Childhood asthma in adult life: a further study at 28 years of age

Crisis in asthma care

Reports of increases in both hospitalizations and deaths due to asthma have provided a sense of crisis in asthma care. This article examines issues concerning this sense of crisis. The authors review current trends in prevalence, morbidity, hospitalization, and mortality from asthma and examine possible reasons for changes that have occurred. A review of data suggesting that asthma can result in irreversible, chronic airway obstruction is presented. Finally, the authors discuss the role of the primary care physician in the management of asthma.

Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group

OBJECTIVE

To assess the feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners.

DESIGN

Randomised double blind parallel group trial of anistreplase 30 units intravenously and placebo given either at home or in hospital.

SETTING

29 rural practices in Grampian admitting patients to teaching hospitals in Aberdeen (average distance 36 (range 16-62) miles).

PATIENTS

311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic therapy seen at home within four hours of onset of symptoms.

MAIN OUTCOME MEASURES

Time saving, adverse events, Q wave infarction, left ventricular function.

RESULTS

Anistreplase was administered at home 101 minutes after onset of symptoms, while anistreplase was given in hospital 240 minutes after onset of symptoms (median times). Adverse events after thrombolysis were infrequent and, apart from cardiac arrest, not a serious problem when they occurred in the community: seven of 13 patients were resuscitated after cardiac arrest out of hospital. By three months after trial entry the relative reduction of deaths from all causes in patients given thrombolytic therapy at home was 49% (13/163 (8.0%) v 23/148 (15.5%); difference -7.6% (95% confidence interval -14.7% to -0.4%), p = 0.04). Full thickness Q wave infarction was less common in patients with confirmed infarction receiving treatment at home (65/122 (53.3%) v 76/112 (67.9%); difference -14.6% (95% confidence interval -27.0% to -2.2%), p = 0.02).

CONCLUSIONS

General practitioners provided rapid pre-hospital coronary care of a high standard. Compared with later administration in hospital, giving anistreplase at home resulted in reduction in mortality, fewer cardiac arrests, fewer Q wave infarcts, and better left ventricular function. Benefits were most marked where thrombolytic therapy was administered within two hours of the onset of symptoms.

Social effects of wheeze in childhood: a 25 year follow up

OBJECTIVES

To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class.

DESIGN

25 year follow up study.

SETTING

Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary.

PARTICIPANTS

Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study.

MAIN OUTCOME MEASURES

Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate.

RESULTS

Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups.

CONCLUSION

Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.

Natural history of asthma in childhood--a birth cohort study

A cohort of 67 babies at risk of developing atopic disorders was followed up prospectively for 11 years. Clinical assessment and skin prick allergen sensitivity testing were performed annually over the first five years. At 11 years the cohort was restudied, symptoms were assessed by questionnaire, and bronchial reactivity (BHR) to histamine was measured. On the basis of skin testing, 35 children were atopic and 32 remained non-atopic. The expression of atopy increased with age. The lifetime prevalence of eczema, wheeze, and hay fever were 46%, 63%, and 56% respectively. The yearly period prevalence of hay fever increased with age, that of eczema declined, while that for wheeze showed a bimodal distribution with a peak before the age of 2 years and a gradual increase thereafter. Of the 21 children who wheezed before their second birthday, most never wheezed again and did not show BHR at 11 years. Of the 21 children whose first wheezing was after 2 years of age, 17 were still wheezing at 11 years and 12 showed BHR. Of the children who wheezed before 2 years of age, 10 were or became atopic, compared with 20 of the 23 children who wheezed at 11 years. These findings suggest that childhood asthma is a heterogeneous condition with atopy being strongly associated with the persistence of wheeze.

Childhood asthma: clinical and immunological changes over a decade

A group of 26 Australian asthmatic children with laboratory-proven bronchial hyper-reactivity to the allergens of rye grass pollen and/or the house dust mite has been studied over a 9-year period. Clinical symptoms and drug scores were used to evaluate the severity of the patients' asthma and, wherever possible, blood samples were obtained before, during and after the rye grass pollen seasons. The cumulative symptom and drug scores for the 20 patients with bronchial hyper-reactivity to rye grass pollen extract tended to increase during and fall after each pollen season but the peaks were of decreasing amplitude over the 9 years. Since a proportion of these patients underwent hyposensitization to rye grass during year 1, longitudinal comparisons were made between year 2 and year 9. Comparing the individuals at the same three seasonal time-points revealed significantly lower drug scores in year 9 compared with year 2, and in parallel with this, significantly lower total IgE, IgE anti-rye and IgG anti-rye antibodies at all three assessment points. In the 14 patients with bronchial hyper-reactivity to house dust mite the severity of the asthma and the median levels of IgE and IgG mite specific antibodies all decreased over the study period. Despite the progressive improvement in asthma and diminishing immune responses to both rye grass and house mite in the patients, no immunological feature could be identified that correlated significantly with clinical outcome.

The progressive nature of childhood asthma

Asthma is the most common chronic disease in childhood. It has been repeatedly stated that childhood asthma is a self-limiting disorder, but this is a misleading and often inaccurate generalization. Prospective studies have demonstrated that many patients who had seemingly outgrown their disease experienced symptoms again as they grew older. In addition, recent evidence suggests that, despite the lack of clinical manifestation of asthma, there is a persistence of bronchial hyperreactivity for several years. A number of epidemiologic studies have identified factors that seem to be associated with the persistence of asthma into later childhood or adult life. Information about the effects of treatment of asthma on the natural history of the disease is vital. While treatment greatly reduces the morbidity from asthma, it is not known whether early recognition and aggressive treatment of the disease have any influence on the outcome of the disease later in life.

Prevalence of respiratory symptoms among 7 and 11 year old schoolchildren and association with asthma

A new self administered questionnaire completed by parents was used to study the prevalences of wheeze, shortness of breath, and cough in 2503 Southampton schoolchildren aged 7 and 11 together with exacerbating factors and background information including treatment and diagnosis. The questionnaire had a response rate of 84% and was found to be highly repeatable with respect to current symptoms. The overall prevalences of wheeze and shortness of breath in the current year (1986) were 12.1% and 8.5% respectively. Social class, home ownership, parental smoking, and presence of a family pet were unrelated to symptom prevalence. According to the parents the overall diagnosis rate for asthma was 9.5%. In common with other studies, however, we found considerable evidence for undertreatment. The symptoms of wheeze and nocturnal and morning breathlessness occurred more commonly in boys, but this sex ratio decreased with increasing age. The prevalences of wheeze and shortness of breath were similar in the two age groups. In contrast, there were only small differences between the sexes with respect to cough whereas, among children without wheeze or shortness of breath, there was a fall in the prevalence of cough from 18.9% at 7 years to 8.7% at 11 years. When controlling for the other respiratory symptoms, wheeze was the only symptom significantly related to parental asthma. The fall in the prevalence of cough between the two age groups is unlikely to be related to changes in asthma prevalence and, when not associated with wheeze, may be an indicator of separate pathology.

Asthma from childhood to adulthood--a follow-up study of 20 subjects with special reference to work capacity and pulmonary gas exchange

Twenty men with a mean age of 24.9 years, who had moderate to severe asthma during childhood, underwent a follow-up examination of their physical fitness, working capacity, maximal oxygen uptake, and pulmonary function during and after physical work. Comparison was made with similar data obtained at the age of 10.9 years. The young men had a normal physical working capacity with a normal oxygen uptake of 3.65 +/- 0.56 L/min. The respiratory parameters and the arterial blood gases during work demonstrated values as in healthy individuals, and no differences between groups with mild and severe asthma during childhood were observed. The alveolar-arterial oxygen difference was normalized, compared to that at 10.9 years. Only a few subjects still had exercise-induced asthma with a postexercise fall of greater than 20% in FEV1 compared to childhood. The mean FEV1 values for the whole group after exercise were lowered and had not returned to the baseline level even after 20 minutes. Oxygen pressure (tension), arterial, measured during 20 minutes after work, demonstrated continuously decreasing values. This might reflect a persisting disturbance in the pulmonary ventilation perfusion relationship caused by the underlying asthma disease.

Asthma from childhood to adult age. A prospective study of twenty subjects with special reference to the clinical course and pulmonary function

Twenty young men with a mean age 24.9 years, who had moderate to severe asthma during childhood, underwent a follow-up examination of their clinical status and pulmonary function. Comparison was made with data obtained at a mean age of 10.9 years. Eight of twenty showed a clinical improvement and 12 no change in their asthma. During childhood 12 of 20 boys had been on longterm ACTH or corticosteroid treatment. In the present study no one was given systemic steroid treatment. The static lung volumes (VC, TLC, FRC RV) were within normal limits for children and adults. In spite of clinical improvement, the expiratory flow rates (FEV1, FEV%) were still significantly reduced (p less than 0.005). Thus, the clinical improvement was not accompanied by a corresponding improvement in expiratory flow rates.