Asthma: what AU general practice does in 2026 (and why blue puffers changed)

What asthma is

Asthma is a chronic inflammatory disease of the airways, characterised by reversible airflow limitation and bronchial hyper-responsiveness. Around 11% of Australian adults and 10% of children have asthma. The condition spans a wide spectrum from very mild (occasional symptoms) to severe (life-threatening attacks despite maximal therapy).

The dominant change in asthma management over the past decade is the move away from reliever-only treatment toward anti-inflammatory at the centre of care from step 1. The blue salbutamol puffer alone is no longer recommended for any patient, including the mildest cases.

A. Core clinical — the AU framework

Diagnosis

The Australian Asthma Handbook — the National Asthma Council’s living guideline — sets out the diagnostic approach:

• History — episodic wheeze, breathlessness, chest tightness, cough; often worse at night or early morning; triggered by viral URTIs, exercise, allergens, weather changes, smoke
• Spirometry — reversible airflow obstruction (FEV1 improvement ≥12% and ≥200 mL post-bronchodilator); peak flow variability as supportive
• Bronchial challenge testing in unclear cases — mannitol or methacholine via respiratory laboratory
• FeNO (fractional exhaled nitric oxide) — adjunct biomarker for type-2 (eosinophilic) inflammation
• Allergen sensitisation — skin-prick or specific IgE where allergic triggers suspected
• Differentials to exclude — COPD, vocal cord dysfunction, cardiac failure, bronchiectasis, post-infectious cough, GORD-related cough

Management — the modern approach

The Australian Asthma Handbook structures management by step, with ICS-formoterol as the preferred reliever from step 1 in adolescents and adults (a substantial change from the old SABA-only step 1):

Step	Treatment
1 (mild intermittent)	As-needed ICS-formoterol
2 (mild persistent)	Daily low-dose ICS + as-needed SABA, or as-needed ICS-formoterol
3	Low-dose ICS-LABA maintenance + as-needed reliever (SMART preferred: ICS-formoterol both maintenance and reliever)
4	Medium-dose ICS-LABA + as-needed reliever; add tiotropium or LTRA if needed
5	High-dose ICS-LABA + add-on (tiotropium, LAMA, biologic) — specialist input

NPS MedicineWise and Therapeutic Guidelines align on this. The key reframe: inhaled corticosteroid is the foundation of treatment, not the optional add-on.

Asthma Action Plan

Every Australian patient with asthma should have a written Asthma Action Plan — green/yellow/red zones with specific medication actions for each. Available from the National Asthma Council and reviewed at every annual check.

Inhaler technique

About 70% of patients use their inhaler incorrectly — the single largest preventable cause of poor control. The fixes are simple:

• Exhale before inhaling
• Match inhalation speed to device type (slow for MDIs, fast and forceful for DPIs)
• Hold breath 5–10 seconds after inhalation
• Rinse mouth after ICS-containing doses (oral candidiasis prevention)
• Use a spacer with pressurised MDIs

Asthma Australia and the National Asthma Council both maintain free video tutorials for every device.

B. Evidence appraisal — what’s changed

The SYGMA trials. SYGMA 1 (NEJM 2018) and SYGMA 2 (NEJM 2018) demonstrated that as-needed ICS-formoterol in mild asthma reduces severe attacks by about 60% compared with as-needed SABA alone, and is non-inferior to daily maintenance ICS for symptom control. The implication: regular reliever use without anti-inflammatory cover is associated with worse outcomes; even mild asthma benefits from anti-inflammatory at point of need.

SMART / AIR for moderate asthma. Single-inhaler maintenance-and-reliever therapy reduces severe attacks by approximately 30% vs maintenance ICS-LABA + separate SABA. The simplification (one device vs two) also improves adherence.

Biologics for severe asthma. Five biologics PBS-listed for severe asthma in Australia, targeting different inflammatory pathways:

• Omalizumab (anti-IgE) — allergic phenotype
• Mepolizumab, benralizumab (anti-IL5) — eosinophilic phenotype
• Dupilumab (anti-IL4/IL13) — type-2 high asthma, also indicated for atopic dermatitis and CRSwNP
• Tezepelumab (anti-TSLP) — broader; effective regardless of phenotype

PBS criteria require specialist initiation, severity despite optimised conventional treatment, and (for most) specific biomarker phenotyping. The Lung Foundation Australia and Thoracic Society maintain current guidance.

Trigger management. TGA-approved sublingual immunotherapy (SLIT) for house dust mite — useful adjunct in allergic asthma with house dust mite as a clear driver. Allergen avoidance protocols (mattress encasings, vacuuming with HEPA, pet exclusion) help when a specific trigger is identified.

What hasn’t held up. Routine SABA-only treatment for any severity. Routine long-term oral corticosteroids for asthma (toxicity profile is significant; biologics or specialist referral preferred). Most herbal remedies for asthma — limited or no trial support.

C. Australian operations — what the visit looks like

The AU pathway integrates several MBS items per the Department of Health:

• Long consultations (items 36 or 44) for new diagnosis, intensification reviews, severe-asthma assessment
• Asthma Cycle of Care — structured review item for general practice
• GPCCMP for chronic asthma — opens 5 subsidised allied-health visits per year (respiratory educator, physiotherapy where indicated, dietitian if obesity-related asthma, exercise physiologist)
• Practice nurse follow-up (item 10997) — inhaler technique reviews and Action Plan reinforcement
• Spirometry (PBS-funded pathology / private respiratory laboratory)
• Mental Health Treatment Plan (item 2715 or 2717) — anxiety often comorbid

(MBS / PBS items verified 2026-05-18 via WebSearch — workspace egress to mbsonline.gov.au + pbs.gov.au still blocked; spot-check confirms current.)

For severe asthma — specialist referral to respiratory medicine for biologic consideration. Many AU centres have dedicated severe-asthma clinics with allergy + respiratory + nursing input.

D. Practical management

A standard AU general practice asthma review covers:

1. Symptom control — using the Asthma Control Questionnaire or Asthma Control Test
2. Inhaler technique — observed at every visit
3. Action Plan — updated annually
4. Reliever use — frequency is a control marker; ≥3 days/week indicates step-up
5. Spirometry — annual where feasible
6. Trigger review — allergens, occupational exposures, viral patterns
7. Vaccinations — annual influenza, Prevenar 20, COVID-19, RSV in eligible adults
8. Comorbidities — rhinitis, sinusitis, GORD, sleep apnoea, anxiety
9. Smoking — active and passive exposure; cessation support if relevant
10. Weight — obesity worsens asthma; weight reduction improves control

For paediatric patients: Asthma Australia has age-specific resources; school Asthma Action Plans are part of routine care.

When to call for help today, not next week

Asthma red flags warranting immediate medical attention:

• Reliever giving less than usual relief, or wearing off quickly (every 1–2 hours)
• Severe breathlessness — difficulty completing sentences, accessory-muscle use, unable to lie flat
• Cyanosis (blue lips or fingertips), exhaustion, confusion
• Peak flow less than 50% of personal best, or unable to perform peak flow due to severity
• Reliever inhaler running out during an attack
• Children: severe respiratory distress, unable to feed or talk, lethargy, retractions, grunting

Acute severe asthma is a medical emergency — call 000.

What this article is and is not

This is general health information drawn from the Australian Asthma Handbook (National Asthma Council), Therapeutic Guidelines, the SYGMA trials, and AU specialty references (Lung Foundation, Thoracic Society). It is not personal medical advice and does not create a doctor–patient relationship. Decisions about your specific asthma treatment plan, including step changes and biologic consideration, are made with your own GP and treating respiratory specialist.

For Australian consumer-friendly sources: Asthma Australia, HealthDirect — Asthma, Better Health Channel, Lung Foundation Australia.

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Sources cited

1. Australian Asthma Handbook
2. RACGP
3. Therapeutic Guidelines (eTG) — Asthma
4. Australian Medicines Handbook
5. NPS MedicineWise
6. Lung Foundation Australia
7. Thoracic Society of Australia and New Zealand
8. TGA
9. HealthDirect — Asthma
10. Better Health Channel — Asthma
11. Asthma Australia
12. O’Byrne PM et al. — SYGMA 1 (NEJM 2018)
13. Bateman ED et al. — SYGMA 2 (NEJM 2018)
14. GINA — Global Initiative for Asthma 2024