A new perspective on concepts of asthma severity and control

Concepts of asthma severity and control are important in the evaluation of patients and their response to treatment but the terminology is not standardised and the terms are often used interchangeably. This review, arising from the work of an American Thoracic Society/European Respiratory Society Task Force, identifies the need for separate concepts of control and severity, describes their evolution in asthma guidelines and provides a framework for understanding the relationship between current concepts of asthma phenotype, severity and control. "Asthma control" refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Its assessment should incorporate the dual components of current clinical control (e.g. symptoms, reliever use and lung function) and future risk (e.g. exacerbations and lung function decline). The most clinically useful concept of asthma severity is based on the intensity of treatment required to achieve good asthma control, i.e. severity is assessed during treatment. Severe asthma is defined as the requirement for (not necessarily just prescription or use of) high-intensity treatment. Asthma severity may be influenced by the underlying disease activity and by the patient's phenotype, both of which may be further described using pathological and physiological markers. These markers can also act as surrogate measures for future risk.

Can lay people deliver asthma self-management education as effectively as primary care based practice nurses?

OBJECTIVES

To determine whether well trained lay people could deliver asthma self-management education with comparable outcomes to that achieved by primary care based practice nurses.

DESIGN

Randomised equivalence trial.

SETTING

39 general practices in West London and North West England.

PARTICIPANTS

567 patients with asthma who were on regular maintenance therapy. 15 lay educators were recruited and trained to deliver asthma self-management education.

INTERVENTION

An initial consultation of up to 45 min offered either by a lay educator or a practice based primary care nurse, followed by a second shorter face to face consultation and telephone follow-up for 1 year.

MAIN OUTCOME MEASURES

Unscheduled need for healthcare.

SECONDARY OUTCOME MEASURES

Patient satisfaction and need for courses of oral steroids.

RESULTS

567 patients were randomised to care by a nurse (n = 287) or a lay educator (n = 280) and 146 and 171, respectively, attended the first face to face educational session. During the first two consultations, management changes were made in 35/146 patients seen by a practice nurse (24.0%) and in 56/171 patients (32.7%) seen by a lay educator. For 418/567 patients (73.7%), we have 1 year data on use of unscheduled healthcare. Under an intention to treat approach, 61/205 patients (29.8%) in the nurse led group required unscheduled care compared with 65/213 (30.5%) in the lay led group (90% CI for difference -8.1% to 6.6%; 95% CI for difference -9.5% to 8.0%). The 90% CI contained the predetermined equivalence region (-5% to +5%) giving an inconclusive result regarding the equivalence of the two approaches. Despite the fact that all patients had been prescribed regular maintenance therapy, 122/418 patients (29.2%) required courses of steroid tablets during the course of 1 year. Patient satisfaction following the initial face to face consultation was similar in both groups.

CONCLUSIONS

It is possible to recruit and train lay educators to deliver a discrete area of respiratory care, with comparable outcomes to those seen by nurses.

Lay educators in asthma self management: reflections on their training and experiences

OBJECTIVE

To capture the experiences and feelings of lay educators in an asthma self-management programme to aid understanding of optimal methods of recruitment, training and retention, and to enhance their value within the programme.

METHODS

A multi site randomised controlled equivalence trial of asthma educators and primary care practice based nurses during which the educators were asked to keep a diary of their experience. A qualitative thematic analysis of these diaries was undertaken.

RESULTS

Eight lay educators supplied diaries. From these diaries emerged personal reasons for involvement in the programme, constructive comments on the training programme, a need for preparation for the realities of clinical practice and significant ongoing support and training.

CONCLUSION

Lay educators are a potential resource for giving self-management education to patients with long-term conditions such as asthma. However, there are some considerations that need to be taken into account regarding contracts, retention and continual support.

PRACTICE IMPLICATIONS

Lay educators need a flexible but comprehensive training programme, contracts, on site mentoring and support. They seem most contented when welcomed by health professionals and treated as part of the team.

A nurse led intermediate care package in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVES

To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Randomised controlled trial.

SETTING

Community and hospital care in west London.

PARTICIPANTS

122 patients with COPD.

INTERVENTION

A care package incorporating initial pulmonary rehabilitation and self-management education, provision of a written, personalised COPD action plan, monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years.

MAIN OUTCOME MEASURE

Hospital readmission rate.

SECONDARY OUTCOMES

Unscheduled primary care consultations and quality of life.

RESULTS

There were no differences in hospital admission rates or in exacerbation rates between the two groups. Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics, and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves. 12 patients in the control group died during the 2 year period, eight as a result of COPD, compared with six patients in the intervention group, of whom one died from COPD. This is a significant difference. When the numbers were adjusted to reflect the numbers still alive at 2 years, in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner (GP) and in the control group, 280 contacts. The number needed to treat was 0.558--ie, for every one COPD patient receiving the intervention and self-management advice, there were 1.79 fewer unscheduled contacts with the GP.

CONCLUSIONS

An intermediate care package incorporating pulmonary rehabilitation, self-management education and the receipt of a written COPD action plan, together with regular nurse contact, is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate.

Is air travel safe for those with lung disease?

Airlines commonly report respiratory in-flight emergencies; flight outcomes have not been examined prospectively in large numbers of respiratory patients. The current authors conducted a prospective, observational study of flight outcomes in this group. UK respiratory specialists were invited to recruit patients planning air travel. Centres undertook their usual pre-flight assessment. Within 2 weeks of returning, patients completed a questionnaire documenting symptoms, in-flight oxygen use and unscheduled healthcare use. In total, 616 patients were recruited. Of these, 500 (81%) returned questionnaires. The most common diagnoses were airway (54%) and diffuse parenchymal lung disease (23%). In total, 12 patients died, seven before flying and five within 1 month. Pre-flight assessment included oximetry (96%), spirometry (95%), hypoxic challenge (45%) and walk test (10%). Of the patients, 11% did not fly. In those who flew, unscheduled respiratory healthcare use increased from 9% in the 4 weeks prior to travel to 19% in the 4 weeks after travel. However, when compared with self-reported data during the preceding year, medical consultations increased by just 2%. In patients flying after careful respiratory specialist assessment, commercial air travel appears generally safe.

The limitations of severe asthma: the results of a European survey

BACKGROUND

Asthma has a major impact on patients' lives, and severe asthma is a serious health problem. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) commissioned a telephonic survey to capture the views of people who are living with severe asthma in Europe.

METHODS

A total of 1300 patients from the UK, France, Germany, Spain and Sweden who reported a previous diagnosis of asthma and reported receiving asthma medication took part in the survey.

RESULTS

Most patients reported having limitations to their lifestyles as a consequence of the symptoms of severe asthma. Almost 70% of patients reported that physical activity was restricted, 50% were restricted from having pets, 30% from taking holidays, and many felt their job prospects were limited. In addition, 50% of this population of patients were not convinced that guideline goals were being achieved, although it is not clear as to the cause of this failing. Patients indicated that they want treatments that are fast-acting, long-lasting and have minimal side effects, and they were optimistic for the development of effective therapies over the next 5 years.

CONCLUSIONS

The results of this study provide insight into how greatly patients' lives are affected by severe asthma.

Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study

OBJECTIVE

To understand factors influencing patients' decisions to attend for outpatient follow up consultations for asthma and to explore patients' attitudes to telephone and email consultations in facilitating access to asthma care.

DESIGN

Exploratory qualitative study using in depth interviews.

SETTING

Hospital outpatient clinic in West London.

PARTICIPANTS

Nineteen patients with moderate to severe asthma (12 "attenders" and 7 "non-attenders").

RESULTS

Patients' main reasons for attending were the wish to improve control over asthma symptoms and a concern not to jeopardise the valued relationship with their doctor. Memory lapses, poor health, and disillusionment with the structure of outpatient care were important factors implicated in non-attendance. The patients were generally sceptical about the suggestion that greater opportunity for telephone consulting might improve access to care. They expressed concerns about the difficulties in effectively communicating through non-face to face media and were worried that clinicians would not be in a position to perform an adequate physical examination over the telephone. Email and text messaging were viewed as potentially useful for sending appointment reminders and sharing clinical information but were not considered to be acceptable alternatives to the face to face clinic encounter.

CONCLUSIONS

Memory lapses, impaired mobility due to poor health, and frustration with outpatient clinic organisation resulting in long waiting times and discontinuity of care are factors that deter patients from attending for hospital asthma assessments. The idea of telephone review assessments was viewed with scepticism by most study subjects. Particular attention should be given to explaining to patients the benefits of telephone consultations, and to seeking their views as to whether they would like to try them out before replacing face to face consultations with them. Email and text messaging may have a role in issuing reminders about imminent appointments.

How is difficult asthma managed?

Most patients with asthma can be easily treated. Some have difficult asthma; in some because the diagnosis is erroneous, in others because of comorbidity or noncompliance. A European Respiratory Society Task Force has called for an integrated approach for these patients, and positive results have been reported using protocols. In the UK, there is no overall understanding of the size of this problem, or how these patients are managed. A postal survey of 683 consultant members of the British Thoracic Society designed to elicit respondents' views on how they would manage four clinical scenarios was conducted. There was a 50.4% response rate. Few reported a uniform approach to the investigation of such patients. The availability of allied healthcare professionals was variable. The 21 consultant respiratory physicans, reporting a special interest in difficult asthma, were significantly more likely to objectively assess compliance, perform skin-prick tests and to utilise a liaison psychiatrist than those without an expressed special interest in asthma. Many reported difficulty in accessing psychologists, liaison psychiatrists and social workers. Approaches to the diagnosis and management of "vocal cord dysfunction" were variable. The results of this postal survey of specialist thoracic physicians in the UK suggest that a protocol for difficult asthma is not in widespread use and that access to necessary allied healthcare professionals is not uniform. Pulmonologists with a declared special interest in difficult asthma may have configured their services and approaches more in line with that proposed by the European Respiratory Society Task Force.

Exacerbations of COPD: quantifying the patient's perspective using discrete choice modelling

Patient-centred care is the current vogue in chronic obstructive pulmonary disease (COPD), but it is only recently that robust techniques have become available to determine patients' values and preferences. In this international cross-sectional study, patients' concerns and expectations regarding COPD exacerbations were explored using discrete choice modelling. A fractional factorial design was used to develop scenarios comprising a combination of levels for nine different attributes. In face-to-face interviews, patients were presented with paired scenarios and asked to choose the least preferable. Multinomial logit (with hierarchical Bayes) methods were used to estimate utilities. A total of 125 patients (82 males; mean age 66 yrs; 4.6 mean exacerbations.yr-1) were recruited. The attributes of exacerbations considered most important were impact on everyday life (20%), need for medical care (16%), number of future attacks (12%) and breathlessness (11%). The next most important attributes were speed of recovery, productive cough and social impact (all 9%), followed by sleep disturbance and impact on mood (both 7%). Importantly, analysis of utility shifts showed that patients most feared being hospitalised, housebound or bedridden. These issues were more important than symptom improvement. Strategies for the clinical management of chronic obstructive pulmonary disease should clearly address patients' concerns and focus on preventing and treating exacerbations to avoid these feared outcomes.

Crosscultural communication in those with airway diseases

Transcultural consultations are becoming commonplace. Such consultations arise because patients from ethnic groups consult doctors, but also because patients consult doctors from other ethnic backgrounds. Such consultations require a cultural awareness and sensitivity which may be particularly necessary when concerning those with respiratory illnesses which are often long-term and about which there may be considerable stigma. The prevalence of respiratory disease can vary between ethnic groups, most noticeably in tuberculosis and smoking; and in diseases such as asthma, health service usage and treatment can vary significantly with ethnicity. Some of this may represent cultural, rather than disease specific differences. Good communication is essential throughout medical practice, but in transcultural consultations it is especially important that the doctor pays appropriate attention to likely patient beliefs and approaches to shared decision making. Usual negotiation regarding goals and outcomes first requires the clinician to understand how a patient's understanding of illness may vary from a traditional western scientific approach. Special attention needs to be paid to the optimal way of using interpreters and more time is often needed for crosscultural consultations. Specific training is necessary for health practitioners to enable them to acquire the skills for crosscultural care and this involves learning about other cultures and an appreciation of how a change in attitude often needs to be incorporated into the clinical approach. Acquiring these skills and understandings to facilitate optimal transcultural consultation enables transfer of these skills to other similar clinical scenarios such as the approach to those with disability. The global burden of long-term respiratory disease, both infectious and noncommunicable, coupled with increased migration and geographical mobility means that a successful crosscultural approach is now a priority area for attention.

Research outputs in respiratory medicine

BACKGROUND

There is currently little information regarding how much the distribution of research activity in respiratory medicine reflects the interests of its clinicians and scientists, the disease burden in any country, or the availability of funding.

METHODS

A total of 81,419 respiratory medicine publications identified in the Science Citation Index for the years 1996-2001 were assigned to 14 subject areas (mainly based on title words) and to 15 OECD countries. Outputs were compared with a nation's disease burdens and, for the UK, the sources of research funding were investigated.

RESULTS AND CONCLUSIONS

Overall, Finland, Canada, Spain and the UK had the greatest relative commitment to respiratory medicine research expressed as a ratio of their share of world biomedical research. The largest subject areas were asthma, lung cancer, and paediatric lung disease, each with over 1400 papers published per year. Australia and Canada led in relative commitment to sleep research and Sweden and Finland led in research on asthma. Australia and the UK produced significant numbers of publications on cystic fibrosis (CF) but Finland produced few. The Netherlands has a strong output on chronic obstructive pulmonary disease (COPD), France and the UK on diffuse parenchymal lung disease (DPLD), and Finland dominated occupational lung disease research but had few publications on HIV/AIDS where Spain proportionately produced most. Finland and Australia had strong outputs in paediatric lung disease research. For most subject areas the research output of a country correlated poorly with disease burden. In the UK, lung cancer research appeared unduly low in relation to the number of deaths and COPD outputs were low compared with those for asthma. However, correlations were positive for the burden of CF and pulmonary complications of HIV/AIDS which explains, for example, the low outputs in these subject areas from Finland. The strong performance in CF research in the UK is likely to reflect significant charitable funding, while sleep research, pulmonary circulatory disease, and DPLD had little stated external funding or sponsorship.

The dissemination of the British Guideline on the Management of Asthma 2003

The BTS/SIGN British Guideline on the Management of Asthma was published in February 2003 (4). If health outcomes are to be influenced successfully, dissemination of the guideline and implementation of recommendations is essential. We report the dissemination activities undertaken during the 18 weeks following the guideline launch. To facilitate implementation a range of educational materials were produced reflecting the key messages from the guideline. In addition to postal mailing of the guideline to appropriate healthcare professionals, both educational materials and the guidelines were made freely available from the BTS and SIGN websites. In total, 135,710 copies of the guideline and 90,198 copies of the Quick Reference Guide were downloaded in the first 18 weeks, representing a considerable increase over the number of copies of the 1997 guidelines disseminated by mailing alone. Large quantities of educational materials were downloaded with many used for teaching purposes. An on-line survey suggested that most respondents rated the materials as useful or very useful. Using websites to disseminate guidelines is a cost-effective method of informing health professionals of their content and is a more active process than the passive receipt of mailed copies. The availability of interactive educational materials for use in teaching appears to have been popular.

Is virtual bronchoscopy useful for physicians practising in a district general hospital?

BACKGROUND

Virtual bronchoscopy software is now available to district general hospitals (DGHs). There is limited information on the clinical utility of virtual bronchoscopy and whether it offers any additional information over conventional axial computed tomography in the setting of a busy DGH chest unit.

METHODS

Virtual bronchoscopy and computed tomography findings were compared in all patients who had a virtual bronchoscopy study over a 12 month period.

RESULTS

Eighteen consecutive patients had virtual bronchoscopy for a specific clinical indication over the study period. Additional information was conveyed by virtual bronchoscopy in five patients (in four patients the airways distal to an obstruction were better visualised thereby influencing decisions about airway stenting and in one patient the virtual bronchoscopy study showed an endobronchial lesion missed on computed tomography). In nine patients who were unfit for fibreoptic bronchoscopy (FOB) the radiologist was more confident in excluding an obstructive airway lesion. The main indication for performing a virtual bronchoscopy study was to rule out an obstructive airway lesion in patients who were unfit for FOB (n = 11).

CONCLUSION

Virtual bronchoscopy is feasible and useful in the management of a few selected patients in a DGH chest unit. Virtual bronchoscopy may convey additional information over computed tomography when the distal airways need to be visualised and for discrete endoluminal lesions.

Positivity in illness: self-delusion or existential growth?

OBJECTIVES

This study investigated the relationship between a measure of positivity in illness, the Silver Lining Questionnaire (SLQ), and measures of personality and spirituality/religious beliefs as a way of determining whether positivity in illness is a delusion or existential growth.

METHOD

This is a cross-sectional study comparing response to the SLQ, to the Eysenck Personality Questionnaire (EPQ-R), breathlessness, illness type, and spiritual and religious beliefs in a final total sample of 194 respiratory outpatients.

RESULTS

The SLQ was associated positively with extraversion (r =.16, p<.05), unrelated to neuroticism (r =.11, n.s.) and repression (r =.10, n.s.) and was positively associated with spiritual and religious beliefs, F(2; 187) = 7.12, p < 001, as predicted by the existential growth but not the delusion interpretation. There was no relationship between positivity and age, r(194) =.09, n.s., or between positivity and gender t(192) = -1.27, n.s., and nor were there relationships with type of illness, F(4, 188) = 2.17, n.s., or breathlessness, F (5, 173) = 0.42, n.s.

CONCLUSIONS

The results suggest that positivity in illness is associated with existential growth, though the cross-sectional nature of the study precludes a conclusion of causal direction. The non-significant correlation between the SLQ and neuroticism is in the opposite direction predicted by the delusion explanation, but the non-significant relationship between the SLQ and repression is in the predicted direction. We cannot rule out the possibility that some positivity is delusion.

Development of the satisfaction with inhaled asthma treatment questionnaire

For the management of a condition such as asthma, patients should feel confident with their medication, feel that the treatment is adequate in controlling symptoms and that side-effects of the treatment are minimal. As no comprehensive instrument to measure patient satisfaction with inhaled asthma medication existed, the Satisfaction with Asthma Treatment Questionnaire was developed. The procedures that were used are described, and the initial validation and reliability tests are reported. The study involved focus group meetings, development, testing and modification of a preliminary instrument, and testing of the revised instrument using different samples of patients with asthma. Factor analysis of the 26-item questionnaire identified four domains reflecting four aspects of satisfaction: effectiveness of treatment, ease of use, medication burden, and side-effects and worries. Cronbach's alpha showed evidence of internal consistency reliability. Test/retest reliability ranged from 0.66-0.74. Interscale correlations were moderate-to-high. Significant correlations were found between domain and overall scale scores and patients' overall level of satisfaction. The Satisfaction with Asthma Treatment Questionnaire is potentially a useful instrument for gaining insight into patient satisfaction with inhaled treatment for asthma.

Self-management education for patients with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The idea of self-management is to teach patients how to carry out the activities of daily living optimally in the face of their physiological impairment, and to prevent or decrease the severity of exacerbations by means of life style adaptation. In chronic obstructive pulmonary disease (COPD) the value of self-management education is not clear. This review was undertaken to clarify the effectiveness of self-management programmes in COPD.

METHODS

A search was made of the Cochrane Airways Group trial registers, Medline, reference lists, and abstracts of medical conferences for controlled trials of self-management education in patients with COPD. Two reviewers independently assessed each paper for methodological quality and extracted the data.

RESULTS

The reviewers included 12 articles describing eight randomised controlled trials and one controlled clinical trial in which self-management education was compared with usual care. The studies assessed a broad spectrum of outcome measures with different follow up times so meta-analysis could not be undertaken. Self-management education had no effect on hospital admissions, emergency room visits, days lost from work, and lung function. Inconclusive results were observed on health related quality of life, COPD symptoms, and use of healthcare facilities such as doctor and nurse visits. Self-management education reduced the need for rescue medication and led to increased use of courses of oral steroids and antibiotics for respiratory symptoms.

CONCLUSIONS

Insufficient data were obtained to make recommendations because of the wide variation in outcome measures used and other limitations to generalisations in the current published literature. Further research in this area is needed.

Living with a variable disease

Asthma is a variable disease which, when not fully controlled, may leave the patient with a sense of bewilderment, fear, anger and a loss of many 'normal' activities of daily living. The reasons for these fears range from the concern of having an asthma attack to concerns about taking medications, perhaps especially steroids. Complex treatment regimens and a lack of understanding by the patient of their asthma may lead to denial and a reduction in adherence to medication resulting in poor treatment outcomes. Patients' lack of understanding may originate from poor communication between patient and physician. Improved communication and ensuring that all of the patient's questions are answered, as well as simpler treatment regimens may improve asthma control. Detailed, written personal asthma action plans should act as a foundation for building good relationships between doctor and patient and enhance adherence. Simplifying treatment regimens, such as having an inhaled corticosteroid and a long-acting, beta(2)-agonist in a single inhaler, used in conjunction with these personal asthma action plans, should provide a therapy that enables patients to be in control of their asthma without having to live in fear of their illness.