Physical training for asthma

Physical training in adults with asthma: An integrative approach on strategies, mechanisms, and benefits

Asthma is a chronic airway disease characterized by airflow limitation and respiratory symptoms associated with chronic airway and systemic inflammation, bronchial hyperreactivity (BHR), and exercise-induced bronchoconstriction (EIB). Asthma is a heterogeneous disease classified according to distinct airway and systemic inflammation. Patients commonly present with several comorbidities, including anxiety, depression, poor sleep quality, and reduced physical activity levels. Individuals with moderate to severe asthma often have more symptoms and difficulty achieving adequate clinical control, which is associated with poor quality of life, despite proper pharmacological treatment. Physical training has been proposed as an adjunctive therapy for asthma. Initially, it was suggested that the effect of physical training might be attributed to the improved oxidative capacity and reduced production of exercise metabolites. However, in the last decade, there has been evidence that aerobic physical training promotes anti-inflammatory effects in asthma patients. Physical training improves BHR and EIB, asthma symptoms, clinical control, anxiety, and depression levels, sleep quality, lung function, exercise capacity, and dyspnea perception. Furthermore, physical training reduces medication consumption. The most commonly used exercise strategies are moderate aerobic and breathing exercises; however, other techniques, such as high-intensity interval training, have shown promising effects. In the present study, we reviewed the strategies and beneficial effects of exercise on clinical and pathophysiological asthma outcomes.

Effects of exercise-based pulmonary rehabilitation on adults with asthma: a systematic review and meta-analysis

BACKGROUND

Pulmonary rehabilitation (PR) has been proposed as an effective method for many respiratory diseases. However, the effects of exercise-based PR on asthma are currently inconclusive. This review aimed to investigate the effects of exercise-based PR on adults with asthma.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science, International Clinical Trials Registry Platform and ClinicalTrials.gov databases were searched from inception to 31 July 2019 without language restriction. Randomized controlled trials (RCTs) investigating the effects of exercise-based PR on adults with asthma were included. Study selection, data extraction and risk of bias assessment were performed by two investigators independently. Meta-analysis was conducted by RevMan software (version 5.3). Evidence quality was rated by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

Ten literatures from nine studies (n = 418 patients) were identified. Asthma quality of life questionnaire total scores (MD = 0.39, 95% CI: 0.02 to 0.76) improved significantly in the experimental group compared to control group, including activity domain scores (MD = 0.58, 95% CI: 0.21 to 0.94), symptom domain scores (MD = 0.52, 95% CI: 0.19 to 0.85), emotion domain scores (MD = 0.53, 95% CI: - 0.03 to 1.09) and environment domain scores (MD = 0.56, 95% CI: 0.00 to 1.11). Both the 6-min walk distance (MD = 34.09, 95% CI: 2.51 to 65.66) and maximum oxygen uptake (MD = 4.45, 95% CI: 3.32 to 5.58) significantly improved. However, improvements in asthma control questionnaire scores (MD = - 0.25, 95% CI: - 0.51 to 0.02) and asthma symptom-free days (MD = 3.35, 95% CI: - 0.21 to 6.90) were not significant. Moreover, there was no significant improvement (MD = 0.10, 95% CI: - 0.08 to 0.29) in forced expiratory volume in 1 s. Nonetheless, improvements in forced vital capacity (MD = 0.23, 95% CI: 0.08 to 0.38) and peak expiratory flow (MD = 0.39, 95% CI: 0.21 to 0.57) were significant.

CONCLUSIONS

Exercise-based PR may improve quality of life, exercise tolerance and some aspects of pulmonary function in adults with asthma and can be considered a supplementary therapy. RCTs of high quality and large sample sizes are required.

CLINICAL TRIAL REGISTRATION

The review was registered with PROSPERO (The website is https://www.crd.york.ac.uk/prospero/ , and the ID is CRD42019147107).

Prevalence and impact of asthma in schoolchildren in the city of Caxias do Sul-RS

OBJECTIVE

To analyze the prevalence and impact of asthma in schoolchildren from the city of Caxias do Sul, RS, Brazil.

METHODS

Cross-sectional observational and case-control study with children and adolescents between 7 and 15 years old, from public schools in Caxias do Sul, RS. The study is composed of two phases: Phase I analyzed the prevalence of asthma in the delimited population, investigating 1915 schoolchildren; Phase II quality of life questionnaires, asthma control and classification (for the asthmatic group), physical activity, school performance, pulmonary function tests and anthropometric measures were applied to 266 asthmatics and 288 controls.

RESULTS

The estimated prevalence of asthma was 16.1%. In the comparison between asthmatics and nonasthmatics premature birth (p<0.001) and diagnosis of another chronic disease at birth (p<0.001) were found. Regarding pulmonary function, significant differences were found in the values between groups in FEV₁, FEV₁/FVC and forced expiratory flow in the 25 and 75% (FEF_25-75%), being that asthmatics presented lower values. Among asthmatics, 133 (50.8%) did not have the disease controlled. In the anthropometric variables, significant differences were observed, with higher values in controls, in the the waist-to-height ratio (p=0.009) and in the perception of health (p<0.001). Quality of life is lower in asthmatics in the physical well-being domain (p=0.001) and in the total score (p=0.016). The total school performance score did not present a statistically significant difference between the groups.

CONCLUSION

The prevalence of asthma is similar to that of other industrialized urban centers and may negatively affect some areas of the development of schoolchildren.

Complementary therapeutic approaches in asthma

Asthma is defined by The Initiative for Asthma (GINA 2018) as a heterogeneous disease, which include chronic airway inflammation and a history of respiratory symptoms. In the last decades asthma had a rise in prevalence, becoming one of the most frequent diagnosed diseases in the world. The main goals of asthma management are to achieve good symptom control, minimize the risks of exacerbations, decrease rescue medication intake, improve the quality of life by decreasing respiratory system inflammation and ameliorating the patient’s lung function. Beside effective medications, asthma continues to impair quality of life for most patients. Due to the difficulty of controlling symptoms and exacerbations, the need of developing complementary options of treatment is increasing in order to achieve an optimum control and a lower risk of acute episodes or fatal events. Pulmonary rehabilitation is suggested for asthma patients when adequate medical therapy poorly control the symptoms and mental, physical or social consequences of illness persist during the daily life. The following non-drug therapy components are included in the rehabilitation program: physical training, comprehensive smoking cessation program, comprehensive patient education, respiratory physiotherapy, psychosocial support and comprehensive nutritional counseling. These complementary therapies have been proven to improve muscle strength, exercise capacity and symptomatology. Also, it has been associated to fewer exacerbations and a lower use of rescue medication, leading to a better quality of life. Key words: asthma, quality of life, symptomatology, rehabilitation, physiotherapy,

In-school asthma management and physical activity: children's perspectives

OBJECTIVE

Regular physical activity (PA) is an important component of pediatric asthma management. No studies have examined how in-school asthma management influences PA from children's perspectives. The aim of this study was to explore children's perceptions of the impact of in-school asthma management on PA.

METHODS

Qualitative interviews with 23 inner-city minority children with asthma (aged 8-10 yrs; 12 girls, 11 boys) were conducted in 10 Bronx, New York elementary schools. Sampling continued until saturation was reached. Interviews were recorded, transcribed and independently coded for common themes.

RESULTS

Interviews produced five themes representing students' perceptions about (1) asthma symptoms during in-school PA; (2) methods to control asthma episodes during school PA; (3) methods to prevent asthma episodes during school; (4) limited accessibility of asthma medications; and (5) negative feelings about asthma and medication use. The majority of students experienced asthma symptoms while performing PA during school. Primary methods of managing asthma symptoms were sitting out during activity, drinking water, and visiting the nurse. Students lacked awareness or adherence to action plans to prevent or control asthma. Students reported limited access to medication during school and feelings of embarrassment and/or concerns of teasing when medicating in front of others.

CONCLUSIONS

Our results indicate inappropriate in-school management of asthma symptoms, poor asthma control, lack of accessible medication, and stigma around publicly using asthma medication. Thus, students often missed or were withheld from PA. Interventions to improve in-school asthma care must consider ways to address these issues.

Adolescent physical activity and health: a systematic review

Physical activity in adolescence may contribute to the development of healthy adult lifestyles, helping reduce chronic disease incidence. However, definition of the optimal amount of physical activity in adolescence requires addressing a number of scientific challenges. This article reviews the evidence on short- and long-term health effects of adolescent physical activity. Systematic reviews of the literature were undertaken using a reference period between 2000 and 2004, based primarily on the MEDLINE/PubMed database. Relevant studies were identified by examination of titles, abstracts and full papers, according to inclusion criteria defined a priori. A conceptual framework is proposed to outline how adolescent physical activity may contribute to adult health, including the following pathways: (i) pathway A--tracking of physical activity from adolescence to adulthood; (ii) pathway B--direct influence of adolescent physical activity on adult morbidity; (iii) pathway C--role of physical activity in treating adolescent morbidity; and (iv) pathway D - short-term benefits of physical activity in adolescence on health. The literature reviews showed consistent evidence supporting pathway 'A', although the magnitude of the association appears to be moderate. Thus, there is an indirect effect on all health benefits resulting from adult physical activity. Regarding pathway 'B', adolescent physical activity seems to provide long-term benefits on bone health, breast cancer and sedentary behaviours. In terms of pathway 'C', water physical activities in adolescence are effective in the treatment of asthma, and exercise is recommended in the treatment of cystic fibrosis. Self-esteem is also positively affected by adolescent physical activity. Regarding pathway 'D', adolescent physical activity provides short-term benefits; the strongest evidence refers to bone and mental health. Appreciation of different mechanisms through which adolescent physical activity may influence adult health is essential for drawing recommendations; however, the amount of exercise needed for achieving different benefits may vary. Physical activity promotion must start in early life; although the 'how much' remains unknown and needs further research, the lifelong benefits of adolescent physical activity on adult health are unequivocal.

Overcoming gaps in the management of asthma in older patients: new insights

Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. Because symptoms and signs of several cardiorespiratory diseases are nonspecific in older people and diseases commonly co-exist, investigations are important. A simple strategy for the investigation of breathlessness in older people should include a full blood count, chest radiograph, ECG, peak flow diary and/or spirometry with reversibility as a minimum. If there are major abnormalities on the ECG, an echocardiogram should also be performed. Diurnal variability in peak flow readings >or=20% or >or=15% reversibility in forced expiratory volume in 1 second, spontaneously or with treatment, support a diagnosis of asthma. Distinguishing asthma from COPD is important to allow appropriate management of disease based on aetiology, accurate prediction of treatment response, correct prognosis and appropriate management of the chest condition and co-morbidities. The two conditions are usually readily differentiated by clinical features, particularly age at onset, variability of symptoms and nocturnal symptoms in asthma, supported by the results of reversibility testing. Full lung function tests may not necessarily help in differentiating the two entities, although gas transfer factor is characteristically reduced in COPD and usually normal or high in asthma. Methacholine challenge tests previously mainly used in research are now also used widely and safely to confirm asthma in clinical settings. Interest in exhaled nitric oxide as a biomarker of airways inflammation is increasing as a noninvasive tool in the diagnosis and monitoring of asthma. Regular inhaled corticosteroids (ICS) are the mainstay of treatment of asthma. Even in mild disease in older adults, regular preventive treatment should be considered, given the poor perception of bronchoconstriction by older asthmatic patients. If symptoms persist despite ICS, addition of long-acting beta(2)-adrenoceptor agonists (LABA) should be considered. Addition of LABA to ICS improves asthma control and allows reduction in ICS dose. However, older people have been grossly under-represented in trials of LABA, many trials having excluded those >or=65 years of age. On meta-analysis, beta(2)-adrenoceptor agonists (both short acting and long acting) are associated with increased cardiovascular mortality and morbidity in asthma and COPD. While the evidence for excess cardiovascular mortality is stronger for short-acting beta(2)-adrenoceptor agonists, it would be prudent to exercise particular care in using beta(2)-adrenoceptor agonists (long acting and short acting) in those at risk of adverse cardiovascular outcomes, including older people. Regular review of cardiovascular status (and monitoring of serum potassium concentration) in patients taking beta(2)-adrenoceptor agonists is crucial. The response to LABA should be carefully monitored and alternative 'add-on' therapy such as leukotriene receptor antagonists (LRA) should be considered. LRA have fewer adverse effects and in individual cases may be more effective and appropriate than LABA. Long-term trials evaluating beta(2)-adrenoceptor agonists and other bronchodilator strategies are needed particularly in the elderly and in patients with cardiovascular co-morbidities. There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan have the potential to improve outcomes.

Update on Cochrane data on paediatric respiratory diseases

INTRODUCTION

Systematic reviews seek to describe and summarise the best evidence for a given intervention by pooling data from relevant quality clinical trials. The Cochrane Collaboration has fostered the development and dissemination of systematic reviews throughout the world. We have identified and summarised The Cochrane systematic reviews of relevance to the paediatric pulmonologist.

METHODS

We performed an expert search of the Cochrane Database of Systematic Reviews using a combination of medical subject headings and free text terms relating to paediatric respiratory disease.

RESULTS

The search identified 120 systematic reviews with interventions specific to children with some relevance to pulmonary disease, and 327 reviews with interventions relating to pulmonary disease in adults and children. After pragmatic exclusions, 81 reviews were sorted by disease and 59 of these are discussed in detail.

CONCLUSIONS

There are now many systematic reviews that make a positive contribution to paediatric pulmonology. The majority of reviews (69%) found evidence that either confirmed or refuted an accepted practice. The remaining reviews concluded that the evidence for an accepted practice is poor and sometimes wholly absent. Clinicians must be aware that lack of evidence of effect is not the same as evidence of lack of effect. Caution must be exercised before applying the conclusions of systematic reviews based upon adult data to childhood disease.

Management of asthma in adults: current therapy and future directions

Asthma is increasing in prevalence worldwide and results in significant use of healthcare resources. Although most patients with asthma can be adequately treated with inhaled corticosteroids, an important number of patients require additional therapy and an increasing number of options are available. A further minority of patients develop severe persistent asthma which remains difficult to manage despite current pharmacological therapies. This review discusses the various treatment options currently available for each stage of asthma severity, highlights some of the limitations of current management, and outlines directions which may improve the management of asthma in the future.

Cost effectiveness of guideline advice for children with asthma: a literature review

Asthma is an important chronic disease among children. This study reviews the cost effectiveness of interventions in the long-term care of asthmatic children and compares these results with treatment advice in four current guidelines. Cost-effectiveness studies were searched for in Medline, Embase, Healthstar, Biosis, and the Office of Health Economics-Health Economic Evaluations Database (OHE-HEED), and the Cochrane Library was searched for meta-analyses of clinical trials. In the four reviewed guidelines, cost effectiveness is not explicitly used as a criterion. The cost-effectiveness studies show sufficient evidence for the cost effectiveness of treatment with inhaled steroids and for self-management programs for severe asthmatic patients. Inclusion of these results in the guidelines would not lead to significant changes in current treatment advice. The effectiveness of various measures for trigger avoidance is not fully proven, and hence neither is their cost effectiveness. Available information on the cost effectiveness of cromolyn could be used to focus the guidelines. Finally, evidence exists that organizational interventions, e.g., the employment of asthma nurses, can result in cost savings, but it is unclear to what extent these results can be generalized. More cost-effectiveness studies are needed, especially on long-acting bronchodilators and self-management programs for mild and moderate asthma, in order to help make the guidelines more informative and reduce the differences between them.