Australia’s east coast was belted with heavy storms last week. Spring and summer storms can trigger thunderstorm asthma – with bursts of pollen often causing sudden, severe asthma attacks, particularly in patients with asthma or allergic rhinitis.
‘There was the big event in Victoria in November 2016 when 10 people died,’ said Clinical Associate Professor Debbie Rigby FPS, pharmacist and Clinical Executive Lead, National Asthma Council Australia (NAC).
‘But there are other peaks that don’t get as much media coverage – for example, there was terrible weather on Melbourne Cup Day this year, and data showed there were over 100 emergency department (ED) admissions and ambulance callouts that day.’
When asthma symptoms spike, so do SABA (short-acting beta2-agonist) requests. With new guidelines that discourage overreliance on SABA, asthma expert A/Prof Rigby explains how pharmacists should manage these situations.
What do the new asthma guidelines say?
In the updated NAC Australian Asthma Handbook, released in September 2025, a key guideline change is that no adult or adolescent with asthma should be using salbutamol alone.
‘Every [adult or adolescent] with confirmed asthma now needs to be on an inhaled corticosteroid (ICS),’ A/Prof Rigby said.
The National Asthma Council recently released data that found there were 478 asthma-related deaths in 2024, equating to more than one per day.
There was a surprising increase in asthma deaths in the youngest patient cohort, those aged 0 to 35.
‘This is largely due to poorly controlled asthma, including people over-relying on SABA, not using preventers, or not using anti-inflammatory reliever therapy,’ Ms Rigby said. ‘Those with more severe symptoms should be on maintenance-and-reliever therapy, or MART.’
But that doesn’t mean pharmacists should deny patients salbutamol, particularly during events such as storms that can trigger exacerbations.
‘Absolutely supply it if a patient has symptoms – it’s potentially life-saving during an acute episode – but we should be alluding to the fact that it’s risky to use salbutamol alone in asthma,’ she said. ‘‘Use it as an opportunity to explain that the guidelines have changed and that we now have better treatment, but also assess them to determine if they need to see a GP straightaway or go to ED.’
For example, if a patient can’t finish a sentence without taking a breath, they need immediate treatment.
Pharmacists should also remind patients that they should have an asthma action plan, which many adults don’t have. ‘Most people can manage with salbutamol in an acute situation – but they can also use budesonide-formoterol.’
It’s also important to point out the benefits of preventative and anti-inflammatory therapy, including improved asthma control and long-term health outcomes.
‘ICS–formoterol reduces the risk of severe episodes, it’s more convenient because you only carry one inhaler and even has environmental benefits,’ A/Prof Rigby said. ‘There are about 15 million salbutamol inhalers used annually, which is a significant carbon footprint.’
What can pharmacists do?
A lot has been learned since the 2016 thunderstorm asthma event, A/Prof Rigby said.
‘The Victoria Department of Health has been very proactive with the pollen-alert apps that give daily high-pollen warnings,’ she said.
There are also similar systems in other states; these apps provide a daily alert using a traffic-light system across mapped regions.
‘For example [on Thursday], the Mildura area was “red” – very high pollen count,’ A/Prof Rigby said.
‘I encourage all pharmacists to sign up, but also to recommend them to patients with asthma and/or allergic rhinitis. When your area is on medium or high alert, pharmacists should be having conversations with patients about being prepared.’
This includes always having a reliever on hand – either salbutamol, or preferably, the anti-inflammatory reliever budesonide-formoterol.
‘During thunderstorm asthma – the “perfect storm” of high pollen plus thunderstorms – people should also avoid being outside, close windows, use air-conditioning, and in cars set air recirculation mode,’ she said.
And when patients present to the pharmacy for treatment for allergic rhinitis, pharmacists should ask: Do you have asthma?
‘Around 80% of people with asthma also have allergic rhinitis, and 40–60% of people with allergic rhinitis also have asthma,’ A/Prof Rigby said. ‘We need to think about “one airway, one disease.” If you get the nose under control, you get better asthma control – and vice versa.’
What’s the approach when it’s not asthma?
During the 2016 thunderstorm asthma event, many people who presented to pharmacies or EDs didn’t have diagnosed asthma, A/Prof Rigby said.
‘Many had hay fever or allergic rhinitis,’ she said. ‘So when people request hay fever treatments, pharmacists should ask about symptoms – such as shortness of breath, cough or chest tightness – which could indicate asthma.’
When these incidents occur, pharmacists should ask whether patients had childhood asthma, hay fever or other respiratory issues. They can also provide Asthma first aid.
‘You can supply a salbutamol puffer – ideally with a spacer – because when people are short of breath they’re less able to coordinate inhalation, and most people don’t use puffers correctly anyway,’ she said.
Pharmacists should use the 4x4x4 method: 4 puffs, one at a time, via a spacer; wait 4 minutes; repeat as needed.
‘If the patient is still short of breath, seek medical advice,’ A/Prof Rigby added. ‘And document everything.’
Pharmacists should also follow-up via phone, text or the next visit.
How should COPD be managed in a storm?
While asthma is reversible with good control, chronic obstructive pulmonary disease (COPD) involves persistent airway inflammation and irreversible obstruction.
Salbutamol may be used to relieve symptoms in patients with COPD, but it does not provide the same level of relief as it does in asthma, A/Prof Rigby said.
‘The perceived benefit of SABA for patients with COPD is often due to the person stopping and resting, or the anxiety relief of “doing something” – rather than actual bronchodilation,’ she said.
But patients with COPD are less likely to have their symptoms triggered by storms.
‘They may be short of breath at rest and have reduced exercise tolerance, so they must take preventative therapy regularly,’ A/Prof Rigby said.
This includes regular use of a long-acting muscarinic antagonist and long-acting beta2-agonist.
‘Only some patients need triple therapy,’ she added.
