The Thoracic Society of Australia and New Zealand: tests, treatments and procedures consumers and clinicians should question

Even for children with persistent asthma, the most recent evidence suggests that adding long-acting beta2 agonists (LABA) to inhaled corticosteroids (ICS) does not result in a statistically significant reduction in exacerbations. However, there is some evidence that LABA/ICS combination therapy increases the risk of hospital admissions and severe asthma-associated adverse events, particularly among asthmatic children aged 4 to 11 years old. Due to the limited paediatric evidence on the safety and efficacy of longacting beta2 agonists, the use of ICS alone is therefore recommended for the initial preventative therapy and the only therapy for children with mild to moderate asthma.

Supporting evidence

  • Canadian Agency for Drugs and Technologies in Health (CADTH). Long-Acting Beta2-Agonist and Inhaled Corticosteroid Combination Therapy for Adult Persistent Asthma: Systematic Review of Clinical Outcomes and Economic Evaluation. CADTH Technology Overviews. 2010;1(3):e0120.
  • Chauhan BF, Chartrand C, Ni Chroinin M, et al. Addition of long-acting beta2-agonists to inhaled corticosteroids for chronicasthma in children. Cochrane Database Syst Rev. 2015 24;(11):CD007949.
  • McMahon AW, Levenson MS, McEvoy BW, et al. Age and Risks of FDA-Approved Long-Acting 2-Adrenergic Receptor Agonists. Pediatrics. 2011;128(5):e1147-54.
  • van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010.

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The most recent Global Initiative for Asthma (GINA) report does not recommend a role for antibiotics in management of asthma exacerbation unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia. This is supported by recent trials involving azithromycin (a commonly prescribed antibiotic for management of asthma), which found that this drug had no statistically significant impacts on severity of symptoms during an exacerbation. One small randomised controlled trial (RCT) in young children with recurrent asthma-like symptoms showed that azithromycin reduced the duration of asthma-like symptoms. No RCT has been conducted in children who have a diagnosis of asthma to determine if the rate of severe asthma exacerbation or the severity of asthma symptoms or duration of an asthma exacerbation is reduced by azithromycin. A potential role for azithromycin in reducing the duration of an episode of asthma-like symptoms in children less than 3 years of age requires further investigation. Antibiotic treatment in addition to its lack of efficacy also increases the risk of bacteria resistance for those on long term treatment regimes.

Supporting evidence

  • Brusselle GG, Vanderstichele C, Jordens P, et al. Azithromycin for prevention of exacerbations in severe asthma (AZISAST): a multicentre randomised double-blind placebo-controlled trial. Thorax. 2013;68(4):322-9.
  • 2018 GINA Report, Global Strategy for Asthma Management and Prevention.
  • Li H, Liu DH, Chen LL, et al. Meta-analysis of the adverse effects of long-term azithromycin use in patients with chronic lung diseases. Antimicrob Agents Chemother. 2014;58(1):511-7.
  • Johnston SL, Szigeti M, Cross M, et al. Azithromycin for Acute Exacerbations of Asthma The AZALEA Randomized Clinical Trial. JAMA Intern Med. 2016;176(11):1630–1637.
  • Stokholm J, Chawes BL, Vissing NH, et al. Azithromycin for episodes with asthma-like symptoms in young children aged 1-3 years: a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2016;4(1):19-26.

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The weight of evidence does not support the use of oral beta2 agonists as bronchodilators in children with asthma, wheeze or bronchiolitis. In the case of asthma, oral beta2 agonists have not been shown to have a significant impact on symptom score or length of hospital stay for acute asthma in infancy when compared to placebo. For wheeze inhalation is the recommended route for delivering relievers for all children and adults. For bronchiolitis, according to the latest evidence, oral bronchodilators are no better than placebo at reducing the time to resolution of illness among infants treated at home or affecting the probability or rates of hospital admission after treatment.

Supporting evidence

  • British Thoracic Society. British guideline on the management of asthma. Thorax 2014;69(Suppl 1):1–192.
  • Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD001266. DOI: 10.1002/14651858.CD001266.pub4

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Clinical guidelines and recent evidence indicate that oxygen supplementation need only be commenced for children with uncomplicated bronchiolitis (i.e. bronchitis without other co-morbidities) if oxygen saturation levels fall below percentage levels around the early 90s. While one guideline cites 92% as the minimum acceptable level, other research shows that management of infants with bronchiolitis to an oxygen saturation target of 90% or higher is as safe and clinically effective as one of 94% or higher. On the balance of evidence, we recommend that children with bronchiolitis without other co-morbidities can be safely discharged if oxygen saturation levels are 90% or higher.

Supporting evidence

  • American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis.  Pediatrics. 2006 Oct;118(4):1774-93
  • Cunningham S, Rodriguez A, Adams T, et al. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet (London, England). 2015;386(9998):1041-1048
  • PREDICT Australasian Bronchiolitis Guideline 31 August 2016.

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Major guidelines on immunisation/vaccination do not cite the presence of minor or moderate acute illness (including mild respiratory symptoms), whether with or without fever, as a contraindication for immunisation. Australian immunisation guidelines explicitly state that ‘mild illness without fever’ is not a contraindication while US guidelines state that mild acute illness ‘with or without fever’ are ‘commonly misperceived’ as contraindications. Failure to immunise children with minor illnesses can reduce the effectiveness of immunisation campaigns. Given these considerations we adopt the conservative formulation that at least in the absence of fever, immunisation should not be delayed due to the mere presence of mild respiratory symptoms.

Supporting evidence

  • Australian Immunisation Handbook 10th edition 2015.
  • Canadian Immunization Guide 2016.
  • Centres for Disease Control and Prevention General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP).

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Last reviewed 14 November 2018