Risk Factor Components (Including Self-Management)

Self-report – Exacerbation risk is increased if the patient does not possess a written action plan or does not use the prescribed plan during exacerbations. For more information see Management – Education & Action Plans

Written Action Plan – Personalised written action plans show patients how to make short term changes to their treatment in response to their symptoms and how and when to access medical care. Templates are available from National Asthma Council Action Plans or see Asthma Action Plans

Patient-completed Asthma Knowledge Questionnaire (PAKQ) – The PAKQ is an asthma knowledge questionnaire, based on international guidelines that can be used to tailor educational interventions to the individual patient (Beaurivage et al. 2018).

The PAKQ can be downloaded here with permissions from Dr. Louis-Philippe Boulet. For permissions to alter, translate or sell (paper or software) the PAKQ contact lpboulet@med.ulaval.ca

Medication review – Prescription of ≥3 different inhaler devices (polypharmacy) can lead to inadequate inhaler technique and poor asthma control (McDonald et al. 2005, Walters et al. 2013).

Self-report by open-ended questions – Non-adherence should be addressed if a patient reports using <80% of prescribed treatment. For more information see Management – Adherence

Morisky Medication Adherence Scale (MMAS-4/8) – The MMAS is a self-reported measure of medication adherence, consisting of 4 or 8 questions. A score of 1-2 indicated medium adherence, while ≥3 indicated low adherence. (Morisky et al. 1986).

For access and permissions: https://morisky.org/

FeNO Suppression Test – Elevated fractional exhaled nitric oxide (FeNO) levels may be indicative of non-adherence to ICS therapy. FeNO suppression testing consists of serial FeNO measurements in conjunction with objectively observed ICS administration for 5-7 days (McNicholl et al. 2012), e.g. with an INCA device. A reduction in FeNO levels after observed ICS administration is indicative of previous treatment non-adherence.

Inhaler Technique Checklists – Produced by NPS Medicinewise, in collaboration with the National Asthma Council Australia. Provides device-specific summaries of the correct sequence of events for teaching inhaler technique. For more information see Management – Inhaler Technique

Exhaled Carbon Monoxide Assessment – Exhaled carbon monoxide measurements ≥10 ppm is indicative of smoking.

Fagerstrom Test for Nicotine Dependence (FTND) – The FTND is a 6-item questionnaire to assess the intensity of physical addiction to nicotine. A score >7 indicates a high level of dependence (Heatherton et al. 1991). Available on the Pharmaceutical Society of Australia website

Smoking Cessation Tools – Resources to assess with smoking cessation are available at the Australian QuitNow government website.

Skin Prick Testing

Blood IgE Assessment – Blood IgE levels can be quantified through a standard pathology service. A documented serum IgE levels ³ 30 IU/mL is required for eligibility for omalizumab treatment.

Body Mass Index (BMI) Calculator – Developed by the Heart Foundation Australia. Provides a rapid calculation of BMI and interpretation of results. Calculate as weight (kg) / height (m)². Underweight = BMI <20. Overweight = BMI between 25 and 30. Obese = BMI >30. The calculator can be accessed here. For more information see Comorbidities – Obesity

Self-report – Self-reported impairment because of an inability to achieve personal activity goals.

International Physical Activity Questionnaire (IPAQ) – The IPAQ was developed to measure health-related physical activity (Craig et al. 2003). It is available in short (assessing physical activity in the last 7 days) and long forms (assessing usual physical activity) for either self- or telephone administration. Versions in range of languages are available for download here

Physical activity recommendations: The Australian Asthma Handbook contains recommendations for exercise and asthma. Australia’s Physical Activity and Sedentary Behaviour Guidelines also provide general recommendations for physical activity (Note: these guidelines are general and not specifically developed for individuals with asthma). For more information see Management – Physical Activity

Osteoporosis fracture risk calculator – Developed by the Garvan Institute. Provides an assessment of fracture risk based on demographics, fracture history and bone mineral density measurements. For more information see Comorbidities – Osteoporosis

Fracture Risk Assessment Tool (FRAX) – The FRAX tool uses demographic information, associated clinical risk factors and bone mineral density to calculate a fracture risk for patients. More information and an online calculator are available here

Dual-energy X-ray Absorptiometry (DEXA) – Sarcopenia refers to the progressive decline in skeletal muscle mass, strength and function, typically associated with ageing (Cruz-Jentoft et al. 2010). DEXA assessment quantifies body fat, bone mineral and lean tissues, and can be used to assess for sarcopenia. Consensus guidelines recommend a cut-off point of 2 standard deviations below the mean for gender-specific young adult for diagnosis of sarcopenia (available here)

Clinical History & Screening Questions –  Ask the patient about the kind of work they do and potential sensitizer exposure. Does the patient think their asthma is related to work and does it get better on weekends and holidays? Material Safety Data Sheets (MSDS) provide information on the ingredients found in workplace chemicals, which can be useful to identify potential sensitisers

Lung Function Assessment and Monitoring – Can be useful to demonstrate an association between symptoms and time at work. Peak expiratory flow (PEF) monitoring (4 measurements / day) including periods at work and off work is commonly used to document associations between lung function and time at work. Note that, bronchial provocation tests can be normal, if the patient is not currently exposed in the workplace. However, a negative methacholine challenge can effectively rule out occupational asthma in symptomatic patients. Serial measurements of bronchial hyperreactivity or airway inflammation, during periods of work versus off-work periods (after holiday) can improve diagnosis specificity.

Sensitiser Allergy Testing – May be useful to identify a specific sensitiser. Specific allergy testing is available for many high molecular weight sensitisers, although specificity is quite low. A positive finding indicates sensitisation, but not necessarily occupational asthma.

Specific Inhalation Challenge – Can be useful if other investigations are equivocal or negative for occupational asthma, or identification of a specific sensitiser is necessary.

Workplace Challenge – May be useful if no causal agent is identified in other investigations, the exposure cannot be recreated in the laboratory or a specific inhalation challenge is negative but occupational asthma is considered likely.

Aspirin-Sensitive Asthma – Non-steroidal anti-inflammatory drugs (NSAIDs) include aspirin, celecoxib, diclofenac, ibuprofen, indomethacin, meloxicam and naproxyn. They are common components in pain medications. More information is available from the Australasian Society of Clinical Immunology and Allergy (ASCIA). Aspirin-exacerbated respiratory disease (AERD) affects around 15% of people with severe asthma (Rajan et al. 2015). AERD typically consists of chronic rhinosinusitis complicated by nasal polyps, severe bronchial asthma and NSAID intolerance. More information on AERD can be found here. Diagnosis is based on a history of adverse reactions to NSAID treatment. In some situations, oral aspirin challenge may be required to confirm the diagnosis.