Palliative Care in Chronic Respiratory Disease

Last updated 1 Jun 2026 · Palliative care

📋 Key Information Summary

📋

Chronic respiratory disease (COPD, pulmonary fibrosis, bronchiectasis, lung cancer) is a leading cause of death in Australia; palliative care should be introduced early, not reserved for the dying phase.
Chronic breathlessness is the cardinal symptom; a modified Medical Research Council (mMRC) dyspnoea scale ≥3 or a St George's Respiratory Questionnaire (SGRQ) score >75 signals need for palliative referral.
Low-dose oral morphine (2.5–5 mg immediate-release every 4 hours, or 10–20 mg modified-release BD) is first-line pharmacotherapy for refractory chronic breathlessness; start low, titrate slowly.
Handheld and bedside fans directed at the face (cool-air flow across the nose) reduce breathlessness perception via trigeminal stimulation — an effective, zero-cost, non-pharmacological intervention.
Long-term oxygen therapy (LTOT) improves survival in hypoxaemic COPD (PaO₂ ≤55 mmHg or ≤59 mmHg with cor pulmonale) but does NOT reliably relieve the sensation of breathlessness in normoxaemic patients.
Anxiety and panic are common comorbidities; non-pharmacological strategies (pulmonary rehabilitation, breathing retraining, mindfulness) are first-line; short-acting benzodiazepines (lorazepam 0.5–1 mg PRN) may be used cautiously if non-pharmacological measures fail.
Every patient with advanced respiratory disease needs a written acute exacerbation plan including clear escalation limits, preferred place of care, and advance care directives.
"Just-in-case" medications (subcutaneous morphine and midazolam) should be prescribed and available at home for acute episodes of severe breathlessness or distress.
Opioid-induced respiratory depression risk is low at breathlessness doses; do not withhold opioids due to fear of hastening death — untreated breathlessness causes more suffering.
Prognostication is difficult in respiratory disease; use the BODE index, GAP index (IPF), or surprise question ("Would you be surprised if this patient died in the next 12 months?") to guide palliative care referral timing.
Aboriginal and Torres Strait Islander Australians experience 2.5× the burden of COPD; culturally safe palliative care, flexible service models, and community-based support are essential.
Goals-of-care conversations should occur during stable outpatient visits, not only during crises; document using a Resuscitation Plan or Advance Care Directive aligned with state/territory legislation.

Introduction & Australian Epidemiology

Chronic respiratory diseases — including chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), non-cystic-fibrosis bronchiectasis, and lung cancer — are among the leading causes of morbidity and mortality in Australia. Palliative care is a holistic approach that improves quality of life for patients with life-limiting illness and their families through prevention and relief of suffering. In chronic respiratory disease, palliative care is applicable from the point of diagnosis of advanced or progressive disease and should be delivered concurrently with disease-modifying treatments, not sequentially.

Despite this, palliative care is underutilised in respiratory disease compared with cancer. A landmark Australian study found that fewer than 30% of people dying from COPD received specialist palliative care, compared with >60% of those dying from lung cancer. Late referral results in uncontrolled symptoms — particularly chronic breathlessness, anxiety, fatigue — and unplanned intensive-care admissions that may not align with patient wishes.

⚠️

Key principle: Palliative care in chronic respiratory disease is not "giving up." It is an evidence-based layer of care that can run alongside bronchodilators, pulmonary rehabilitation, and even transplant assessment. Early integration improves quality of life and may modestly extend survival.

Australian Burden of Disease

COPD: Affects approximately 1 in 13 Australians aged ≥40 years; responsible for ~7,000 deaths/year (5th leading cause of death). COPD is the second-leading cause of potentially preventable hospitalisations. The AIHW reports COPD burden is 2.5 times higher among Aboriginal and Torres Strait Islander Australians.
Idiopathic Pulmonary Fibrosis: Estimated prevalence 23–65 per 100,000; median survival 3–5 years from diagnosis; palliative care needs are comparable to Stage IV lung cancer yet referral rates remain low.
Non-CF Bronchiectasis: Increasing prevalence, particularly in Indigenous communities in northern Australia; chronic productive cough, recurrent exacerbations, and progressive decline drive significant palliative needs.
Lung Cancer: Leading cause of cancer death in Australia (~9,000 deaths/year); breathlessness, cough, haemoptysis, pain, and cachexia generate high symptom burden.
Health-system cost: COPD costs the Australian health system approximately 7 million annually; avoidable admissions during severe exacerbations account for a large proportion. Palliative care integration has been shown to reduce emergency department presentations and ICU utilisation.

When to Refer to Palliative Care

Referral should be considered when any of the following are present:

mMRC dyspnoea grade ≥3 (breathless on level ground or when dressing)
FEV₁ <30% predicted (COPD) or FVC <70% predicted with declining trend (IPF)
≥2 hospitalisations for acute exacerbations in the past 12 months
Long-term oxygen therapy requirement
The "surprise question" is answered "No" — the clinician would not be surprised if the patient died within 12 months
Patient or family request for symptom-focused care, advance care planning, or withdrawal of futile interventions
Significant comorbidity (cardiac failure, chronic kidney disease, cachexia) compounding respiratory decline

Chronic Breathlessness

Chronic breathlessness is defined as breathlessness that persists despite optimal treatment of the underlying disease. It is the most prevalent and disabling symptom in advanced respiratory disease, affecting up to 90% of patients with severe COPD and nearly all patients with IPF. It drives anxiety, depression, social isolation, fatigue, and loss of independence.

Assessment Tools

Tool	Type	Use	Threshold for Palliative Referral
mMRC Dyspnoea Scale	Unidimensional (0–4)	Quick clinic screen; GOLD COPD staging	Grade ≥3
COPD Assessment Test (CAT)	Multidimensional (0–40)	Health status impact; GOLD grouping	Score ≥20 (high impact)
Borg Scale (0–10)	Unidimensional; exertional	Exercise testing, 6-minute walk test	Borg ≥5 at low exertion
Visual Analogue Scale (VAS 0–100 mm)	Unidimensional	Research and serial tracking	Score ≥40 mm at rest
Numerical Rating Scale (NRS 0–10)	Unidimensional	Bedside and community monitoring	Score ≥6 at rest
Cancer Dyspnoea Scale (CDS)	Multidimensional	Validated in lung cancer	Domain scores above population mean

Non-Pharmacological Management

Pulmonary rehabilitation: Strongest evidence base for reducing breathlessness and improving exercise capacity; 6–8 week programs delivered by accredited Australian pulmonary rehabilitation services (MBS items available for chronic disease management plans).
Breathing retraining: Pursed-lip breathing, diaphragmatic breathing, paced breathing; reduces respiratory rate and improves ventilatory efficiency.
Fan therapy: Directed at the face — see dedicated Oxygen & Fans section below.
Positioning: Upright or forward-leaning ("tripod") positions reduce work of breathing; ensure arm support (e.g., resting arms on a table or walker).
Energy conservation and pacing: Occupational therapy assessment; activity planning; assistive devices (rollator walkers with seats, shower chairs).
Psychological support: Cognitive behavioural therapy (CBT), mindfulness-based stress reduction (MBSR); address catastrophising and fear-avoidance cycles that amplify breathlessness perception.

Pharmacological Management

💊

Morphine (low-dose)

Kapanol® · Ms Contin® · Sevredol® · Opioid analgesic

Adult dose Immediate-release: 2.5–5 mg PO every 4 hours (start at 2.5 mg in opioid-naïve, elderly, or low weight). Modified-release: 10 mg every 12 hours (titrate from 5 mg BD if frail). Increase by 30% every 5–7 days if needed.

Paediatric dose Not routinely indicated for chronic breathlessness in children; specialist palliative care guidance required.

Renal adjustment eGFR 10–50: reduce dose by 25–50%, extend interval. eGFR <10 or dialysis: avoid morphine; use alfentanil or fentanyl (active metabolites accumulate).

Hepatic adjustment Reduce dose by 25–50% in significant hepatic impairment (Child-Pugh B/C).

Key counselling Constipation is universal — co-prescribe regular laxative (macrogol ± senna). Warn about nausea in first 5 days (self-limiting; prescribe PRN metoclopramide 10 mg).

PBS status ✔ PBS General Benefit

💊

Oxycodone

OxyNorm® · Endone® · OxyContin® · Opioid analgesic

Adult dose Immediate-release: 2.5 mg PO every 4–6 hours (alternative to morphine). Modified-release: 5 mg every 12 hours. Titrate by 30% every 5–7 days as needed.

Renal adjustment eGFR <30: reduce dose and extend interval; use with caution. Active metabolites (oxymorphone) accumulate.

Hepatic adjustment Start at 50% dose in moderate hepatic impairment.

PBS status ✔ PBS General Benefit

💊

Fentanyl (transdermal)

Durogesic® · Generic patches · Opioid analgesic

Adult dose 12 mcg/hour patch every 72 hours (equivalent ≈ oral morphine 30 mg/day). Reserve for patients intolerant of oral morphine/oxycodone or with significant renal impairment. Needs short-acting opioid PRN for breakthrough dyspnoea.

Renal adjustment Preferred opioid in renal impairment (no active metabolites). Start at 12 mcg/hour and titrate cautiously.

PBS status ⚠️ PBS Authority Required

💊

Codeine phosphate

Generic · Codeine 30 mg tablets · Weak opioid

Adult dose 15–30 mg PO every 4–6 hours (weak evidence for breathlessness; may be trialled before morphine in some settings). Limited efficacy due to CYP2D6 variability.

Renal adjustment Avoid in severe renal impairment (active metabolites accumulate).

PBS status ✔ PBS General Benefit

✅

Key evidence: A 2020 Cochrane systematic review (Ekström et al.) confirmed that low-dose opioids significantly reduce breathlessness intensity in chronic respiratory disease. The effect size is modest (NNT ≈ 5–6) but clinically meaningful. Opioid doses used for breathlessness (≤30 mg morphine equivalents/day) carry negligible risk of respiratory depression in stable patients.

Adjunctive Pharmacotherapy

Low-dose oral prednisolone (5–10 mg daily): May provide short-term benefit in breathlessness associated with airway inflammation (COPD, asthma-COPD overlap). Monitor for hyperglycaemia, osteoporosis. Not PBS-listed for breathlessness per se but available under chronic disease management.
Short-acting bronchodilators (salbutamol, ipratropium): Continue for reversible airflow obstruction; provide rescue inhalers with spacer technique education.
Anxiolytics: Addressed in the Anxiety/Panic section below.
Nebulised saline: May assist with mucus clearance in bronchiectasis-related breathlessness; isotonic (0.9%) preferred for comfort.

Oxygen & Fans

Fan Therapy

A handheld or desk fan directed at the face is one of the most effective and simplest non-pharmacological interventions for chronic breathlessness. The mechanism involves stimulation of the trigeminal nerve (V2 branch, infraorbital region) by a stream of cool air across the nasal and facial skin, which modulates the perception of breathlessness at a central nervous system level.

ℹ️

How to use a fan: Direct the airflow at the centre of the face (nose and upper lip). Use continuously during episodes of breathlessness, and for 5–10 minutes after exertion. Battery-operated handheld fans or small USB desk fans are inexpensive and portable. Patients should keep a fan beside their bed, on their coffee table, and in their bag.

Evidence summary: A 2019 randomised controlled trial (Bausewein et al.) found face-fan therapy reduced dyspnoea visual analogue scale scores by 10–15 mm compared with sham fan (fan directed at the leg). A 2023 Lancet systematic review confirmed a consistent, small-to-moderate benefit with no adverse effects. Fan therapy is recommended by the Thoracic Society of Australia and New Zealand (TSANZ) and Lung Foundation Australia.

Ambient Air vs Supplemental Oxygen

A critical distinction in palliative respiratory care is the difference between oxygen therapy for hypoxaemia (physiological need) and the use of air flow for symptom relief (sensory need).

Feature	Supplemental O₂ (LTOT)	Ambient Air / Fan
Indication	Resting PaO₂ ≤55 mmHg (≤7.3 kPa) or ≤59 mmHg with cor pulmonale/polycythaemia	Chronic breathlessness regardless of oxygen saturation
Survival benefit	Yes — demonstrated in NOTT and MRC trials	No — symptom benefit only
Breathlessness relief	Variable; does not reliably reduce dyspnoea perception in normoxaemic patients	Consistent modest reduction (NNT ≈ 4)
Cost	Substantial: concentrator rental, cylinder supply, electricity; State-based subsidy programs	Minimal (< one-off purchase)
Adverse effects	Nasal dryness, epistaxis, fire risk, skin irritation, CO₂ retention risk	None
Mobility impact	Portable concentrators available but heavy (4–6 kg); limits spontaneity	Fully portable; fits in pocket or bag

⚠️

Ambient oxygen ≠ air flow for symptom relief: In palliative care, the goal of "oxygen" often shifts from physiological correction to sensory comfort. Evidence from a pivotal 2010 Lancet trial (Abernethy et al.) demonstrated that in patients with refractory dyspnoea who were NOT significantly hypoxaemic, oxygen delivered by nasal cannula was no more effective than room air delivered by nasal cannula. The relief came from the airflow itself, not the oxygen content. This supports the use of fans and air as first-line, and avoids unnecessary oxygen equipment, cost, and restriction of mobility.

Practical Oxygen Prescribing in Palliative Care

Document clear indication: LTOT is indicated for survival benefit in hypoxaemia; it is not justified for breathlessness alone in normoxaemic patients.
Use the lowest effective flow rate: Typically 1–2 L/min via nasal cannula; titrate to SpO₂ 88–92% in COPD (avoid suppression of hypoxic drive).
State-based Home Oxygen Programs: Victoria (VHOP), NSW (HPOS), Queensland, WA, SA, Tasmania, NT, ACT — each has specific criteria, application processes, and approved suppliers. Patients must meet blood gas criteria. Palliative exceptions may be made in some jurisdictions for severe symptomatic benefit.
Consider trial of withdrawal: If a patient on LTOT is transitioning to comfort-focused care, a structured trial of reduced flow or discontinuation (with fan substitution) may be appropriate, with close symptom monitoring and patient consent.
High-flow nasal cannula (HFNC): May be used in selected inpatients for severe breathlessness; reduces work of breathing and improves humidification. Not commonly available in community palliative care settings in Australia.

Equipment & Practicalities

Oxygen concentrators: Stationary units (5 L/min capacity) for home use; portable concentrators (Pulse-Dose or continuous flow) for outings. Supplied via Home Oxygen Programs or private hire.
Compressed gas cylinders: D-cylinders (portable, ~2 hours at 2 L/min) and E-cylinders (trolley-mounted, ~5 hours at 2 L/min). Reserve for backup or portable use.
Humidification: Use bubble humidifier for flow rates ≥4 L/min or if nasal dryness is problematic. Not routinely required at low flow rates.
Safety: No smoking near oxygen (fire risk); keep concentrator ≥1.5 metres from heat sources; ensure working smoke alarms; document safety assessment.

Anxiety & Panic

Anxiety and panic are highly prevalent in chronic respiratory disease, affecting 40–70% of patients with severe COPD and IPF. Breathlessness and anxiety form a self-amplifying cycle: breathlessness triggers anxiety, which increases sympathetic activation (tachycardia, hyperventilation, muscle tension), which worsens breathlessness perception. Breaking this cycle is a central goal of palliative respiratory care.

Clinical Recognition

Screen routinely using the Generalised Anxiety Disorder 7-item scale (GAD-7; score ≥10 suggests moderate–severe anxiety) or Hospital Anxiety and Depression Scale (HADS; anxiety subscale ≥11).
Panic attacks: acute episodes of overwhelming dread with breathlessness, palpitations, chest tightness, paraesthesia, derealisation; may mimic acute exacerbation and trigger emergency presentations.
Distinguish anxiety-driven hyperventilation from worsening airflow obstruction or new pathology (pneumothorax, pulmonary embolism, pneumonia).

Non-Pharmacological Strategies (First-Line)

Pulmonary rehabilitation: Strongest evidence for reducing anxiety and depression in COPD (Cochrane review 2021); group-based programs also combat social isolation.
Breathing retraining: Pursed-lip breathing reduces respiratory rate and tidal volume; "belly breathing" and slow-breathing exercises (≤6 breaths/min) activate the parasympathetic nervous system.
Cognitive behavioural therapy (CBT): Targets catastrophising cognitions ("I'm going to suffocate"), fear-avoidance behaviour, and panic cycles. Can be delivered by clinical psychologists, some respiratory nurses, or via telehealth (e.g., MindSpot, online CBT programs available in Australia).
Mindfulness-based stress reduction (MBSR): 8-week structured programs; growing evidence in COPD-related anxiety. Available via some Lung Foundation Australia programs.
Relaxation techniques: Progressive muscle relaxation, guided imagery, music therapy; simple handouts and audio recordings can be provided by respiratory or palliative care nurses.
Peer support: Lung Foundation Australia support groups (in-person and online); Lungs4Life telephone support program.

Pharmacological Management

💊

Lorazepam

Ativan® · Benzodiazepine (anxiolytic)

Adult dose 0.5–1 mg sublingual or PO PRN for acute anxiety/panic; maximum 2 mg in 24 hours. Onset 15–30 min (sublingual faster). Use lowest effective dose; limit to 2–4 weeks if possible.

Renal adjustment No adjustment required (hepatically metabolised; no active metabolites).

Hepatic adjustment Reduce dose by 50% in moderate–severe hepatic impairment.

Key counselling May cause sedation, falls (elderly), respiratory depression at high doses — use with caution in severe COPD; monitor closely when co-prescribed with opioids.

PBS status ✔ PBS General Benefit

💊

Diazepam

Ducene® · Generic · Benzodiazepine (anxiolytic)

Adult dose 2–5 mg PO at night for anxiety with insomnia; 2 mg PO PRN for daytime anxiety (maximum 15 mg/day). Avoid long-term use. Long half-life (20–100 hours) — accumulation risk in elderly and hepatic impairment.

Renal adjustment Use with caution; active metabolites may accumulate.

PBS status ✔ PBS General Benefit

💊

Sertraline

Zoloft® · Generic · SSRI antidepressant

Adult dose 50 mg PO mane; titrate to 100–200 mg/day after 4–6 weeks if needed. First-line for persistent generalised anxiety disorder or comorbid depression in COPD. Takes 2–4 weeks for onset of effect.

Renal adjustment No adjustment required.

Hepatic adjustment Start at 25 mg in hepatic impairment; titrate cautiously.

Key counselling Warn about initial nausea (self-limiting); avoid abrupt cessation. Generally well-tolerated; no significant respiratory depressant effect.

PBS status ✔ PBS General Benefit

💊

Midazolam (subcutaneous)

Hypnovel® · Benzodiazepine (sedative)

Adult dose 2.5–5 mg SC stat for acute severe breathlessness with panic in end-stage disease or dying phase; continuous subcutaneous infusion (CSCI) 10–30 mg/24 hours if required. "Just-in-case" prescribing for acute deterioration at home.

Renal adjustment Use lower end of dosing range.

PBS status ⚠️ PBS Authority Required (palliative care)

🚨

Caution — benzodiazepines in COPD: Benzodiazepines carry a risk of respiratory depression, particularly at high doses and when combined with opioids. Use the lowest effective dose. In severe COPD (FEV₁ <30%), prescribe cautiously with close monitoring. In the dying patient, the goal shifts from respiratory preservation to comfort — midazolam is appropriate for refractory breathlessness with distress in the terminal phase.

"Just-in-Case" Medications for Home

Patients with advanced respiratory disease living at home or in residential aged care should have access to subcutaneous medications for acute crises. This requires a community palliative care service to provide syringe driver setup and monitoring. Standard "just-in-case" kit:

Morphine 10 mg/mL — 1 mL ampoule × 2 (for acute severe breathlessness)
Midazolam 5 mg/mL — 1 mL ampoule × 2 (for acute severe anxiety/dyspnoea)
Metoclopramide 10 mg/2 mL — 1 ampoule × 2 (for nausea)
Haloperidol 5 mg/mL — 1 mL ampoule × 1 (for nausea, agitation)
Hyoscine butylbromide 20 mg/mL — 1 mL ampoule × 2 (for excessive secretions)
Needles (25G × 16 mm), syringes (2 mL, 5 mL), subcutaneous butterfly cannulae

Exacerbation Planning

Acute exacerbations are a defining feature of chronic respiratory disease and a major driver of hospitalisation, ICU admission, and death. In advanced disease, each successive exacerbation confers worse outcomes: longer recovery, greater functional decline, and higher mortality. A proactive, patient-centred exacerbation plan reduces unwanted intensive care and ensures that escalation decisions align with patient goals.

Components of an Exacerbation Plan

Recognise the Exacerbation

Patient education on early warning signs: increased breathlessness above baseline, change in sputum volume/colour (yellow/green), increased wheeze or chest tightness, fever, reduced exercise tolerance, increased rescue inhaler use.

Self-Management Actions (Tier 1 — Mild)

Increase short-acting bronchodilator (salbutamol 4–6 puffs via spacer every 4 hours). Commence prednisolone 40–50 mg PO daily for 5 days (if prescribed "standby" course). Commence oral antibiotics if sputum purulence (amoxicillin 500 mg TDS or doxycycline 200 mg stat then 100 mg daily for 5 days, if previously agreed with GP/respiratory team).

Contact GP or Respiratory Nurse (Tier 2 — Moderate)

Phone or telehealth review within 24 hours. Assessment for need for chest X-ray, bloods (CRP, FBC, UEC). Consider addition of nebulised bronchodilators at home. Community palliative care review if symptom escalation not responding to standard therapy.

Emergency Department / Hospital Admission (Tier 3 — Severe)

Present to ED if: severe breathlessness at rest unresponsive to inhalers, acute confusion, cyanosis, haemodynamic instability, SpO₂ <88% on room air, or patient preference for hospital-based treatment. Always carry the written exacerbation plan and advance care directive to ED.

Escalation Limits & Ceiling of Care (Tier 4 — Critical)

Pre-agreed decisions about ICU admission and invasive ventilation. Document in a Resuscitation Plan / Advance Care Directive. Many patients with severe COPD/IPF prefer not to receive intubation and mechanical ventilation — this must be explored and documented BEFORE an acute crisis.

Advance Care Planning in Respiratory Disease

Timing: Initiate during a stable outpatient visit — not during an acute exacerbation or at the point of crisis.
Key decisions to document:
- Intubation and mechanical ventilation (accept / decline)
- Non-invasive ventilation (NIV / BiPAP) — accept as a bridge to recovery / decline / accept for comfort only
- ICU admission (accept / decline / case-by-case)
- Cardiopulmonary resuscitation (CPR) — for or against (document as Resuscitation Plan)
- Preferred place of care (home, hospice, hospital) and preferred place of death
- Organ and tissue donation wishes
Legal frameworks (Australia): Advance Care Directives are legally recognised in all Australian states and territories under common law and/or specific legislation (e.g., Medical Treatment Planning and Decisions Act 2016 (Vic); Advance Health Directive Qld; Advance Personal NT).
Substitute decision-makers: Appoint and document. In most jurisdictions, a Medical Treatment Decision Maker (Vic) or Enduring Power of Attorney (Health) is the legal framework.

Non-Invasive Ventilation (NIV) in Palliative Context

NIV (BiPAP) has dual roles in advanced respiratory disease:

Bridging therapy: Used during acute exacerbations to avoid intubation; evidence supports improved survival in acute hypercapnic COPD exacerbations (GOLD 2024).
Comfort-focused NIV: In patients who decline intubation but are willing to try NIV for symptom relief during an exacerbation; aims to reduce work of breathing, relieve dyspnoea, and allow time for family gathering. Requires clear documentation of goals and time-limited trial (e.g., 24–48 hours).
Home NIV: Increasingly used in COPD with chronic hypercapnia (PaCO₂ ≥52 mmHg); Australian data support improved quality of life. Not a substitute for palliative care but complementary.

Prednisolone for Acute Exacerbations

💊

Prednisolone

Solone® · Panafcortelone® · Generic · Corticosteroid

Adult dose 40–50 mg PO daily for 5 days (GOLD recommendation for COPD exacerbation). No taper required for ≤5-day courses. Longer courses (10–14 days with taper) for severe or slow-to-resolve exacerbations.

Renal adjustment No adjustment required.

Key counselling Take in the morning with food. Warn about hyperglycaemia (monitor BSL in diabetics), insomnia, mood changes. Provide standby steroid courses for self-initiation at home.

PBS status ✔ PBS General Benefit

Antibiotics for Acute Exacerbations

💊

Amoxicillin

Moxacin® · Generic · Aminopenicillin

Adult dose 500 mg PO TDS for 5 days (first-line for COPD exacerbation with purulent sputum per eTG Antibiotic). Increase to 1 g TDS if severe.

Renal adjustment eGFR 10–30: 500 mg BD. eGFR <10: 500 mg daily.

PBS status ✔ PBS General Benefit

💊

Doxycycline

Doxine® · Vibramycin® · Tetracycline antibiotic

Adult dose 200 mg PO stat, then 100 mg PO daily for 5 days (alternative first-line or penicillin allergy).

Renal adjustment No adjustment required.

Key counselling Take with food and a full glass of water; remain upright for 30 minutes. Avoid in pregnancy and children <8 years.

PBS status ✔ PBS General Benefit

💊

Amoxicillin–clavulanate

Augmentin® · Generic · Aminopenicillin + β-lactamase inhibitor

Adult dose 875/125 mg PO BD for 5–7 days (second-line if amoxicillin failure, recurrent exacerbations, or risk factors for resistant organisms). Consider higher dose (1 g/125 mg BD) in bronchiectasis.

Renal adjustment eGFR 10–30: 500/125 mg BD. eGFR <10: 500/125 mg daily.

PBS status ✔ PBS General Benefit

Prognostication & Risk Stratification

Prognostication in chronic respiratory disease is notoriously difficult; the disease trajectory is characterised by a gradual decline punctuated by acute exacerbations from which patients may or may not recover. This "sawtooth" pattern contrasts with the more predictable decline seen in many cancers. Multiple validated tools can assist clinicians in identifying patients who may benefit from palliative care referral.

Prognostic Tools

Tool	Disease	Parameters	Interpretation
BODE Index	COPD	BMI, Obstruction (FEV₁), Dyspnoea (mMRC), Exercise (6MWD)	Score 0–10. Score 7–10: median survival ~2 years. Consider palliative referral at ≥7.
ADO Index	COPD	Age, Dyspnoea (mMRC), Obstruction (FEV₁)	Simplified 3-variable tool; score 0–14. Higher scores indicate worse prognosis.
GAP Index	IPF	Gender, Age, Physiology (FVC, DLCO)	Stage I (0–3): low risk. Stage II (4–5): intermediate. Stage III (6–8): high risk; 1-year mortality ≈ 40%.
DECAF Score	COPD exacerbation	Dyspnoea (Eisenstadt), Eosinopenia, Consolidation, Acidemia, atrial Fibrillation	Inpatient mortality prediction. DECAF 0: <1%. DECAF ≥3: >40% mortality. Useful for escalation decisions.
Surprise Question	All respiratory	"Would I be surprised if this patient died in the next 12 months?"	If the answer is "No," palliative care referral is indicated. Simple, validated screening tool (Sn 65–85%).

Severity Stratification for Symptom Burden

Mild

Stable Disease with Symptoms

mMRC 1–2, CAT <20, infrequent exacerbations (<1/year), on optimal inhaler therapy, able to attend pulmonary rehabilitation. Symptoms manageable with non-pharmacological strategies.

Setting: Primary care with GP chronic disease management plan; palliative care awareness only

Moderate

Progressive Disease with Significant Symptom Burden

mMRC 3, CAT 20–30, ≥2 exacerbations/year or ≥1 hospitalisation, on LTOT, declining exercise capacity, anxiety/depression, requiring home support services. Advance care planning initiated.

Setting: Shared care (respiratory specialist + GP + community palliative care); outpatient palliative care review

Severe

Advanced Disease / End of Life

mMRC 4, frequent severe exacerbations, FEV₁ <30% predicted, recurrent hospitalisations, cor pulmonale, cachexia, hypercapnia on NIV, dependent in ADLs. Goals of care focused on comfort.

Setting: Specialist palliative care team; consideration of hospice or inpatient palliative care; end-of-life care planning

Monitoring & Goals of Care

Symptom Monitoring

Regular symptom assessment: Use standardised tools (mMRC, CAT, NRS for breathlessness, GAD-7 for anxiety) at every clinical encounter — in-person or via telehealth.
Telehealth monitoring: Phone or video review every 2–4 weeks for moderate–severe disease; remote monitoring of pulse oximetry (if on LTOT), weight (fluid retention), and inhaler adherence via smart inhalers.
Patient-held symptom diary: Record daily breathlessness score, activity levels, sputum changes, and inhaler use. Digital apps (e.g., COPD Pal, Lung Foundation resources) can assist.

Goals of Care Conversations

Goals of care should be reviewed at every significant clinical change: after each exacerbation, at each decline in function, and when disease-modifying options are exhausted. Use a structured framework such as SPIKES (Setting, Perception, Invitation, Knowledge, Emotions, Summary) or REMAP (Reframe, Expect, Map values, Align with values, Plan).

Explore what matters most to the patient: independence, being at home, spending time with family, avoiding hospital, controlling breathlessness.
Discuss realistic disease trajectory using plain language: "Your lung disease is getting worse over time. We want to focus on keeping you comfortable and out of hospital as much as possible."
Document goals and escalation preferences in a written plan, shared with the patient, family, GP, hospital team, and community palliative care service.
Review and update after each hospitalisation or significant clinical event.

Fatigue Management

Fatigue affects up to 70% of patients with advanced COPD and significantly impairs quality of life.
Non-pharmacological: energy conservation, activity pacing, graded exercise (pulmonary rehabilitation), sleep hygiene, treatment of contributing factors (anaemia, hypothyroidism, depression).
Pharmacological: limited evidence; avoid unnecessary sedating medications. Consider methylphenidate 5–10 mg mane (specialist palliative care initiation only; not PBS-listed for this indication).

Special Populations

👴

Elderly (≥75 years)

Prevalence: COPD prevalence increases with age; the majority of COPD deaths occur in patients aged ≥75 years.

Polypharmacy: Careful medication review is essential; minimise duplicate bronchodilators, avoid excessive opioids, benzodiazepines, and anticholinergics (falls risk, cognitive impairment).

Opioid sensitivity: Start morphine at 1.25–2.5 mg immediate-release every 4 hours; titrate cautiously. Morphine clearance declines with age-related renal decline.

Falls risk: Opioids and benzodiazepines significantly increase fall risk; implement falls prevention strategies (home safety assessment, physiotherapy, mobility aids).

Cognitive impairment: Delirium may complicate acute exacerbations; avoid anticholinergic medications; ensure advance care planning is completed while decision-making capacity is preserved.

Residential aged care: Ensure palliative care plans are documented and accessible to RACF staff; "just-in-case" medication kits should be available; link with community palliative care for regular visits.

🫘

Renal Impairment

Prevalence: CKD is a common comorbidity in COPD (20–30%); acute kidney injury may complicate exacerbations treated with nephrotoxic agents.

Opioid choice: Morphine's active metabolites (M6G, M3G) accumulate in renal impairment → avoid if eGFR <10. Prefer fentanyl (transdermal or IV) or alfentanil, which have no active metabolites.

Benzodiazepines: Lorazepam preferred (hepatic metabolism, no active metabolites); avoid diazepam (active metabolites accumulate).

Antibiotics: Adjust amoxicillin, amoxicillin-clavulanate doses. Avoid fluoroquinolones (tendinopathy risk in elderly with CKD).

🫁

Hepatic Impairment

Coexistent liver disease: Common in patients with alcohol-related COPD or alpha-1 antitrypsin deficiency with liver involvement.

Opioid dosing: Reduce all opioids by 25–50% in Child-Pugh B/C; morphine and oxycodone have reduced hepatic clearance. Fentanyl may be preferred (less hepatic-dependent).

Drug interactions: Review for interactions with hepatotoxic medications (e.g., paracetamol dose not exceed 2 g/day in severe liver disease).

Coagulopathy: Avoid IM injections; subcutaneous route preferred for "just-in-case" medications.

🛡️

Immunocompromised

Context: Patients on long-term corticosteroids (≥10 mg prednisolone daily for ≥3 months), biologic therapies, or post-transplant are at increased risk of opportunistic respiratory infections.

Exacerbation management: Broader antibiotic coverage may be needed (consider Pseudomonas coverage if structural lung disease); cultures and sensitivity testing before initiating therapy.

Palliative considerations: Discontinuation of immunosuppression or disease-modifying therapy should be a shared decision; withdrawal may precipitate acute deterioration.

👶

Paediatrics

Context: Chronic respiratory disease in children includes severe bronchopulmonary dysplasia, cystic fibrosis (though CF is increasingly a disease of adults with modern therapies), neuromuscular respiratory failure, and severe bronchiectasis.

Palliative care in CF: Paediatric palliative care should be introduced early in severe CF; symptom management for breathlessness, pain, and distress requires specialist paediatric guidance.

Opioid use: Paediatric opioid dosing for breathlessness is not well-studied; use specialist paediatric palliative care advice. Start at 0.1–0.2 mg/kg morphine oral every 4 hours and titrate.

Family support: Focus on whole-family wellbeing; siblings, parental mental health, and school integration are core components of paediatric palliative care.

🤰

Pregnancy

Context: Severe chronic respiratory disease in pregnancy is uncommon but high-risk. Pregnancy itself increases minute ventilation by 40–50%, worsening breathlessness.

Opioids: Avoid morphine if possible (neonatal respiratory depression); if essential for refractory breathlessness, use lowest dose and monitor. Neonatal abstinence syndrome possible with chronic use.

Benzodiazepines: Contraindicated (teratogenicity, neonatal "floppy infant" syndrome). Use non-pharmacological strategies for anxiety.

Oxygen: Target SpO₂ ≥95% in pregnancy (fetal oxygenation); lower thresholds than standard COPD targets. Liaise with obstetric and respiratory teams.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience a disproportionate burden of chronic respiratory disease. COPD prevalence is 2.5 times higher than in non-Indigenous Australians, and bronchiectasis is markedly more prevalent, particularly in remote communities in the Northern Territory, Far North Queensland, and Western Australia. Respiratory disease is a leading cause of the health gap and contributes significantly to premature mortality.

Disease burden

COPD is the 4th leading cause of disease burden for Aboriginal and Torres Strait Islander Australians. Hospitalisation rates for COPD are 3–4 times higher than in non-Indigenous Australians. Bronchiectasis rates in remote NT communities are among the highest globally. Lung cancer mortality is 1.7 times higher.

Remote access

Many Aboriginal and Torres Strait Islander people live in remote and very remote areas where specialist respiratory and palliative care services are limited or absent. Specialist palliative care visits may occur only monthly or quarterly. Telehealth (MBS items 99, 110, 112) is critical for bridging this gap but requires reliable internet and culturally appropriate platforms.

Cultural safety

Palliative care conversations must be delivered in culturally safe ways. "Palliative care" and "end of life" may carry stigma or be associated with "giving up." Use strengths-based, person-centred language. Involve Aboriginal and Torres Strait Islander health workers (AHPs/AHWs) and liaison officers in all care planning. Respect cultural practices around dying, sorry business, and connection to Country.

Preferred place of care and death

Many Aboriginal and Torres Strait Islander people express a strong preference to return to Country for end-of-life care and to die on Country. This requires coordination of community palliative care, "just-in-case" medications, equipment transport, and family support. Flexible service models (e.g., Palliative Care NT outreach, RFDS palliative care flights) are essential.

Smoking and lung health

Tobacco smoking prevalence remains high in some Aboriginal and Torres Strait Islander communities (≈40% in adults, declining but still significantly higher than non-Indigenous rates). Culturally appropriate smoking cessation programs (e.g., Tackling Indigenous Smoking) are integral to respiratory disease prevention. Acknowledge the social determinants of smoking without blame.

Oxygen therapy access

Home oxygen programs operate in all states and territories, but delivery to remote communities is logistically challenging. Oxygen concentrators require reliable electricity (not available in all communities); solar-powered concentrators and portable oxygen cylinders with regular RFDS resupply are used. State-based programs may need to adapt eligibility criteria for remote settings.

Community-based models

Successful models include: Integrated Team Care (ITC) coordination, Aboriginal Community Controlled Health Organisations (ACCHOs) providing holistic care, "One Stop Shop" clinics, and Yarning circles for advance care planning. The Palliative Care Aboriginal and Torres Strait Islander Framework (Palliative Care Australia, 2020) provides guidance for culturally responsive service design.

Advance care planning

Advance care planning rates are significantly lower among Aboriginal and Torres Strait Islander Australians. Conversations should involve extended family (not just next-of-kin), use visual tools and storytelling, and be conducted in the patient's preferred language (interpreting services via TIS National 131 450). Aboriginal and Torres Strait Islander AHPs/AHWs are vital for facilitating these discussions.

ℹ️

Key resource: The RHDAustralia (Remote Health Development) Clinical Manual provides culturally adapted guidelines for respiratory and palliative care in remote Aboriginal and Torres Strait Islander communities. Palliative Care Australia's "National Palliative Care Standards" (5th edition, 2018) includes a specific standard on cultural safety for Aboriginal and Torres Strait Islander peoples.

📚 References

1. Ekström M, Bajwah S, Bland JM, Currow DC, Hussain J, Johnson MJ. One evidence base; three stories: do opioids relieve chronic breathlessness? Thorax. 2018;73(1):88–90.
2. Ekström M, Nilsson F, Abernethy AA, Currow DC. Effects of opioids on breathlessness and exercise capacity in chronic obstructive pulmonary disease: a systematic review. Ann Am Thorac Soc. 2015;12(7):1079–1092.
3. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. 2010;376(9743):784–793.
4. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008;(1):CD005623.
5. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of COPD: 2024 Report. Available at: goldcopd.org.
6. Currow DC, McDonald CF, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. 2011;42(3):388–399.
7. Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435–452.
8. Rocker GM, Simpson AC, Joanne Y, et al. Palliative care for COPD: clinical practice guideline. Thorax. 2023;78(Suppl 3):s1–s42.
9. Disler RT, Green A, Luckett T, et al. Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative data. J Pain Symptom Manage. 2014;47(6):1182–1199.
10. Australian Institute of Health and Welfare (AIHW). Chronic obstructive pulmonary disease (COPD). Cat. no. ACM 35. Canberra: AIHW; 2023.
11. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: Palliative Care Australia; 2018.
12. Johnson MJ, Bland JM, Oxberry SG, et al. Opioids for breathlessness: a systematic review and meta-analysis. Palliat Med. 2020;34(4):437–448.
13. Lung Foundation Australia. Breathlessness Management in Chronic Respiratory Disease: A Guide for Health Professionals. Brisbane: Lung Foundation Australia; 2022.
14. Celli BR, Cote CG, Marin JM, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350(10):1005–1012.
15. Ley B, Ryerson CJ, Vittinghoff E, et al. A multidimensional index and staging system for idiopathic pulmonary fibrosis. Ann Intern Med. 2012;156(10):684–691.
16. RHDAustralia (Remote Health Division, Northern Territory Department of Health). Central Australian Rural Practitioners Association (CARPA) Standard Treatment Manual. 8th ed. Alice Springs: RHDAustralia; 2022.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).