Managing outpatient asthma exacerbations

The equine asthma model of airway remodeling: from a veterinary to a human perspective

Human asthma is a complex and heterogeneous disorder characterized by chronic inflammation, bronchospasm and airway remodeling. The latter is a major determinant of the structure-function relationship of the respiratory system and likely contributes to the progressive and accelerated decline in lung function observed in patients over time. Corticosteroids are the cornerstone of asthma treatment. While their action on inflammation and lung function is well characterized, their effect on remodeling remains largely unknown. An important hindrance to the study of airway remodeling as a major focus in asthma research is the lack of reliable non-invasive biomarkers. In consequence, the physiologic and clinical consequences of airway wall thickening and altered composition are not well understood. In this perspective, equine asthma provides a unique and ethical (non-terminal) preclinical model for hypothesis testing and generation. Severe equine asthma is a spontaneous disease affecting adult horses characterized by recurrent and reversible episodes of disease exacerbations. It is associated with bronchoalveolar neutrophilic inflammation, bronchospasm, and excessive mucus secretion. Severe equine asthma is also characterized by bronchial remodeling, which is only partially improved by prolonged period of disease remission induced by therapy or antigen avoidance strategies. This review will focus on the similarities and differences of airway remodeling in equine and human asthma, on the strengths and limitations of the equine model, and on the challenges the model has to face to keep up with human asthma research.

The effectiveness of clinical pharmacist's intervention in improving asthma care in children and adolescents: Randomized controlled study in Jordan

OBJECTIVE

To evaluate the effectiveness of clinical pharmacist's intervention on achieving better asthma control, quality of life and other clinical parameters.

METHODS

A prospective randomized controlled study in north Jordan was conducted. Pediatric patients with asthma (aged 7-18 years old) were included and randomly allocated into two groups, intervention and control. Both groups were interviewed at the first visit and followed up twice by phone (at 3 and 6 months). Education was provided to patients and their caregivers in the intervention group only.

RESULTS

Of 206 eligible patients recruited and randomized to our study, 178 patients completed the study (48.3% intervention versus 51.7% control). There were no significant differences in all baseline data between both groups. We identified significant differences in the improvement of asthma control (p<0.001) and consequently pediatric and caregiver quality of life (p<0.001) between both groups at the end of study. Significant differences were also detected in other clinical parameters (p<0.05).

CONCLUSION

Implementation of clinical pharmacy service can positively influence asthma control, pediatric and caregiver's quality of life, and other clinical parameters.

PRACTICE IMPLICATIONS

To maintain a good asthma status, education of pediatric patients and their caregivers should be part of routine assessment during clinic visit.

Triggers of asthma and COPD: are they different?

BACKGROUND

Asthma symptoms can be triggered by a variety of factors commonly referred to as "triggers". Some of these factors can also induce severe asthma exacerbations. Thus, it can be assumed that actions taken against such triggers may prevent the progression of the disease. However, limited data exist on the clinical importance of these triggers in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To compare the effect of triggers on symptoms and actions taken against certain modifiable triggers in patients with asthma and COPD.

METHODS

The study was conducted in a university hospital between June 2009 and June 2010. Patients with asthma and COPD were asked to complete a questionnaire in which both the factors triggering symptoms and the actions taken against several triggers were assessed.

RESULTS

Three hundred consecutive adult patients (150 asthma, 150 COPD) were enrolled to the study. The frequency of triggering factors was similar in both groups. Vaccination rates for influenza and pneumococcus were significantly higher in patients with COPD. However, such anti-allergic approaches as the use of strategies to decrease dust exposure, the use of anti-mite bed sheets, and the removal of pets from the home were more commonly employed by asthmatic patients.

CONCLUSION

This study revealed that certain triggers affected COPD and asthma patients to the same degree. Therefore, triggers and strategies for controlling modifiable triggers should be more concentrated on during education in both groups. However, the preventive effect of these strategies on disease progression, particularly in patients with COPD, needs clarification.

Asthma outcomes: exacerbations

BACKGROUND

The goals of asthma treatment include preventing recurrent exacerbations. Yet there is no consensus about the terminology for describing or defining "exacerbation" or about how to characterize an episode's severity.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to propose how asthma exacerbation should be assessed as a standardized asthma outcome in future asthma clinical research studies.

METHODS

We used comprehensive literature reviews and expert opinion to compile a list of asthma exacerbation outcomes and classified them as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop in March 2010 and finalized in September 2011.

RESULTS

No dominant definition of "exacerbation" was found. The most widely used definitions included 3 components, all related to treatment, rather than symptoms: (1) systemic use of corticosteroids, (2) asthma-specific emergency department visits or hospitalizations, and (3) use of short-acting β-agonists as quick-relief (sometimes referred to as "rescue" or "reliever") medications.

CONCLUSIONS

The working group participants propose that the definition of "asthma exacerbation" be "a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome." As core outcomes, they propose inclusion and separate reporting of several essential variables of an exacerbation. Furthermore, they propose the development of a standardized, component-based definition of "exacerbation" with clear thresholds of severity for each component.

Early Identification of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease

Frequent exacerbations of chronic obstructive pulmonary disease (COPD) place a considerable burden on the health care system and are a major cause of decreased health-related quality of life, accelerated pulmonary decline, and mortality in individual patients. Primary care physicians are usually the first point of contact for patients experiencing an exacerbation and are therefore best placed to prevent, identify, and treat these events in a timely manner. This review addresses the triggers and risk factors for COPD exacerbations, including the exacerbation-prone phenotype. The prevention, prompt diagnosis, and early appropriate pharmacological/nonpharmacological treatment of COPD exacerbations is important, as early recognition of symptoms (as supported by tools for measuring the illness/wellness experience of COPD patients in primary care) and treatment lead to optimal recovery in these patients. The review also highlights the importance of the urgency in identifying exacerbations and the important role played by primary care physicians in the prevention and postexacerbation management of patients with COPD.