torres Strait Islander children aged 5–14 years and female adults aged 25–44 years.2 Those who are socioeconomically disadvantaged are at higher risk,2 whereas the data on remoteness are inconsistent.3 In many remote and regional Aboriginal and Torres Strait Islander communities, asthma is commonly known as ‘short wind’.19

Diagnosis and related conditions

The initial step in primary care is to establish whether the patient has asthma or another respiratory condition, or both, because management is specific to each condition (see below).

The diagnosis of asthma is predominantly clinical, with objective confirmation when possible in older children (usually aged ≥6 years) and adults.1 Spirometry, including reversibility testing (ie response before and after bronchodilator medication), is the preferred initial test to determine the presence and severity of airway obstruction.1 However, normal spirometry results, particularly when the patient is not symptomatic, do not exclude asthma.1 Thus, tests for airway hyper-responsiveness (eg an exercise challenge or mannitol test) are sometimes undertaken.1 

However, controversy remains about making adjustments for race in biological measurements,20 including spirometry21 (see Chapter 1: Health impacts of racism). Current international practice in interpreting spirometry uses the Global Lung Initiative (GLI) equations, which are based on broad racial categories. The most appropriate reference that should be used is the GLI ‘Other/mixed equation’ when undertaking spirometry in Aboriginal and Torres Strait Islander people.22

After many years of experiencing asthma, particularly in adults, the ability to reverse airflow limitation may be incomplete in some people due to cellular and structural changes to the airways known as airway remodelling.23 It is increasingly appreciated that people with asthma, including childhood asthma, are at higher risk of developing chronic obstructive pulmonary disease (COPD) in adulthood.24 Further, asthma in adults can overlap with features of COPD (asthma–COPD overlap syndrome) and bronchiectasis.25

When considering a diagnosis of asthma, assessing for the presence of symptoms and signs suggestive of other diagnoses is important.4 Chronic suppurative lung disease, including bronchiectasis, and COPD can also clinically manifest as wheeze, airway obstruction and bronchial hyper-responsiveness25 (see Chapter X: xxxx). Among Aboriginal and Torres Strait Islander people, consideration of bronchiectasis is particularly important (see Chapter 14: Bronchiectasis and chronic suppurative lung disease). These overlapping syndromes need to be identified and treated appropriately. In addition, secondary prevention is different for these conditions and, because they are also common among Aboriginal and Torres Strait Islander people,1,26 it is important to differentiate these conditions in primary care.

In adults who are newly symptomatic with breathlessness and/or wheeze, it is important to ensure that the symptoms are not due to cardiac failure, which is best done with a transthoracic echocardiogram. Obesity is a major comorbidity that also influences asthma control. 

Opportunities for prevention

To decrease the burden of asthma, prevention and the better management of those with asthma are required.1,5 Even in remote communities, lung function can improve significantly with culturally appropriate management in both children27 and adults.28 However, despite a large number of studies, there are few primary prevention measures with a high level of evidence that can be currently recommended.1 This reflects the multifactorial, complex and incompletely understood mechanisms for developing asthma, which likely involves an interplay of genetics, epigenetics, environment, early viral and bacterial infection and behavioural and psychosocial factors.1,29 External factors, such as environmental and lifestyle factors, interact with genetic factors, such as allergic tendency, to increase the risk of developing asthma.1 However, reliably predicting the risk of asthma is difficult and there are no data specific to Aboriginal and Torres Strait Islander people. Known generic risk factors include a family history of asthma and allergies (particularly maternal), atopy, obesity, work-related exposures, premature birth, tobacco smoke exposure and diet.1 Although observational studies have found many other risk factors, including allergen exposure, the early use of antibiotics, low levels of vitamin D and psychosocial factors, the data are inconsistent across studies and outcomes did not appear to be improved when intervention trials were performed. 1 

Although there are no Aboriginal and Torres Strait Islander-specific data, in the general population approximately 5–20% of new adult-onset asthma is related to occupational factors, representing the most common cause of new-onset adult asthma.1 For people with high-risk occupations (eg those exposed to isocyanates, flour, wood and grain dust, animals and latex), the presence of non-specific bronchial hyper-responsiveness, allergic rhinitis and smoking is associated with an increased risk of occupational asthma, but the positive predictive values of such markers are too low to make them useful for screening purposes.14 

A gene–environment interaction is the driver of asthma.1

Primary prevention: Certain evidence for prevention

The most important and modifiable risk factor to reduce asthma is reducing both in utero and childhood exposure to environmental tobacco smoke (ETS).1 This is of particular importance given the high rates of in utero smoke exposure, ETS exposure for Aboriginal and Torres Strait Islander children and active smoking among adults.18 Interventions to reduce smoking among pregnant women and ETS exposure reduce the risk of childhood wheeze, asthma and later persistent asthma.1,5,17 Darwin-based data on children hospitalised for asthma found that a significantly higher proportion of Aboriginal and Torres Strait Islander children (95.2%) were exposed to ETS than non-Indigenous children (45.7%),11 and second-hand smoke increased the risk of hospital readmission of infants with bronchiolitis.30

Primary prevention: Certain evidence that does not prevent asthma

Except for avoidance of ETS, there are currently few practical, evidence-based preventive strategies to reduce the development of asthma.1 In children at risk of developing asthma (ie those with eczema and whose parents have atopy), in utero or childhood avoidance of house dust mite or pets is not an effective primary preventive measure and hence should not be recommended.1 Similarly, maternal food allergen avoidance during pregnancy and lactation is also not recommended.1 Sensitisation to allergens, such as house dust mite and cats, is associated with asthma, but interventions to reduce exposure to these allergens in childhood have not been shown to prevent asthma.1 Although multifaceted interventions (eg dietary allergen reduction combined with a reduction in aeroallergens through environmental manoeuvres) reduce asthma in children at risk of developing asthma, this cannot be recommended given the inconvenience (feasibility), cost and demands on the family.1

Primary prevention: Uncertain/possible prevention

Although data on breastfeeding and asthma prevention are inconclusive, breastfeeding should be encouraged because of its many other beneficial effects.1 The evidence for the link between obesity and asthma has increased, although consistent RCT evidence is currently lacking. Nevertheless, children who are obese or overweight should be offered weight reduction programs to reduce the risk of developing asthma.1 Similarly, weight reduction in adults who are obese should be promoted to improve general health and reduce asthma-like symptoms.1

Diets high in fruit and vegetables have been shown to be associated with less asthma in children and adults in observational studies.1 However, there is insufficient evidence that dietary changes and/or supplements for mothers or infants with probiotics, fish oil, modified infant formula or antioxidants are of benefit in reducing childhood asthma.1 In addition, RCTs found that using inhaled corticosteroids in children with a high risk of developing asthma did not prevent the development of asthma, and hence they are not recommended as a primary preventive measure.9,10

Reducing exposure to potential environmental factors such as airborne pollutants and allergens in the workplace may decrease the occupational risks of developing asthma. However, total avoidance of the factor is the best strategy.1,14 Nevertheless, this may not be straightforward, because ‘prevention has its own ethical, anthropological, economical dilemmas’.14 A reduction in exposure levels, including the use of respiratory protective equipment, should be viewed as a ‘last resort’ option because it reduces but does not eliminate the risk of occupational asthma.6 Because the diagnosis of workplace-induced asthma may have legal implications, specialist referral is usually necessary.1

Secondary prevention to decrease the risk of severe acute asthma and hospitalisations

Given the higher morbidity and mortality in Aboriginal and Torres Strait Islander people compared with non-Indigenous people with asthma,2,3 secondary measures are particularly important and are actionable in primary care. The correct use of preventer medications is vital to secondary asthma prevention, with inhaled corticosteroids the mainstay of treatment. Checking correct inhaler technique and supporting and monitoring adherence to prescribed treatment are important components of asthma care in primary care settings.

A systematic review evaluating asthma care and community-based interventions found the important features were care coordination strategies (culturally appropriate education, community asthma awareness and physician education), policy and environmental change (improving poor housing, reducing air pollution, including smoke-free laws), home-based interventions (home visitations with education and healthy home assessments with remediation) and community-based health services (improved healthcare access).8 Although the data were predominantly US based, there is high-level evidence that culturally appropriate education and care, including provision by Aboriginal and Torres Strait Islander health practitioners, improves clinical outcomes.5,31,32 A Western Australian data-linkage study reported that preventable risk factors for asthma-related hospitalisations were being hospitalised for acute lower respiratory infections, area-level disadvantage (but not remoteness), maternal smoking and being born premature (<33 weeks gestation)/low birthweight (<1.5 kg), with an attributable risk of 31%, 18%, 5% and 3–7%, respectively.3

Effective asthma management resulting in good asthma control reduces exacerbations, hospitalisations and death.1,5 Suboptimal asthma control, including moderate–severe exacerbations, should always result in comprehensive follow-up to review cause and risk and to optimise management, including an assessment of triggers, device technique and adherence to treatment. All Aboriginal and Torres Strait Islander people with asthma should be regularly reviewed and managed in a culturally secure way, in accordance with age-appropriate clinical practice guidelines. This includes effective education, the provision of an asthma management plan and medications using a stepwise approach in the use of classes, devices and doses of asthma medications.17,33 For example, in young children, dry powder devices should not be used because children are unable to generate a high enough peak inspiratory flow.

Personalised management plans (devices, medications, dose and written plan) in accordance with the patient’s asthma pattern/severity and preference for device type is recommended (see box 3.8 in the GINA guidelines).1 The single maintenance and reliever therapy (‘SMART’ or ‘MART’) approach for adults and children aged >12 years significantly reduces exacerbations requiring steroids and hospitalisations.34 National data in 2018–19 reported that only 32% of Aboriginal and Torres Strait Islander people with asthma or symptoms in the past 12 months had a written asthma action plan.18

Other secondary prevention strategies addressing modifiable factors, such as comorbidities (eg gastroesophageal reflux, COPD, obesity, depression, obstructive sleep disordered breathing, rhinosinusitis)5 and factors associated with poor control and/or exacerbations (eg tobacco and e-cigarettes smoking, second-hand smoke exposure, pollution, food allergy, allergen exposure1 and respiratory infections),3 should be undertaken when relevant. Although the GINA guidelines advise against allergen avoidance as a general management strategy for asthma, the Australian asthma handbook advises allergy reduction measures in patients with proven allergen sensitivity for patients in whom the particular allergen is considered a significant asthma trigger, and in a context where the patient or carer is motivated to implement allergen reduction measures and can afford to do so.5 When asthma is difficult to treat (poor asthma control or recurrent exacerbations despite routine medications), input from a respiratory physician may be helpful because various biologics, such as anti-IgE, anti-interleukin (IL)-5, anti-IL receptor and anti-IL-4 receptor antibodies, are now available.1

  1. [Accessed 11 April 2024].
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  4. Chang AB, Bell SC, Byrnes CA, et al. Thoracic Society of Australia and New Zealand (TSANZ) position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand. Respirology 2023;28(4):339–49. doi: 10.1111/resp.14479.
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  9. Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med 2006;354(19):1985–97. doi: 10.1056/NEJMoa051378.
  10. Murray CS, Woodcock A, Langley SJ, Morris J, Custovic A; IFWIN study team. Secondary prevention of asthma by the use of Inhaled Fluticasone propionate in Wheezy INfants (IFWIN): Double-blind, randomised, controlled study. Lancet 2006;368(9537):754–62. doi: 10.1016/S0140-6736(06)69285-4.
  11. Giarola BF, McCallum GB, Bailey EJ, Morris PS, Maclennan C, Chang AB. Retrospective review of 200 children hospitalised with acute asthma. Identification of intervention points: A single centre study. J Paediatr Child Health 2014;50(4):286–90. doi: 10.1111/jpc.12470.
  12. McMullen C, Eastwood A, Ward J. Environmental attributable fractions in remote Australia: The potential of a new approach for local public health action. Aust N Z J Public Health 2016;40(2):174–80. doi: 10.1111/1753-6405.12425.
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  14. Baur X, Aasen TB, Burge PS, et al. The management of work-related asthma guidelines: A broader perspective. Eur Respir Rev 2012;21(124):125–39. doi: 10.1183/09059180.00004711.
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  16. Versteegh LA, Chang AB, Chirgwin S, Tenorio FP, Wilson CA, McCallum GB. Multi-lingual ‘Asthma APP’ improves health knowledge of asthma among Australian First Nations carers of children with asthma. Front Pediatr 2022;10:925189. doi: 10.3389/fped.2022.925189.
  17. Kaplan A, Hardjojo A, Yu S, Price D. Asthma across age: Insights from primary care. Front Pediatr 2019;7:162. doi: 10.3389/fped.2019.00162.
  18. [Accessed 2 March 2023].
  19. Valery PC, Chang AB, Shibasaki S, et al. High prevalence of asthma in five remote Indigenous communities in Australia. Eur Respir J 2001;17(6):1089–96. doi: 10.1183/09031936.01.00099901.
  20. Young BA. Removal of race from estimation of kidney function. Nat Rev Nephrol 2022;18(4):201–02. doi: 10.1038/s41581-021-00524-1.
  21. Agrawal A, Aggarwal M, Sonnappa S, Bush A. Ethnicity and spirometric indices: Hostage to tunnel vision? Lancet Respir Med 2019;7(9):743–44. doi: 10.1016/S2213-2600(19)30204-8.
  22. Blake TL, Chang AB, Chatfield MD, Marchant JM, McElrea MS. Global Lung Function Initiative – 2012 ‘other/mixed’ spirometry reference equation provides the best overall fit for Australian Aboriginal and/or Torres Strait Islander children and young adults. Respirology 2020;25(3):281–88. doi: 10.1111/resp.13649.
  23. Martinez FD. Early-life origins of chronic obstructive pulmonary disease. N Engl J Med 2016;375(9):871–78. doi: 10.1056/NEJMra1603287.
  24. Polverino E, Dimakou K, Hurst J, et al. The overlap between bronchiectasis and chronic airway diseases: State of the art and future directions. Eur Respir J 2018;52(3):1800328. doi: 10.1183/13993003.00328-2018.
  25. Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax 2019;74(Suppl 1):1–69. doi: 10.1136/thoraxjnl-2018-212463.
  26. McCallum GB, Oguoma VM, Versteegh LA, et al. Comparison of profiles of First Nations and non-First Nations children with bronchiectasis over two 5-year periods in the Northern Territory, Australia. Chest 2021;160:1200–10. doi: 10.1016/j.chest.2021.04.057.
  27. Collaro AJ, Chang AB, Marchant JM, et al. Pediatric patients of outreach specialist Queensland clinics have lung function improvement comparable to that of tertiary pediatric patients. Chest 2020;158(4):1566–75. doi: 10.1016/j.chest.2020.03.084.
  28. Collaro AJ, Chang AB, Marchant JM, et al. Determinants and follow-up of lung function data from a predominantly First Nations cohort of adults referred to specialist respiratory outreach clinics in regional and remote Queensland. Lung 2021;199(4):417–25. doi: 10.1007/s00408-021-00453-7.
  29. Bønnelykke K, Vissing NH, Sevelsted A, Johnston SL, Bisgaard H. Association between respiratory infections in early life and later asthma is independent of virus type. J Allergy Clin Immunol 2015;136(1):81–86.e4. doi: 10.1016/j.jaci.2015.02.024.
  30. McCallum GB, Chatfield MD, Morris PS, Chang AB. Risk factors for adverse outcomes of Indigenous infants hospitalized with bronchiolitis. Pediatr Pulmonol 2016;51(6):613–23. doi: 10.1002/ppul.23342.
  31. Valery PC, Masters IB, Taylor B, Laifoo Y, O’Rourke PK, Chang AB. An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: A randomised controlled trial. Med J Aust 2010;192(10):574–79. doi: 10.5694/j.1326-5377.2010.tb03640.x.
  32. McCallum GB, Morris PS, Brown N, Chang AB. Culture‐specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev. 2017;8:CD006580. doi: 10.1002/14651858.CD006580.pub5.
  33. Trivedi M, Denton E. Asthma in children and adults – what are the differences and what can they tell us about asthma? Front Pediatr 2019;7:256. doi: 10.3389/fped.2019.00256.
  34. Reddel HK, Bateman ED, Schatz M, Krishnan JA, Cloutier MM. A practical guide to implementing SMART in asthma management. J Allergy Clin Immunol Pract 2022;10(1S):S31–38. doi: 10.1016/j.jaip.2021.10.011.




 

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