ASTHMA CARE
Introduction
The patient is a female aged 41 years; she works as a garage admin. She is brought to the hospital with a productive cough of 3/52, asthma and rhinitis, she has used Ventolin, but she complained that the Ventolin is not helping solve the situation.
The patient has never experienced atopic asthma before or its effects; she has also never smoked. Some few weeks ago, she was diagnosed with some chest infections and some form of flu. She has been fighting gastritis for three years previously. She was recently detected with respiratory asthma in her previous admittance two weeks in the past. The patient was on symiboart 200/6 and Ventolin 100mcg, two puffs B.D. when necessary and two puffs BRN respectively for asthma bronchial. She again was put on a Beconose Nasal spray.
Consciousness and the alert was her condition on examining the patient. She was pink and seemed to be legitimately hydrated. Her speech was full and with lots of ease, and there was no form of tachypnoeic. Her airflow into the lungs was reduced with an inspirational polyphonic wheeze, U.L. lung. The wheeze and the crackles in the lungs led to the reduced airflow into the lungs. Her peak expiratory flow was at litres per min (L/Min), while her Pulmonary peak expiratory flow was at 469 litres per minute (L/Min). Her pulse rate (P.R.) was 85 bpm, i.e. beats per minute, and her temperature was 36.50C. Her SATO2, oxygen saturation, was 98%.
During her admission, her capillary refill rate was examined and was satisfactory; typical testbed examinations were conceded and were attained. It was observed that her Accessory muscles of ventilation were working perfectly. She was initially diagnosed with reduced airflow into the lungs and a wheeze and crackles, which was leading to her low airflow into the lungs.
She is currently under medication, continues and was given suitable nebuliser, 2.5mg of salbutamol. The patient was given prednisolone, 5mg only once per day and Doxycycline 100mg twice a day was also recommended. Her oxygen saturation (SATO2) was monitored; her SpO2 and peak expiratory flow rate was checked. After a while, her chest was re-examined, and her airflow into the lungs had increased and flowing well.
During the follow-up, the patient was afebrile showing some good clinical progress, was enduring verbally fine and had no sore throat—her condition of the non-productive and cough, which was mild. An ECG was carried out, and it indicated that she had sinus rhythm with no ischaemic changes. The chest x-ray indicated that her chest was clear, and there was some good avoidable air entry. Her peak expiratory flow rate (PEFR) had increased to 330 l/min, and her pulmonary peak expiratory flow was at 469 l/min. She was also supposed to use the Ventolin for 12 months. On Day 2 of her stay, she was recommended to use a steroid to ease her inflammation on her nose. Statistics have shown that steroid usage among the teens is leading accounting to over 75% of these users worldwide. Steroid drugs have got numerous side effects on the part of the user, whether male or female. Statistics indicate that male tend to have higher rates of depression, high suicidal cases, low self-esteem and poor knowledge of attitudes, (Lee et al. 2018).
The patient was supposed to be taking Ventolin, 100mcg three times a day, accompanied by Doxycycline PO ABX three times a day too, she was also supposed to be under the Symbicort 200/6 turbo after every 6 hours and Steroid prednisolone once per day. The patient had some allergies, including hitch nose and body rashes arising from the usage of the drugs and was put under the penicillin drugs to curb the issue. The patient has had no SOB seen, and she had good bronchodilator system.
Pharmacological Options
During her hospital stay in various departments, she was removed from the oxygen and the nebuliser Combivent. She was so comfortable by day 4, and her productive cough and sputum were minimal (McDonald et al. 2018). Investigation on her breathing system indicated that she had persistent breath out outcomes. Subsequently, strengthening on the bronchodilator system by the posologist, on the fifth day, she was discharged as she had a negligible cough, (Ivanova at al. 2012).
The Asthma guide provided for by the British Guideline of Management is the point of reference and needs to be adhered to adequately. Prednisolone dose should be accelerated to once a day in 50mg dosages until the patient fully recovers or a minimum of five days. Theophylline toxicity signs and symptoms need to be communicated to the patient in time and counselled properly in case she experiences such symptoms.
A phlegm full exam infinitesimal investigation should be bid to discover the causative microbes of the respiratory contamination as an issue concerning the selection of antibiotics for the remedy of this patient. If experimental management is to begin the desired pills of choice might be 500mg of amoxicillin X 3 for each day. Moreover, alongside amoxicillin, a combination of both erythromycin 500mg X 4 for each day or clarithromycin 500mg X2 each day. Alternative choices would be levofloxacin 500mg once a day by day or moxifloxacin 400mg X1 for each day in case the patient remains illiberal of the dosage regimen preferred for her.
The treatment of the patient with a statin agent for a long period of time implies that her liver enzymes ought to be observed frequently. Moreover, if her liver enzymes are raised with the aid of three-fold, she ought to prevent taking the Lovastatin, and thus the cholesterol levels in the patient’s blood must be monitored and recorded. In addition, the best manner of statins utilisation ought to be considered. She needs to additionally be cautioned regarding any possible signs of rhabdomyolysis which is associated with the prolonged statins’ use, including dark urine colouration, stiffness, weak spot and the increased magnitude of pain within the muscles.
Asthma
This is a continual provocative sickness of the airlines in which many cells and cellular rudiments are critical. This ends in continuing incidences of gasping, stiffness on the chest, wheezing, and proficient incidences of coughing, mainly at night or very early in the morning (Kemp et al., 2010). Provocative signs are universally related with giant, but adjustable airflow impediment in the lung alongside hyperresponsiveness within the airways which is revocable either on personal aspects or upon a remedy.
Asthma is global trouble because it is projected that about 4.5% of the global population is prone to its effects. The latter translates to approximately 300 million people. The worldwide incidence of asthma has a variation of 1-18% among the global populations in international locations everywhere (Parkinson et al. 2018).
Characteristically, three major distinctive attributes are linked to asthma. These trains encompass hindrances on the flow of air in the airways, hyperresponsiveness, with the respiratory airways and infection in the bronchi. Airflow hindrance is commonly managed naturally by the body’s immunity; however, for patients who have chronic allergies, irritation may also bring about irreversible airflow difficulty. Upgrades alongside aggravations or allergens may moreover act like triggers in aviation route hyperresponsiveness, and the emergence of bronchial disease is related to eosinophil, pole cells and the T-lymphocytes. The hallmarks of these immunological calls are several complications such as plasma exudation, changes in epithelial tissues, muscular hypertrophy, and mucous stopping (Willson et al. 2014). Occasionally, it is demonstrated that carrier bothering plays a principle position inside the bronchial asthma pathology which begins when the immunological allergens are elevated or when aggravation triggers the initiation of cells that incorporates the macrophages, epithelial cells, pole cells and lymphocytes. This finishes in cytokine or middle person dispatch and smooth muscle compression bringing about the portable invasion of eosinophil and neutrophils perpetrating aviation route irritation, for example, oedema, epithelial penetrability or mischief, mucous discharge and vascular porousness which inevitably prompts aviation route check and hyperresponsiveness, (Upham & Chung 2018).
Asthma analysis is dependent on several side effects without a moderate reason for them. In addition, spirometry forms one of the first tests for the assessment of any wind current hindrance present and its volume. For perceived asthmatic patients, intense intensifications may likewise emerge, and due to the reality, patients with serious asthma are at an expanded danger of being subjected to death following intensifications, tests of intensifications are basic, (Sanchis, Gich & Pedersen. 2016). Clinical elements of intense bronchial asthma intensifications comprise of tachypnoea, quiet chest, tachycardia, cyanosis, outrageous shortness of breath, or syncope.
Pinnacle Expiratory Flow (PEF) or Forced Expiratory Volume in one second (FEV1) is in like manner used to degree the lung limit. Oxygen immersion (SpO2) is estimated the utilisation of heartbeat oximetry, and this guides oxygen cure as oxygen treatment is given in the event that you need to safeguard SpO2 degrees at 94-ninety eight%. Estimations of blood vessel blood gases (ABG) are by and large now not indispensable aside from patients present with elements of ways of life compromising hypersensitivities or have SpO2 of under 92% as there can be a risk of hypercapnia if SpO2 is decline than ninety-two %. Chest X-beams are additionally not, at this point supported except if patients are associated with pneumonia or lung unions, stricken by hazardous bronchial asthma, having an unacceptable response to treatment or on the off chance that they require wind stream, (Reddel et al. 2015).
Oxygen treatment is required upon time limit since the victims who are experiencing intense asthma regularly present hypoxia-like symptoms as pleasantly. Henceforth, hypoxic patients who are blasted by intense and serious asthma requires frequent administration of oxygen. Moreover, their levels of SpO2 must be maintained at 94-98% (Radhakrishna et al. 2017).
As the first-line remedy, an excessive inhalation dose of β2 agonist bronchodilators is administered as quickly as viable for the relief of bronchospasm. In the case of the patients who are incapable of applying inhaled therapy, intravenous β2-agonists are thus administered. The β2 agonist bronchodilators paintings by way of stimulating the β2 adrenoceptors within the lungs, thus inflicting the rest of the airlines. Examples of brief appearing β2-agonist are salbutamol and Terbutaline, and an extended acting β2-agonist is salmeterol, (Price et al. 2011).
Steroids have to continually receive in all instances of acute bronchial asthma. Examples of these agents constitute prednisolone, prednisone, hydrocortisone and dexamethasone. These agents have some anti-inflammatory effects on the respiratory airways via the inhibition of gene transcription that encode the cytokines implicated in asthmatic inflammation and for this reason, lessen airway hyper-responsiveness.
Ipratropium bromide is an anticholinergic marketer that is often utilised extensively in the remedy of acute asthma culminations. Nebulised ipratropium bromide is utilised in aggregate with an β2-agonist bronchodilator as a remedy for asthmatic patients which is characteristically life-threatening, intense and acute. Anticholinergic paintings by way of inhibiting the M1 and M3 muscarinic receptors. The latter emanates in the reduction of the formation of cGMP and an impending decrease in the contractility of the lung’s muscles. This subsequently outcomes in Broncho dilation and decreases the secretion of mucus (Dhuper et al. 2011).
Other therapies consist of the usage of magnesium sulphate. An unmarried intravenous bolus dose of magnesium sulphate is run to acute asthmatic patients. Ultimately, there is a preceding unsatisfactory response to inhaled bronchodilator remedy. Moreover, it can affect patients affected with a life-threatening or deadly bronchial asthma. On assumptions, magnesium sulphate lowers the uptake of calcium via the bronchial smooth muscle cells, inflicting bronchodilation while inhibiting the degranulation of the mast cells, thereby decreasing the discharge of inflammatory mediators such as the leukotrienes and histamines.
Management of Acute Asthma
Allergy management in asthmatic patients can be categorised two components; long-time management and acute treatment. In the cases where nebulisers are therapeutically required, then oxygen-pushed nebulisers are preferred over those which might be air-driven as a result of oxygen desaturation when pushed by air on my own. It has been demonstrated that most acute asthmatic patients with intensive bronchial asthma are hypoxemic. Consequently, it’s far important to adopt supplementary oxygen therapy to such patients (Dhuper et al. 2011). This oxygen is run through a nasal prong or face mask with the SpO2 of the patient stored between 94-98%. However, the failure to supply supplemental oxygen should not be avoided as it can omit nebulised remedy in the management if deemed suitable (Nimon, Zigarmi & Allen. 2011).
Discussing the case presented above, the patient responded well to treatment; hence without delay, she was administered with supplemental oxygen. Moreover, the patient’s SpO2 turned in and was constantly maintained above 96% during hospital periods (Ismaila et al. 2013).
As intense asthma is related with signs and manifestations of bronchospasms comprehensive of wheezing and tachypnoea, the primary point of treatment is too rapid determination these signs and side effects and frequently, high dosages of breathed in β2 agonist bronchodilators are amazing with negligible unfriendly outcomes (Drazen et al. 2018). Salbutamol is regularly the medication of want despite the fact that there are no generous varieties in expressions of viability contrasted with Terbutaline. It is demonstrated that there aren’t any acceptable estimated logical favours with the guide of the utilisation of a non-specific β2 agonist including epinephrine rather than particular β2 agonists. In view of a meta-examination, it is seen that β2 agonists controlled through inward breath are extra best and has comparable viability with those managed intravenously face to face intense allergies. Sixteen In ventilated patients or those in dangerous circumstances, parenteral β2 agonists can be conveyed to breathed in β2 agonist treatment despite the fact that there’s little proof helping this treatment, (Israel & Reddel 2017). Albeit an unmarried bolus nebulisation can likewise ease most extreme intense hypersensitivities cases, it is demonstrated that relentless nebulised treatment of β2 agonists is more prominent incredible in assuaging intense sensitivities for individuals with inadmissible reaction to beginning treatment (Franco et al. 2014).
Steroid cure is continually given in intense intensifications of bronchial asthma, and it is tried that it has better final product whenever given ahead of time. It not, at this point, least difficult decreases mortality, yet it likewise diminishes backslides and the wide assortment of clinical organisation affirmations as appropriately. The administration of oral steroids poses similar viability as a parenteral treatment. In this perspective, parenteral steroid administration may not be necessary unless the patient is unable to endure an oral administration. Prednisolone 40-50mg is administered on a daily basis as a base 5 days or until mending, which can be halted following the recuperation of the patient. As extensive in light of the fact that the patient is on breathed in steroids, there’s no requirement for the portion to be tightened gradually past to end.
For the situation offered, the influenced individual was on steroid treatment. However, she becomes under-treated as she transformed into her best condition after being given prednisolone 30mg. Thus, there might be a need to build the portion of prednisolone to 50mg and to safeguard is for at any rate some other four days or until recuperating sooner than forestalling this kind of treatment. In medical care, anticholinergic remedies are often administered to intense asthma exacerbations, and nebulised ipratropium bromide is continually the medication of desire utilised in clinical settings.
A combination of nebulised ipratropium bromide with an β2 agonist bronchodilator is frequently administered as a remedy because it is demonstrated that these retailers play significant roles in bronchodilatation in comparison to when β2 agonist is administered to the patients. Hence, there is a faster recuperation which is adequate to lessen the duration of sanatorium live. Notably, anticholinergic treatment is not mainly efficacious and effective in instances of mild exacerbations of allergies, and after the affected person has undergone stabilisation, consequently, the drug is not appropriate for those instances.
The affected person in this case study changed demonstrated a mild culmination into of acute asthma, and therefore nebulised ipratropium bromide medication was no longer essential. In any case, the utilisation of nebulised Combivent, a blend of ipratropium bromide and salbutamol transformed into legitimised in light of the fact that this influenced individual became re-going to with a backslide and the person in question become disappeared with pneumonia too. Henceforth, there have been likely a need at a quicker cost of bronchodilation just as speedier recuperating for her.
The utilisation of magnesium sulfate in clinical organisation treatment of AEBA isn’t in every case broadly obvious, anyway, there was a couple of verification showing the bronchodilatory impacts of magnesium sulfate while utilised in grown-ups. There likewise are research which records that nebulised magnesium sulfate mixed with an β2 agonist demonstrates top-notch results and top clinical viability in sanatorium settings. The utilisation of an intravenous bolus the board of magnesium sulfate is thought to advance lung work in victims who have serious bronchial asthma without unsafe feature results. By and by, there were no investigations on the rehashed organisations of magnesium sulfate, in spite of the fact that it is assumed that rehashed use may likewise result in hypermagnesaemia, incurring shaky muscle area and breathe disappointment. As comparably enormous investigations should be done to decide the most appropriate dosage of magnesium sulfate. This kind of medication is held handiest for patients with intense extraordinary bronchial asthma without pleasant reaction to breathed in bronchodilator cure and victims with ways of life compromising of close to lethal bronchial asthma.
Checking should be done continually all through wellbeing and in intense bronchial asthma cases, following the indispensable PEF. PEF readings have to be estimated and recorded after every half an hour after the treatment initiation. PEF needs to likewise be checked pre-and distribute nebulisation cures insofar as the influenced individual is in the clinic and till the asthma is pleasantly underneath overseen after release.
It is seen that after sanatorium release, a general measure of patients both revel in backsliding or are readmitted into the centre within any event 15% inside weeks following release. In this way, it’s far crucial that influenced individual tutoring along with right inhaler procedure, and very much archived PEF accounts with development plans depending on indications talented ought to be imparted with an end goal to diminish the expense of backslides notwithstanding decline inconveniences related with intensifications after release.
Checking of the influenced individual’s PEF changed into completed reliably during her wellbeing community remain and the patient changed into given enough guiding before release on her inhaler technique. In any case, there has been no evidence that the patient becomes taught on self-archiving PEF accounts just as activity plans dependent on side effects talented after release and this should be executed in this circumstance to keep away from each other worsening of her circumstance.
Long Term Management of Asthma
The main aim of allergy management is to maintain the asthma cases appropriately without requiring any rescue medications alongside limited exacerbations and limited limitations to everyday sports that consist of exercises. Moreover, everyday lung characteristics must be managed appropriately. Stepwise asthma management method is utilised in asthmatic patients. This process is often done to accumulate preliminary manipulation and maintenance by using stepping up as a remedy to enhance manipulation. Also, the vital or stepping down remedy is an ideal control over the circumstance for the maintenance of the lowest step in order to control the patient’s circumstance (Crouch, Robinson, Pitts. 2011).
Since the patient in the case study is currently on medication with inhaled steroids, she is presently on the second step of the control of allergies. Much research has been conducted to evaluate the kind of inhaled steroids being used for bronchial asthma, and its miles proved that beclomethasone disproportionate and budesonide are both clinically powerful despite the fact that there may be extraordinary gadgets for shipping. Besides, it has been noticeable that fluticasone and mometasone being directed at half of the measurement of beclomethasone and budesonide shows equivalent clinical adequacy, anyway, there is very lacking proof that fluticasone has fewer side results and also need to be executed on setting up the assurance profile of mometasone.
Another breathed in steroid has been presented, which is ciclesonide, and clinical preliminaries have demonstrated proof that it has more close by enthusiasm than foundational and less oropharyngeal reactions when contrasted with the ordinary breathed in steroids. In spite of the fact that this appears to be encouraging, this logical addition stays begging to be proven wrong as its wellbeing to viability proportion has yet to be snared and as contrasted and the conventional breathed in steroids. Breathed in steroids are supported as preventer medicate solution for grown-ups as they’re most clinically amazing in controlling hypersensitivities basically based on the treatment dreams referenced, (Chung et al. 2014). The recurrence of dosing of breathed in steroids are for the most part two times every day, and it’s far shown that there may be moderate scientific benefit acquired whilst taken twice a day than as soon as every day, however, a dose of X1 each day dosing may additionally suffice in the patients experiencing milder bronchial asthma.
There also exists constrained evidence of benefit with the extended X2 dosage frequency extension for a single day. Moreover, the dosage begins at higher than encouraged doses which do not have any enormous efficacy in the treatment and management of mild to moderate bronchial asthma (Chidwick et al. 2018). As such, the endorsed inhaled steroids. The dosage might be 200-800mcg day by day. This might be an upload-on remedy to the step 1 control of the use of inhaled brief acting β2 agonist bronchodilator as required.
With regard to the case study given, the affected person was on budesonide 200mcg after the night previous to admission, but this accelerated upon hospital admission. The patient was also keeping up with the encouraged guidelines as she became received some relief upon budesonide 400mcg administration 2x on the afternoon together with salbutamol 200mcg as required following discharge (Colice et al., 2013).
Other preventer healing procedures can be included for the affected person notwithstanding inhaled steroids being the first desire of drugs for preventer therapy, (Bhanji et al. 2012). These options are much less effective despite the fact that they’ve proven a few medical advantages in sufferers who’re on short performing β2 agonists only. Chromones which act as mast cell stabilisers along with sodium cromoglicate and nedocromil sodium pose potential benefits in adults. Besides, leukotriene receptor antagonists montelukast and zafirlukast too have scientific blessings. Theophylline additionally has a few evidence in showing blessings in adults, (González-Chica et al. 2018).
The affected person in the case study was to be prescribed with sustained-release theophylline on the ultimate day of hospital admission (Abavaratne et al., (2011). Although sustained-release theophylline remains an alternative choice that can be administered alongside everyday controller medications for step 2 management, minimal evidence underpin the clinical efficacy of this agent as a long-time controller. Moreover, the justification of the use of theophylline is rendered inappropriate in this case study as the patient depicts signs is responsiveness and can be controlled upon the administration of inhaled steroids. Furthermore, theophylline demonstrates a narrow healing index, and close tracking of plasma theophylline levels is vital because at concentrations above 25µg/ml, there’s an excessive risk of tachycardia and seizures may additionally arise if concentrations exceed 35µg/ml.
Conclusion
It can be established that she was treated sufficiently grounded on the present recommendations and suggestions achievable. This is in view of reviewing the management of the patient’s situation during the hospitalisation period. She was accorded all indispensable treatment at the purpose of affirmation, and there was no absent of solutions in every one of the four days of her clinic permission. Apart from that, monitoring of her condition was carried out consistently, and all data was updated, ruling out inquisitive. A couple of issues came to be including suggestions of various meds that were unnecessary, for example, diphenhydramine and theophylline, (Aaron et al. 2017). There were minute and no reasonable sign that these medications prescribed would be of favourable position to the patient, and may likewise escalate the risk of symptoms to her also.
Alongside her treatment of her intense condition, regulator meds were explored, and ensuing changes were made properly. Other than that, her other comorbidities were likewise overseen well as medicines for her condition were given accordingly.
References
Aaron SD, Vandemheen KL, FitzGerald JM, Ainslie M, Gupta S, Lemiere C, Field SK, McIvor RA, Hernandez P, Mayers I, et al. (2017). Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA. 317(3):269–79.
Abavaratne D et al., (2011). Can the multidisciplinary input of an asthma nurse specialist and respiratory physician improve the discharge management of acute asthma admissions? Clin Med August 1, 2011 vol. 11 no. 4 414-415.
Bhanji F, Gottesman R, de Grave W, Steinert Y, Winer LR. (2012). The retrospective pre-post: a practical method to evaluate learning from an educational program. Acad Emerg Med. 19(2):189–94.
Colice G, et al., (2013). Asthma outcomes and costs of therapy with extra fine beclomethasone and fluticasone. J Allergy Clin Immunol, 2013 Jul;132(1):45
Chidwick K, Kiss D, Gray R, Yoo J, Aufgang M, Zekry A.(2018) Insights into the management of chronic hepatitis C. Aust J Gen Pract. 47:639–45.
Chung KF et al. (2014). International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 43(2):343-73
Crouch S, Robinson P, Pitts M. (2011). A comparison of general practitioner response rates to electronic and postal surveys in the setting of the national STI prevention program. Aust N Z J Public Health. 35(2):187–9.
Dhuper S, at al. (2011). Efficacy and cost comparisons of bronchodilator administration between metered-dose inhalers with disposable spacers and nebulisers for acute asthma treatment. J Emerg Med, 40(3), 247-55
Drazen JM, Harrington D. (2018). New biologics for asthma. N Engl J Med. 378(26):2533–4.
Franco R et al. (2014). The economic impact of severe asthma to low‐income families. Allergy; 64(3), 478-83.
González-Chica DA, Vanlint S, Hoon E, Stocks N. (2018). Epidemiology of arthritis, chronic back pain, gout, osteoporosis, spondyloarthropathies and rheumatoid arthritis among 1.5 million patients in Australian general practice: NPS MedicineWise MedicineInsight dataset. BMC Musculoskelet Disord. 19(1):20.
Ivanova J.I., at al. (2012). Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma. J Allergy Clin Immunol, 129 (5), 1229-35.
Ismaila et al. (2013). Costs and health care resource utilisation associated with Asthma in Canada: A systematic review. Value in Health, 16(3), A188.
Israel E, Reddel HK. (2017). Severe and difficult-to-treat asthma in adults. N Engl J Med. 377(10):965–76.
Kemp L, et al., (2010). Cost-effectiveness analysis of corticosteroid inhaler devices in primary care asthma management: A real-world observational study. Clinicoecon Outcomes Res, 2, 75-85
Lee J, Tay TR, Radhakrishna N, Hore-Lacy F, Mackay A, Hoy R, Dabscheck E, O’Hehir R, Hew M. (2018). Nonadherence in the era of severe asthma biologics and thermoplastic. Eur Respir J. 1701836.
McDonald VM, Maltby S, Reddel HK, King GG, Wark PA, Smith L, Upham JW, James AL, Marks GB, Gibson PG. (2017). Severe asthma: Current management, targeted therapies and future directions-a roundtable report. Respirology. 22(1):53–60.
Nimon K, Zigarmi D, Allen J. (2011). Measures of program effectiveness based on retrospective pretest data: are all created equal? Am J Eval.32 (1):8–28?
Parkinson A, Jorm L, Douglas KA, Gee A, Sargent GM, Lujic S, McRae IS. (2015). Recruiting general practitioners for surveys: reflections on the difficulties and some lessons learned. Aust J Prim Health. 21(2):254–8.
Price D, et al. (2011). A pragmatic single-blind randomised controlled trial and economic evaluation of the use of leukotriene receptor antagonists in primary care at steps 2 and 3 of the national asthma guidelines (ELEVATE study). Health Technol Assess,15 (21), 1-132.
Radhakrishna N, Tay TR, Hore-Lacy F, Stirling R, Hoy R, Dabscheck E, Hew M. (2017). Validated questionnaires heighten detection of difficult asthma comorbidities. J Asthma. 54(3):294–9.
Reddel HK, Sawyer SM, Everett PW, Flood PV, Peters MJ. (2015). Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust. 202(9):492–7.
Sanchis J, Gich I, Pedersen S. (2016). A systematic review of errors in inhaler use: has patient technique improved over time? Chest. 150(2):394–406.
Upham JW, Chung LP. (2018). Optimising treatment for severe asthma. Med J Aust. 209(2 suppl): S22–S7.
Willson J et al. (2014). Cost-effectiveness of Tiotropium in patients with asthma. Applied Health Economics and Health Policy. 2014 Aug;12(4):447-59