The impact of anxiety and depression on outpatients with asthma

The prevalence of anxiety in respiratory and sleep diseases: A systematic review and meta-analysis

BACKGROUND

Anxiety is common in those with chronic physical health conditions and can have significant impacts on both quality of life and physical health outcomes. Despite this, there are limited studies comprehensively investigating the prevalence of anxiety in respiratory and sleep medicine settings. This systematic review and meta-analysis aims to provide insight into the global prevalence of anxiety symptoms/disorders in respiratory and sleep medicine outpatients.

METHODS

PubMed, Embase, Cochrane, PsycINFO and Google Scholar databases were searched from database inception to January 23, 2023 for studies assessing the prevalence of anxiety in adult (≥16 years) respiratory and sleep medicine outpatients. Data was screened and extracted independently by two investigators. Anxiety was measured using various self-report questionnaires, structured interviews, and/or patient records. Using CMA software for the meta-analysis, a random-effects model was used for pooled estimates, and subgroup analysis was conducted on relevant models using a mixed-effects model.

RESULTS

116 studies were included, featuring 36,340 participants across 40 countries. The pooled prevalence of anxiety was 30.3 % (95%CI 27.9-32.9 %, 10,679/36,340). Subgroup analysis found a significant difference across type of condition, with pulmonary tuberculosis the highest at 43.1 % and COVID-19 outpatients the lowest at 23.4 %. No significant difference was found across anxiety types, country or age. Female sex and the use of self-report measures was associated with significantly higher anxiety estimates.

CONCLUSIONS

Anxiety is a common experience amongst patients in respiratory and sleep medicine outpatient settings. Thus, it is crucial that anxiety identification and management is considered by physicians in the field.

REGISTRATION

The protocol is registered in PROSPERO (CRD42021282416).

Impact of Anxiety and Depression on the Level of Asthma Control Among Jordanian Adults with Asthma

Purpose

Recent studies imply that psychological factors may actively contribute to the development of asthma. It is generally known that people with asthma frequently suffer from psychological illnesses. This association can make it challenging to reach asthma control. This study aimed to assess the prevalence of depression and anxiety among Jordanian adults with asthma, in addition to the link between asthma control levels and these psychological disorders.

Patients and Methods

This cross-sectional study included 175 adults with asthma who visited the tertiary asthma clinic in three Jordanian Governmental hospitals. Sociodemographic data was collected directly from the patients who were assessed for their level of depression and anxiety using a self-administered questionnaire, the Hospital Anxiety and Depression Scale (HADS). Also, asthma control was assessed using the Asthma Control Test (ACT). The relation between the different sociodemographic variables and clinical data, particularly depression and anxiety and asthma control level, was assessed.

Results

Among 175 asthmatic patients, 60.57% had poor disease control, 8% had anxiety alone, 11.43% had depression alone, and 53.14% had anxiety plus depression. Poor asthma control was significantly associated with anxiety and depression (p= 0.044) and low levels of education (p=0.001). Further, a lower level of education was also related to higher levels of anxiety and depression.

Conclusion

Most of the assessed Jordanian patients with asthma had their disease poorly controlled. Anxiety and depression are common among the studied sample of adults with asthma, and they appear to affect the level of disease control, suggesting the possibility that addressing these psychological conditions could enhance asthma control levels.

Work-related asthma in adults with severe asthma from the Korean Severe Asthma Registry (KoSAR)

Background

Exposure to allergens or irritants in the workplace may affect asthma control and the quality of life (QoL) of patients with asthma.

Objective

To examine the prevalence and characteristics of work-related asthma (WRA) in adult patients with severe asthma.

Methods

We analyzed data from the Korean Severe Asthma Registry (KoSAR), which is a nationwide multicenter observational study on severe asthma in Korea. Severe asthma was defined according to the American Thoracic Society (ATS) and the European Respiratory Society (ERS) guidelines. WRA was identified on the basis of asthma symptom aggravation at the workplace, as indicated by responses to a structured questionnaire. We compared the demographic and clinical characteristics and QoL between adult patients with severe asthma and WRA and those without WRA.

Results

Among 364 patients with severe asthma who were employed at the time of enrollment, 65 (17.9%) had WRA. There were no significant differences in age, sex, obesity, or smoking history between the WRA and non-WRA groups. However, individuals with WRA exhibited a higher prevalence of anxiety (7.7% vs 2.4%, P = 0.046) and depression (12.3% vs 3.7%, P = 0.010) than those without. The levels of asthma control, lung function, and frequency of asthma exacerbations were similar between the two groups, but patients with WRA reported lower QoL, as determined by the Quality of Life Questionnaire for Adult Korean Asthmatics (56.6 ± 14.6 vs. 63.5 ± 13.9, P < 0.001).

Conclusion

Patients with severe asthma and WRA are more likely to experience anxiety and depression and have lower QoL than those without WRA.

Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway?

Airway inflammation in asthma has been well recognized for several decades, with general agreement on its role in asthma pathogenesis, symptoms, propensity toward exacerbation, and decline in lung function. This has led to universal recommendation in asthma management guidelines to incorporate the use of inhaled corticosteroid as an anti-inflammatory therapy for all patients with persistent asthma symptoms. However, there has been limited attention paid to the presence and potential impact of systemic inflammation in asthma. Accumulating evidence from epidemiological observations and cohort studies points to a host of downstream organ dysfunction in asthma especially among patients with longstanding or more severe disease, frequent exacerbations, and underlying risk factors for organ dysfunction. Most studies to date have focused on cognitive impairment, depression/anxiety, metabolic syndrome, and cardiovascular abnormalities. In this review, we summarize some of the evidence demonstrating these abnormalities and highlight the proposed mechanisms and potential benefits of treatment in limiting these extrapulmonary abnormalities in patients with asthma. The goal of this commentary is to raise awareness of the importance of recognizing potential extrapulmonary conditions associated with systemic inflammation of asthma. This area of treatment of patients with asthma is a large unmet need.

Assessment and management of anxiety and depression in a pediatric high-risk asthma clinic

OBJECTIVE

The aims of this study were to determine the prevalence of positive mental health (MH) screens in a pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of engagement in MH services before and after adding a clinical psychologist to our multidisciplinary clinic.

HYPOTHESIS

We hypothesized that the HRA population would have a higher prevalence of anxiety/depression symptoms than that previously reported for the general pediatric asthma population. We anticipated that the presence of an embedded psychologist in HRA clinic would facilitate successful connection to MH services.

METHODS

Pediatric patients in the HRA clinic were prospectively screened for anxiety and depression using validated screening instruments. Positive scores were referred for MH services. Time to MH service engagement was recorded before and after the addition of a clinical psychologist.

RESULTS

A total of 186 patients were screened; 60% had a positive MH screen. Female sex was associated with higher median scores on both screening tools and higher likelihood of engagement in MH services. After addition of a clinical psychologist, new engagement in MH services increased (20% vs. 80%, p < 0.0001), and median time to engagement decreased (14.5 vs. 0.0 months, p = 0.003).

CONCLUSION

There is a high prevalence of anxiety and depression in this pediatric HRA population. Success of engagement in MH services improved after a clinical psychologist joined our multidisciplinary team, suggesting access to care as a primary barrier to engagement.

Differences in the health-related quality of life in patients with asthma living in urban and rural areas in the Amur Region of Russian Federation

BACKGROUND

Asthma usually arises from an interaction between host and environmental factors. Growing attention has been paid to a place of residence as a factor shaping health-related quality of life (QoL). This study investigated the rural-urban disparity in QoL among adult asthma patients in the Amur region of Russian Federation.

MATERIALS AND METHODS

This cross-sectional study included 351 randomly selected adults with asthma. We analyzed QoL (SF-36 and AQLQ scores), asthma control (ACT), and anxiety and depression (HADS) depending on the place of residence (urban vs. rural).

RESULTS

The scale "Role Emotional" (RE) of SF-36 was significantly lower in patients from rural areas compared to urban residents (59.3±3.1 vs. 70.4±2.3 points; p = 0.0042). In the urban group, the correlation analysis demonstrated a clear influence of RE on patients' own assessment of their physical functioning (PF, r = 0.53; p<0.0001). Both groups demonstrated low "Social Functioning" (SF). In the group of urban residents, correlation analysis revealed the presence of positive correlations of SF-36 domains reflecting physical (PF, RP, BP) and social functioning (SF, VT) with most scales of both QoL questionnaires. The domains of the emotional sphere (RE and MH) positively correlated with all scales of both QoL questionnaires among urban residents. In the group of rural residents, a comparative analysis showed the absence of significant correlations between more of the QoL scales. Although Asthma Control Test did not differ between groups, we noted a significantly higher need for β2-agonists in rural areas compared to urban areas (4.2±0.6 vs. 2.7±0.3 inh/day, respectively; p = 0.0221). The frequency of urban residents with a clinically significant level of anxiety (56 persons, or 25.2%) turned out to be lower compared to rural residents (45 persons, or 34.8%; χ2 = 34.08; p<0.001).

CONCLUSION

The burden of asthma introduces a greater imbalance in the health-related QoL of rural residents compared to urban residents in the Amur region of the Russian Federation. The absence of interrelationships of some QoL domains in rural residents suggested a disunity of the physical, psychological and social aspects of life. The rural residents suppress physical discomfort by the more frequent use of short bronchodilators. They often showed emotional instability with a predominance of anxiety, which affected the decrease in QoL in the psycho-emotional sphere.

Neuroimmune pathways regulating airway inflammation

Airways diseases are typically accompanied by inflammation, which has long been known to contribute to obstruction, mucus hypersecretion, dyspnea, cough, and other characteristic symptoms displayed in patients. Clinical interventions, therefore, often target inflammation to reverse lung pathology and reduce morbidity. The airways and lungs are densely innervated by subsets of nerve fibers, which are not only impacted by pulmonary inflammation but, in addition, likely serve as important regulators of immune cell function. This bidirectional neuroimmune crosstalk is supported by close spatial relationships between immune cells and airway nerve fibers, complementary neural and immune signaling pathways, local specialized airway chemosensory cells, and dedicated reflex circuits. In this article, we review the recent literature on this topic and present state-of-the-art evidence supporting the role of neuroimmune interactions in airway inflammation. In addition, we extend this evidence to synthesize considerations for the clinical translation of these discoveries to improve the management of patients with airway disease.

Brain structural and functional alterations related to anxiety in allergic asthma

Psychiatric disorders are common in patients with allergic asthma, and they can have a significant impact on their quality of life and disease control. Recent studies have suggested that there may be potential immune-brain communication mechanisms in asthma, which can activate inflammatory responses in different brain areas, leading to structural and functional alterations and behavioral changes. However, the precise mechanisms underlying these alterations remain unclear. In this paper, we comprehensively review the relevant research on asthma-induced brain structural and functional alterations that lead to the initiation and promotion of anxiety. We summarize the possible pathways for peripheral inflammation to affect the brain's structure and function. Our review highlights the importance of addressing neuropsychiatric disorders in the clinical guidelines of asthma, to improve the quality of life of these patients. We suggest that a better understanding of the mechanisms underlying psychiatric comorbidities in asthma could lead to the development of more effective treatments for these patients.

The Relationship Between Depressive Symptoms, eHealth Literacy, and Asthma Outcomes in the Context of a Mobile Health Intervention

OBJECTIVE

The ASTHMAXcel PRO mobile app provides asthma education and collects asthma outcome data. The objective of this study was to evaluate the associations between health/electronic health literacy (eHealth literacy) and depressive symptoms with app usage and clinical outcomes.

METHODS

Adults with persistent asthma were recruited to use the app. Participants completed the Patient Health Questionnaire-9 to assess for depressive symptoms, Asthma Control Test, Mini Asthma Quality of Life (QOL) Questionnaire, and the Newest Vital Sign tool to measure health literacy. Data on a subset of participants were available on eHealth literacy ( n = 24) and average number of app logins across 2 months ( n = 40).

RESULTS

The total study sample included 96 participants (46% non-Hispanic Black, 44.4% Hispanic). The average participant age was 44.0 (standard deviation = 14.9) years, with 74% identifying as female. Increased depressive symptoms were associated with worse asthma control ( β = -0.46, p < .001) and asthma QOL ( β = -0.38, p < .001), but not eHealth literacy. Higher eHealth literacy was associated with worse asthma QOL ( β = -0.48, p = .02) and more app logins ( β = 0.59, p = .04). Newest Vital Sign scores were not associated with any of the other measures.

CONCLUSIONS

Depressive symptoms were associated with worse asthma outcomes. eHealth literacy was associated with increased patient engagement with the app and worse asthma QOL, which may reflect patients with worse QOL seeking out health information on the Internet (although directionality could not be assessed). Digital health literacy may be key to increasing patient engagement with mobile health interventions.Trial Registration: National Clinical Trial No. 03847142, https://clinicaltrials.gov/ct2/show/NCT03847142 .

Risk factors for depression in asthmatic individuals: Findings from NHANES (2005-2018)

BACKGROUND

The risk factors for depression in asthma are still unclear. The objective of this study was to identify the risk factors associated with depression in asthmatic individuals.

METHODS

We used data from the 2005-2018 National Health and Nutrition Examination Survey (NHANES). Univariate analysis and multivariate logistic regression analyses were used to identify risk factors for depression and calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 5,379 asthmatic participants were included. Of these subjects, 767 individuals had depression, and 4,612 individuals had no depression. Univariate analysis and multivariate analyses suggested that asthmatic individuals with smoking (OR 1.98, 95% CI 1.19-3.29), hypertension (OR 2.73, 95% CI 1.48-5.04), and arthritis (OR 2.83, 95% CI 1.53-5.22) were more likely to have depression. Asthmatic individuals who had more than a high school education had lower depression risk than those with less than a high school education (OR 0.55, 95% CI 0.30-0.99). Increasing age was also associated with decreased depression risk (OR 0.97, 95% CI 0.95-0.99).

CONCLUSIONS

Depression was more likely in asthmatic individuals with smoking, hypertension, and arthritis and less likely in individuals with higher education and increasing age. These findings could improve the identification of target populations for effective interventions to improve the mental health of asthmatic individuals.

Anxiety and depression in women with asthma prior to fertility treatment

Objective

We investigate symptoms of anxiety and depression among women with asthma prior to fertility treatment.

Methods

This is a cross-sectional study of women screened for eligibility to the PRO-ART study (RCT of omalizumab versus placebo in asthmatic women undergoing fertility treatment (NCT03727971)). All participants were scheduled for in vitro fertilization (IVF) treatment at four public fertility clinics in Denmark. Data on demographics and asthma control (ACQ-5) were obtained. Symptoms of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS-A and D, respectively) and defined as being present on both subscales if a score >7 was obtained. Spirometry, diagnostic asthma test, and measurement of fractional exhaled nitric oxide (FeNO) were conducted.

Results

A total of 109 women with asthma were included (mean age 31.8 ± 4.6 and BMI 25.5 ± 4.6). Most women had male factor infertility (36.4%) or unexplained infertility (35.5%). Twenty-two percent of the patients reported uncontrolled asthma (ACQ-5 score > 1.5). The mean HADS-A and HADS-D scores were 6.0 ± 3.8 (95% CI 5.3-6.7) and 2.5 ± 2.2 (95% CI 2.1-3.0), respectively. Thirty (28.0%) women reported anxiety symptoms, and four (3.7%) had concomitant depressive symptoms. Uncontrolled asthma was significantly associated with both depressive (p = 0.04) and anxiety symptoms (p = 0.03).

Conclusions

More than 25% of women with asthma prior to fertility treatment had self-reported symptoms of anxiety, and just below 5% had self-reported depressive symptoms, possibly related to uncontrolled asthma.

Characteristics of Severe Non-Eosinophilic Asthma: Analysis of Data from 1075 Patients Included in the FASE-CPHG Study

Purpose

Data on severe non-eosinophilic asthma are scarce. Moreover, as compared with eosinophilic asthma, non-eosinophilic asthma less frequently benefits from the latest therapeutic advances. This study aimed to highlight differences between non-eosinophilic and eosinophilic asthma as they may help the development of new therapeutic agents.

Patients and Methods

Data from 1075 adult patients with severe asthma (GINA treatment: 4/5) collected during the cross-sectional non-interventional FASE-CPHG study were analyzed. Two groups of patients (EOS-/EOS+) were constituted based on blood eosinophil counts (cutoff value: 300 G/l). Characteristics of EOS- (N = 500) and EOS+ (N = 575) patients were described; EOS- patients were also described according to their allergic profile based on skin allergy or allergen-specific immunoglobulin E (IgE) assays (cutoff value: 150 IU/mL).

Results

Percentages of patients with obesity (29%), allergen sensitization (57%), or ≥2 annual exacerbations in the last 12 months (68%) were similar in both groups. As compared with EOS+ patients, EOS- patients less frequently reported chronic rhinitis (41.1% vs 50.5%, p < 0.01) or nasal polyposis (13.6% vs 27.5%, p < 0.01), and more frequently reported GERD (45.2% vs 37.1%, p < 0.01), anxiety (45.5% vs 38.1%, p = 0.01), or depression (18.3% vs 13.3%, p = 0.02). EOS- patients had lower serum total IgE levels (median: 158 vs 319 IU/mL, p < 0.01) and were less frequently treated with long-term oral corticosteroid therapy (16.0% vs 23.7%; p < 0.01). Their asthma was more frequently uncontrolled (48% vs 40%, p < 0.01). Similar results were found with a cutoff value for blood eosinophil counts at 150 G/l. EOS- patients with allergic profile less frequently reported high serum IgE levels (35.6% vs 57.9%, p < 0.01). EOS- and EOS+ patients treated with long-term oral corticosteroids had similar profiles.

Conclusion

In our patients with severe asthma, EOS- asthma was approximately as frequent as EOS+ asthma; EOS- asthma was frequently poorly controlled or uncontrolled, confirming the need for a better management. Allergy did not appear to worsen clinical profile.

Racial and Ethnic Minorities at the Highest Risk of Uncontrolled Moderate-to-Severe Asthma: A United States Electronic Health Record Analysis

Purpose

The identification of risk factors associated with uncontrolled moderate-to-severe asthma is important to improve asthma outcomes. Aim of this study was to identify risk factors for uncontrolled asthma in United States cohort using electronic health record (EHR)-derived data.

Patients and Methods

In this retrospective real-world study, de-identified data of adolescent and adult patients (≥12 years old) with moderate-to-severe asthma, based on asthma medications within 12 months prior to asthma-related visit (index date), were extracted from the Optum^® Humedica EHR. The baseline period was 12 months prior to the index date. Uncontrolled asthma was defined as ≥2 outpatient oral corticosteroid bursts for asthma or ≥2 emergency department visits or ≥1 inpatient visit for asthma. A Cox proportional hazard model was applied.

Results

There were 402,403 patients in the EHR between January 1, 2012, and December 31, 2018, who met the inclusion criteria and were analyzed. African American (AA) race (hazard ratio [HR]: 2.08), Medicaid insurance (HR: 1.71), Hispanic ethnicity (HR: 1.34), age of 12 to <18 years (HR 1.20), body mass index of ≥35 kg/m² (HR: 1.20), and female sex (HR 1.19) were identified as risk factors associated with uncontrolled asthma (P < 0.001). Comorbidities characterized by type 2 inflammation, including a blood eosinophil count of ≥300 cells/μL (as compared with eosinophil <150 cells/μL; HR: 1.40, P < 0.001) and food allergy (HR: 1.31), were associated with a significantly higher risk of uncontrolled asthma; pneumonia was also a comorbidity associated with an increased risk (HR: 1.35) of uncontrolled asthma. Conversely, allergic rhinitis (HR: 0.84) was associated with a significantly lower risk of uncontrolled asthma.

Conclusion

This large study demonstrates multiple risk factors for uncontrolled asthma. Of note, AA and Hispanic individuals with Medicaid insurance are at a significantly higher risk of uncontrolled asthma versus their White, non-Hispanic counterparts with commercial insurance.

Fatigue, Depression, and Anxiety in Patients with COPD, Asthma and Asthma-COPD Overlap

INTRODUCTION

Asthma and COPD are extremely common respiratory diseases that have a serious impact on people's lives around the world. A disease characterized by symptoms characteristic for asthma and COPD is called asthma-COPD overlap (ACO). Fatigue and certain psychological disorders such as anxiety and depression are important comorbidities in these diseases. The purpose of this study was to assess the prevalence of fatigue, anxiety, and depression in patients with asthma, COPD, and ACO and to also consider their mutual correlations.

MATERIAL AND METHODS

A total of 325 patients were enrolled in the study. There were 159 women and 166 men and their mean age was 63. Two standardized questionnaires were used: the Modified Fatigue Impact Scale (MFIS) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The mean total MFIS score for all patients was 33.03. Patients with asthma generally scored lower than patients with COPD and ACO. There were no statistical differences in the HADS for anxiety between the groups, although around half of the patients registered a score indicating some level of disorder. Patients with COPD and ACO were proven to suffer more from depression than patients with asthma. The HADS and MFIS scores were found to correlate significantly and positively.

CONCLUSIONS

Our study showed that patients with COPD, asthma, and ACO generally suffered from an increased level of fatigue and depression. Anxiety was high in all groups, but it was at a similar level for patients suffering from each of the three diseases under consideration. It is important to treat the physical symptoms as well as the psychological disorders since they greatly impact on the patient outcomes.

Depression in Childhood Asthma vs. Adult-Onset Asthma: A Cross-Sectional Study from the National Health and Nutrition Examination Survey (NHANES)

Background: asthma, a chronic respiratory disease caused by inflammation and narrowing of the small airways in the lungs, is the most common chronic childhood disease. Prevalence of childhood asthma in the United States is 5.8%. In boys, prevalence is 5.7% and it is 6% in girls. Asthma is associated with other comorbidities such as major depressive disorder and anxiety disorder. This study explores the association between asthma and depression. Methods: we conducted a retrospective cross-sectional study using NHANES data from 2013 to 2018. Asthma and childhood onset asthma were assessed using questionnaires MCQ010 and MCQ025, respectively. Sociodemographic variables were summarized, and univariate analysis was performed to determine the association between asthma and major depressive disorder and its individual symptoms. Results: there were 402,167 participants from 2013−2018 in our study: no asthma in 84.70%; asthma in 15.30%. Childhood onset asthma (COA) included 10.51% and adult-onset asthma (AOA) included 4.79%. Median age of COA is 5 years and AOA is 41 years. Among the asthma groups, most AOA were females (67.77%, p < 0.0001), most COA were males (52.16%, p < 0.0001), and ethnicity was predominantly White in AOA (42.39%, p < 0001) and in COA (35.24%, p < 0.0001). AOA mostly had annual household income from $0−24,999 (35.91%, p < 0.0001), while COA mostly had annual household income from $25,000−64,999 (36.66%, p < 0.0001). There was a significantly higher prevalence of MDD in COA (38.90%) and AOA (47.30%) compared to NOA (31.91%). Frequency of symptoms related to MDD were found to have a significantly higher prevalence and severity in the asthma groups compared to no asthma, and slightly greater and more severe in AOA than in COA. Symptoms include having little interest in doing things (COA 18.38% vs. AOA 22.50% vs. NOA 15.44%), feeling down, depressed, or hopeless (COA 20.05% vs. AOA 22.77% vs. NOA 15.85%), having trouble sleeping or sleeping too much (COA 27.38% vs. AOA 23.15% vs. NOA 22.24%), feeling tired or having little energy (COA 39.17% vs. AOA 34.24% vs. NOA 33.97%), having poor appetite or overeating (COA 19.88% vs. AOA 20.02% vs. NOA 15.11%), feeling bad about yourself (COA 13.90% vs. AOA 13.79% vs. NOA 10.78%), having trouble concentrating on things (COA 12.34% vs. AOA 14.41% vs. NOA 10.06%), moving or speaking slowly or too fast (COA 8.59% vs. AOA 9.72% vs. NOA 6.09%), thinking you would be better off dead (COA 3.12% vs. AOA 4.38% vs. NOA 1.95%) and having the difficulties these problems have caused (COA 21.66% vs. AOA 26.73% vs. NOA 19.34%, p < 0.0001). Conclusion: MDD and related symptoms were significantly higher and more severe in participants with asthma compared to no asthma. Between adult-onset asthma compared to childhood onset asthma, adult-onset asthma had slightly greater and more severe MDD and related symptoms compared to childhood onset asthma.

Anxiety level in severe asthmatics undergoing bronchial thermoplasty procedure: An observational study

Bronchial thermoplasty (BT) is one of the novel approved modalities in treating severe asthmatics to overcome their exacerbating symptoms such as increased anxiety. The purpose of this study was to evaluate anxiety level among severe asthmatics while undergoing BT procedure. This was an observational study where subjects self-evaluated their overall anxiety level using the burns anxiety inventory (BAI) questionnaire at baseline and prior to each of three BT treatments (broncho thermoplasty procedure 1, broncho thermoplasty procedure 2, and broncho thermoplasty procedure 3). The BAI questionnaire consisted of three different categories with each category having specific symptoms. Categories were grouped as: Anxious feelings, Anxious thoughts, and Physical symptoms. Subjects' Asthma Control Tests were also collected for analysis before and after the BT procedure. A total of 17 subjects with a mean age of 55.9 ± 14.5 years participated in the study. Fifty three percent were females (n = 9) and 41.2% (n = 7) were on prescribed anxiety medications. There was a significant drop in the patients' overall BAI anxiety level over time, P < .0001, in Anxious feelings (P = .0001), anxious thoughts (P = .001), and physical symptoms (P = .025). When analyzing the change in anxiety level among those who were not on prescribed anxiety medications, significant drop in overall anxiety level and in the subcategories were also noted. (P < .05). In addition, ACT scores showed a significant improvement (post vs pre) (18.5 ± 4.0 vs 13.3 ± 6.3, P = .03; Cohen's d = 0.73). This study shows the effectiveness of BT in decreasing severe asthmatic anxiety levels from baseline to last BT treatment and this benefit was mostly noted in those who were not on any anxiety medications. A limitation of this study is that all subjects were recruited from a single center. Therefore, to further validate the study findings, a multi-center study needs to be conducted with a larger sample size.

Further Understanding of Neuro-Immune Interactions in Allergy: Implications in Pathophysiology and Role in Disease Progression

The complicated interaction between the central and the autonomic (sympathetic, parasympathetic, and enteric) nervous systems on the one hand and the immune system and its components, on the other hand, seems to substantially contribute to allergy pathophysiology, uncovering an under-recognized association that could have diagnostic and therapeutic potentials. Neurons connect directly with and regulate the function of many immune cells, including mast cells, the cells that have a leading role in allergic disorders. Proinflammatory mediators such as cytokines, neurotrophins, chemokines, and neuropeptides are released by immune cells, which stimulate sensory neurons. The release of neurotransmitters and neuropeptides caused by the activation of these neurons directly impacts the functional activity of immune cells and vice versa, playing a decisive role in this communication. Successful application of Pavlovian conditioning in allergic disorders supports the existence of a psychoneuroimmunological interplay in classical allergic hypersensitivity reactions. Activation of neuronal homeostatic reflexes, like sneezing in allergic rhinitis, coughing in allergic asthma, and vomiting in food allergy, offers additional evidence of a neuroimmunological interaction that aims to maintain homeostasis. Dysregulation of this interaction may cause overstimulation of the immune system that will produce profound symptoms and exaggerated hemodynamic responses that will lead to severe allergic pathophysiological events, including anaphylaxis. In this article, we have systematically reviewed and discussed the evidence regarding the role of the neuro-immune interactions in common allergic clinical modalities like allergic rhinitis, chronic rhinosinusitis, allergic asthma, food allergy, atopic dermatitis, and urticaria. It is essential to understand unknown – to most of the immunology and allergy experts – neurological networks that not only physiologically cooperate with the immune system to regulate homeostasis but also pathogenetically interact with more or less known immunological pathways, contribute to what is known as neuroimmunological inflammation, and shift homeostasis to instability and disease clinical expression. This understanding will provide recognition of new allergic phenotypes/endotypes and directions to focus on specialized treatments, as the era of personalized patient-centered medicine, is hastening apace.

The Detrimental Clinical Associations of Anxiety and Depression with Difficult Asthma Outcomes

Difficult asthma describes asthma in which comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence impede good asthma control. The association of anxiety and depression with difficult asthma outcomes (exacerbations, hospital admissions, asthma control, etc.) is unclear. This study assessed the clinical associations of anxiety and depression with difficult asthma outcomes in patients with a specialist diagnosis of difficult asthma. Using real-world data, we retrospectively phenotyped patients from the Wessex Asthma Cohort of Difficult Asthma (N = 441) using clinical diagnoses of anxiety and depression against those without anxiety or depression (controls). Additionally, we stratified patients by severity of psychological distress using the Hospital Anxiety and Depression Scale (HADS). We found that depression and/or anxiety were reported in 43.1% of subjects and were associated with worse disease-related questionnaire scores. Each psychological comorbidity group showed differential associations with difficult asthma outcomes. Anxiety alone (7.9%) was associated with dysfunctional breathing and more hospitalisations [anxiety, median (IQR): 0 (2) vs. controls: 0 (0)], while depression alone (11.6%) was associated with obesity and obstructive sleep apnoea. The dual anxiety and depression group (23.6%) displayed multimorbidity, worse asthma outcomes, female predominance and earlier asthma onset. Worse HADS-A scores in patients with anxiety were associated with worse subjective outcomes (questionnaire scores), while worse HADS-D scores in patients with depression were associated with worse objective (ICU admissions and maintenance oral corticosteroid requirements) and subjective outcomes. In conclusion, anxiety and depression are common in difficult asthma but exert differential detrimental effects. Difficult asthma patients with dual anxiety and depression experience worse asthma outcomes alongside worse measures of psychological distress. There is a severity-gradient association of HADS scores with worse difficult asthma outcomes. Collectively, our findings highlight the need for holistic, multidisciplinary approaches that promote early identification and management of anxiety and depression in difficult asthma patients.

The Management of Extrapulmonary Comorbidities and Treatable Traits; Obesity, Physical Inactivity, Anxiety, and Depression, in Adults With Asthma

Asthma is a complex and heterogenous disease characterized by variability in disease expression and severity. Multiple extrapulmonary comorbidities and treatable traits are common in people with asthma, and there is an increasing appreciation of how these may complicate asthma management. This review will discuss the prevalence and impact of extrapulmonary comorbidities/risk factors or "traits," which have been found to co-exist in asthma (obesity, symptoms of depression and/or anxiety and physical inactivity), the impact these traits have on future outcomes (including exacerbation risk and quality of life) and asthma management, and how we should target treatment in asthma when these extrapulmonary traits are present.

Assessment of Predictor Factors Associated with Multiple Emergency Department Attendance with Asthma Attack: A Qualitative and Multicentric Prospective Observational Study

Purpose

Identified factors associated with multiple emergency department (ED) visits (≥) for asthma, which is associated with death.

Patients and Methods

We first conducted a qualitative study. We invited French-speaking adults (≥18 years old) with a diagnosis of asthma for more than 6 months. The identified concepts were transcribed into items. A Delphi method allowed for selecting items for a self-reported questionnaire. In an observational multicentric cross-sectional quantitative study, the resulting 20-item questionnaire and 12-item General Health Questionnaire, exploring psychological distress, were administered to adults visiting an ED for asthma exacerbation. Multivariable logistic regression was used to assess factors associated with ED visits.

Results

Data saturation was obtained after 8 patient interviews. Patients who came to the ED seemed unfamiliar with their illness or treatments but were concerned by the disease. The questionnaire was administered to 182 patients. On multivariable logistic regression, multiple and systematic ED visits were associated with asthma exacerbation (adjusted odds ratio (aOR) = 6.89, 95% confidence interval [CI]: 2.25–21.09), asthma perceived as a handicap (aOR=3.19, 95% CI: 1.55–6.57) and reported atopy (OR=2.09, 95% CI: 1.03–4.26). High educational level and lack of maintenance inhaled corticosteroids were protective for multiple ED visits.

Conclusion

Inadequate medical care is frequent in patients attending the ED for an asthma exacerbation, associated with strong psychological impact. Questioning the reasons for consulting the ED may help quickly identify patients requiring asthma education and improve their referral.

Clinical and Inflammatory Characteristics of the Chinese APAC Cough Variant Asthma Cohort

Background

The AtyPical Asthma in China (APAC) cohort is a multi-center prospective, observational cohort set-up to investigate the clinical, pathophysiological features, prognosis, and mechanisms of cough variant asthma (CVA).

Objectives

To present the characteristics of newly physician-diagnosed adults with CVA (n = 328) compared to mild-moderate classic asthma (CA, n = 206).

Methods and Main Results

CVA subjects showed a higher proportion of female (67.1 vs. 55.3%, P = 0.0084), abnormal laryngopharyngeal sensations (71 vs. 51%, p < 0.0001) than CA, but presented with near normal spirometry and higher methacholine PD20-FEV1 values [4.2 (1, 8.6) vs. 0.8 (0.4, 4.7), P < 0.0001]. Lower fractional exhaled nitric oxide (FENO) levels [38.5 (19.8, 72.5) vs. 53. (28.5, 92.2), P = 0.0019], blood eosinophil counts [0.2 (0.1, 0.4) vs. 0.3 (0.2, 0.5), P = 0.0014], and sputum eosinophils [2.3 (0.3, 8.0) vs. 12.2 (2, 34.5), p < 0.0001] were found in CVA. Despite lower total serum IgE levels in CVA, there was similar proportion of atopy in both groups. The prevalence of cough in CA was 86.4%, while CVA reported more severe cough on Visual Analog Scale, Cough Evaluation Test, and Leicester Cough Questionnaire, similar anxiety and depression scores but better asthma control scores as reflected by Asthma Control Test compared to CA. No correlation was found between cough assessment outcomes and sputum eosinophil count, blood eosinophil count, FENO, spirometry variables, or PD20-FEV1.

Conclusion

Cough variant asthma is distinctive from classic asthma in regard to clinical features, lung function, and airway inflammation. Quality of life is badly impaired as well in spite of better asthma control scores.

The Effect of Short Sleep Duration on the Development of Asthma

Asthma is regarded as a heterogeneous disease with chronic airway inflammation and reversible airway limitation. Asthma itself and recurrent attacks of asthma can decrease sleep duration and increase the prevalence of short sleep duration. Systemic low-grade inflammation and obesity caused by short sleep duration have been known for a long time, which potentially affect the development of asthma. It would be interesting to study the interaction between short sleep duration and asthma. However, there are relatively few studies and no review about the association between short sleep duration and asthma. This article performed a review about the relationships between short sleep duration and asthmatic phenotype, laboratory tests, comorbidity, and clinical outcomes. Pooled studies about short sleep duration and asthma provided following four results: (1) compared with healthy sleep duration, short sleep duration seemingly increased the risk of central obesity in asthmatics; (2) short sleep duration potentially reduced the level of FeNO and increased lung function impairment in patients with asthma; (3) asthmatic comorbidities, mainly obesity and depression, were negatively associated with short sleep duration among asthmatics; (4) short sleep duration potentially increased the risks of asthma-related hospitalization and emergency care. However, almost all studies are based on subjective but not objective sleep duration. In addition, the study on sleep duration and cause-specific mortality in patients with asthma is relatively scant. Considering the effect of short sleep duration on the development of asthma, we recommend that periodic sleep monitoring for asthmatic management is very necessary.

Severe asthma in adult, inner-city predominantly African-American and latinx population: demographic, clinical and phenotypic characteristics

INTRODUCTION

The burden of asthma morbidity with co-existing atopy among the racial/ethnic minorities in the socio-economically disadvantaged NYC borough of the Bronx is unusually high. The multidisciplinary Montefiore Asthma Center (MAC) provides guideline-based treatment to this high-risk population through the joint efforts of Allergists/Immunologists, Pulmonologists, and on-site health educators.

METHODS

The objective of this prospective, observational study was to define the demographic and clinical characteristics of severe asthma, evaluate improvement in asthma severity and lung function through the course of treatment at the MAC, and describe the asthma phenotypes of the patients managed at the MAC. Adults with severe asthma receiving treatment at the MAC were followed from their first to their last visit at the MAC. Patient demographics, along with asthma severity and co-existing allergies, were assessed. Possible phenotypes were defined (based on presence or absence of atopy, age at asthma onset, and blood eosinophil counts).

RESULTS

227 patients were included in the final analysis, of which 55.5% were Hispanic and 33.9% identified as non-Hispanic Black. Ninety-one percent (91%) of our cohort was found to be atopic and allergic rhinoconjunctivitis (ARC) was the most commonly identified co-existing allergic condition (86.3%). Mean Asthma Control Test (ACT) scores improved from 11.1 (± 4.9) at the initial visit to 14.8 (± 6.1) at the last visit. The spirometric values did not improve despite treatment at MAC.

CONCLUSION

A multidisciplinary severe asthma center is an ideal setting to phenotype patients and offer personalized guideline-based management and education to adults with severe asthma.

Depression and Anxiety Symptoms During and After Pediatric Asthma Hospitalization

OBJECTIVES

Depression and anxiety are common in children with asthma, and asthma hospitalization is an underused opportunity to identify mental health concerns. We assessed depression and anxiety symptoms during asthma hospitalization and 1 to 2 months post discharge.

METHODS

This prospective cohort study included children aged 7 to 17 years who were hospitalized for asthma exacerbation. Participants completed the self-report PROMIS (Patient-Reported Outcomes Measurement Information System) depression and anxiety symptom scales (T score mean = 50, SD = 10) during hospitalization and 1 to 2 months after discharge. Higher scores indicate more symptoms and/or greater severity. We compared patients' scores during hospitalization and at follow-up using paired t tests and examined individual patients' depression and anxiety symptom trajectories using a Sankey diagram.

RESULTS

Among 96 participants who completed the study, 53% had elevated symptoms of depression, anxiety, or both either during hospitalization or after discharge. During hospitalization, 38% had elevated depression symptoms and 45% had elevated anxiety symptoms. At postdischarge follow-up, 18% had elevated depression symptoms and 20% had elevated anxiety symptoms. We observed all possible symptom trajectories: symptoms during hospitalization that persisted (especially if both depression and anxiety symptoms were present), symptoms that resolved, and symptoms that were present at follow-up only.

CONCLUSIONS

Just more than half of youth hospitalized for asthma exacerbation experienced depression and/or anxiety symptoms during hospitalization or at follow-up. Patients who had both depression and anxiety symptoms during hospitalization were the most likely to have persistent symptoms at follow-up. Screening at both time points may be useful to identify mental health symptoms.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma

OBJECTIVE

Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function.

METHODS

We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average.

RESULTS

Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (β = 0.14, p = .029), worse self-reported asthma control (β = 0.17, p = .003), and lower asthma-related quality of life (β = -0.33, p < .001), but not with lung function (β = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (β = 0.14, p = .021), but not lung function (β = -0.05, p = .41).

CONCLUSIONS

Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

Intervención Cognitivo-Conductual para disminuir depresión y ansiedad en una persona con asma: Estudio de caso

Se ha identificado que la percepción de la enfermedad es una variable que regula el afrontamiento de la enfermedad y su impacto emocional en pacientes con enfermedades crónicas como el asma. Las intervenciones psicológicas en este padecimiento van dirigidas, principalmente, a mejorar la adaptación a la enfermedad y disminuir sus consecuencias emocionales. Se presenta un estudio de caso sistemático de una mujer con asma, ansiedad y depresión. El propósito de la intervención fue modificar la percepción de enfermedad y disminuir los síntomas de ansiedad y depresión. La evaluación se basó en el Análisis Funcional de la Conducta, el Cuestionario Breve de Percepción de Enfermedad (BIPQ) y la Escala de Ansiedad y Depresión Hospitalaria (HADS). Los resultados se valoraron con el Cambio Clínico Objetivo (CCO) y mostraron una modificación clínicamente significativa en la percepción de enfermedad, específicamente en la percepción de impacto emocional (-100%), en las consecuencias percibidas de esta (-85%) y en su control percibido (100%). Además, decrementó el nivel de ansiedad (-45 %) y depresión (-75%). Se concluye que las intervenciones psicológicas deben de formar parte del tratamiento multidisciplinario en pacientes con enfermedades crónicas para favorecer una mejoría en calidad de vida y minimizar sus repercusiones emocionales

Relationship between anxiety symptoms, clinical control and quality of life of children with asthma: A cross-sectional study

OBJECTIVE

To investigate the relationship between anxiety symptoms and factors related to clinical control and quality of life of children with asthma aged 7-12 years.

METHODS

A cross-sectional comparative study involving children recruited from a reference center for asthma treatment in the city of Natal-RN. Diagnosis, control and severity were performed following GINA recommendations (2019). Sociodemographic information and spirometry results from a bronchodilator test were collected. Modified Fisher's scale, clinical control questionnaires (c-ACT and ACT), quality of life assessment (PAQLQ) (total score and domains) and anxiety symptoms assessment (SCAS) (total score and domains) were applied.

RESULTS

The sample consisted of 42 children with asthma. Symptoms of social phobia (as identified by SCAS), and household head education were related to clinical asthma control (p = .006; R ²  = .19). Total SCAS score, guardian's education and physical activity were related to total PAQLQ (p < .0001; R ²  = .33). SCAS was related to the activity limitation domain of PAQLQ (p = .004; R ²  = .17). SCAS, gender, and physical activity were related to the PAQLQ symptoms domain (p = .003; R ²  = .32). The guardian's education, physical activity practice, and the symptoms of separation anxiety, panic attack and agoraphobia (as identified by SCAS) were related to the emotional domain of PAQLQ (p = .004; R ²  = .45).

CONCLUSION

The present study shows evidence of an association between anxiety symptoms, poorer clinical control, and health-related quality of life in children with asthma.

Novel therapeutic approaches targeting endotypes of severe airway disease

Introduction: Severe asthma and chronic rhinosinusitis (CRS), with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP), are heterogeneous diseases characterized by different mechanistic pathways (endotypes) and variable clinical presentations (phenotypes).Areas covered: This review provides the clinician with an overview of the prevalence and clinical impact of severe chronic upper and lower airways disease and suggests a novel therapeutic approach with biological agents with possible biomarkers. To select relevant literature for inclusion in this review, we conducted a literature search using the PubMed database, using terms 'severe airways disease' AND 'endotype' AND 'treatment.' The literature review was performed for publication years 2010-2020, restricting the articles to humans and English language publications.Expert opinion: The coronavirus disease (COVID-19) pandemic has brought forth many challenges for patients with severe airway disease and healthcare practitioners involved in care. These patients could have an increased risk of developing severe SARS-CoV-2 disease, although treatment with biologics is not associated with a worse prognosis. Eosinopenia on hospital admission plays a key role as a diagnostic and prognostic biomarker.

Management of adult asthma and chronic rhinitis as one airway disease

Introduction: Chronic rhinitis is defined as nasal inflammation with the presence of minimum two symptoms such as nasal obstruction, rhinorrhea, sneezing and/or itching one hour daily for a minimum of 12 weeks/year. According their etiology, four groups of rhinitis are described: allergic, infectious, non-allergic non-infectious and mixed.Chronic rhinitis is frequently associated with asthma, shares similar mechanisms of the pathogenesis and has a negative impact of its outcomes sustaining the concept of unified airways disease.Areas covered: The present review summarizes the complex relationship between chronic rhinitis and asthma on the basis of recent epidemiological data, clinical characteristics, diagnosis and therapeutic management. All four groups are discussed with the impact of their specific treatment on asthma outcomes. Some medications are common for chronic rhinitis and asthma while others are more specific but able to treat the associated comorbidity.Expert opinion: The systematic assessment of chronic rhinitis in patients with asthma and its specific treatment improves both disease outcomes. Conversely, several therapies of asthma demonstrated beneficial effects on chronic rhinitis. Treating both diseases at the same time by only one medication is an interesting option to explore in the future in order to limit drugs administration, related costs and side effects.

Predictors of Asthma Control and Exacerbations: A Real-World Study

BACKGROUND

Achieving optimal asthma control and minimizing the risk of exacerbation are the main goals of asthma treatment.

OBJECTIVE

This study aimed to assess the predictors of poor asthma control and asthma exacerbations within a population of moderate to severe asthmatic patients treated in a tertiary-care center.

METHODS

We conducted a cohort study assessing 738 patients enrolled in the Quebec registry in respiratory health (RESP) with a diagnosis of asthma confirmed by a respirologist and treated in a tertiary care center from April 2010 to March 2016. Sociodemographic and clinical data, including Asthma Control Questionnaire score, were collected at enrollment in the registry (ie, cohort entry) and patients were followed for a 2-year period thereafter. The information regarding exacerbations that occurred during follow-up was collected in administrative databases (Régie d l'assurance médicale du Québec [RAMQ], Maintenance et exploitation des données pour l'étude de la clientèle hospitalière [MED-ECHO], and medication data registry [reMed]).

RESULTS

We assessed 738 subjects (64% women). Psychological distress (odds ratio [OR] 1.91; 95% confidence interval [95% CI] 1.21-3.02), smoking (OR 3.72; 95% CI 1.72-8.05]), and poor lung function, forced expiratory volume in 1 second less than 50% (OR 4.1; 95% CI 1.48-11.34]) appeared as significant factors associated with uncontrolled asthma. Occurrence of previous asthma exacerbations (hazard ratio [HR] 6.25; 95% CI 4.01-9.75]), poor asthma control (HR 1.60; 95% CI 1.07-2.38]), forced expiratory volume in 1 second between 50% and 80% (HR 2.25; 95% CI 1.58-3.34]), and older age (HR 2.26; 95% CI 1.37-3.74]) were associated with asthma exacerbations. Adherence to asthma treatment was very low in patients with (44.4% ± 34.4%) and without asthma exacerbations (37.5% ± 33.0%).

CONCLUSIONS

Psychological distress and current smoking are modifiable factors that need to be addressed in tailored behavioral interventions to improve asthma control. Asthma exacerbations are mostly associated with the intrinsic severity of the disease.

Self-care practice and associated factors among adult asthmatic patients on follow-up care at Northwest Amhara referral hospitals, Northwest Ethiopia 2020

BACKGROUND

Self-care practice of asthma is the strategy for asthma symptom control and future reduction of exacerbation, but it is poorly implemented in clinical settings due to the patients, professionals, and organizational related factors. Therefore, the study aimed to assess the self-care practice and associated factors among adult asthmatic patients at Northwest Amhara referral hospitals.

METHODS

Institution-based cross-sectional study was conducted among asthmatic patients on follow-up care at Northwest Amhara Regional State referral hospitals from February 1st, 2020 to March 30, 2020. Data were collected through an interviewer-administered technique. Asthma self-care practice tool was used to measure the outcome. Data were entered into EPI info version 7 and exported to SPSS version 22 for analysis. A binary logistic regression analysis was used. In multivariable logistic regression analysis, those independent variables having p value < 0.05 were considered as statistically significant with poor self-care practice of asthma.

RESULTS

A total of 470 participants enrolled in the study with a response rate of 100%. The proportion of good self-care practice among asthmatic patients was found to be 42.3%. The study revealed that; age group ≥ 55 years, having a co-morbid illness and borderline anxiety, having no social support, and drinking alcohol were significantly associated with poor asthma self-care practice.

CONCLUSIONS

Poor-self care practice in this study was high. Efforts need to be implemented for asthmatic patients with older age, having co-morbid illness and borderline anxiety, having no social support, and drinking alcohol.

Anxiety disorders and asthma among adolescents in Uganda: role of early-life exposures

The reasons for the positive association between anxiety disorders and asthma are unknown. We investigated the possible role of shared exposures in early life. We conducted a case-control study among adolescents (age 12-17 years) with and without asthma in urban Uganda, as part of a larger asthma case-control study. Anxiety disorders were diagnosed by psychiatric clinical officers. We focused on generalised anxiety disorder (GAD), panic disorder and social anxiety disorder. Asthma was doctor-diagnosed by study clinicians. We used questionnaires to collect data on early-life exposures. The data were analysed using multiple logistic regression. We enrolled 162 adolescents; 73 of them had asthma. Adolescents with asthma were more likely to have any of the three anxiety disorders studied (46.6%) than adolescents without asthma (21.4%) (adjusted OR (aOR) 2.68, 95% CI 1.30-5.53). The association was strong for GAD (aOR 4.49, 95% CI 1.48-13.56) and panic disorder (aOR 5.43, 95% CI 2.11-14.02), but not for social anxiety disorder. The early-life risk factors associated with anxiety disorders among adolescents were similar to asthma risk factors previously published, including urban residence at birth (aOR 3.42, 95% CI 1.29-9.09) and during most of the first 5 years of life (aOR 2.87, 95% CI 1.07-7.66), father's tertiary education (aOR 2.09, 95% CI 1.00-4.37), and adolescent's history of other allergy-related diseases (aOR 4.64, 95% CI 1.66-13.00). We confirm a positive association between anxiety disorders and asthma among adolescents in urban Uganda. The early-life risk factors associated with anxiety disorders among adolescents were similar to those for asthma in the same age group, suggesting shared underlying environmental exposures.

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

Association of Home Quarantine and Mental Health Among Teenagers in Wuhan, China, During the COVID-19 Pandemic

This cross-sectional study investigates the prevalence of depression and anxiety and their associations with lifestyle changes among adolescents in Wuhan, China, during the coronavirus disease 2019 pandemic.

Level of asthma control and mental health of asthma patients during lockdown for COVID-19: a cross-sectional survey

Background

Lockdown has been enforced globally to curb the spread of SARS-CoV-2. Patients with uncontrolled asthma are at risk of severe illness from COVID-19, highlighting the priority of adequate asthma control during the pandemic. Staying indoors exposes asthmatics to indoor asthma triggers, including disinfectants used for limiting the virus spread, in addition to psychological stresses of the pandemic which represent crucial contributors to loss of asthma control. Elective medical care, curtailed by the lockdown procedures, compromises adequate asthma follow up. The current study evaluated the effect of COVID-19 lockdown on the level of asthma control and mental health of bronchial asthma patients. The study included 264 bronchial asthma patients, aged 12 years and older, who responded to an online questionnaire including the asthma control test to evaluate asthma control in the preceding 4 weeks. Anxiety and depression scores and the impact of event scale were also provided.

Results

Seventy percent of asthmatics had uncontrolled asthma, and disinfectant use was associated with perceived increase in asthma symptoms in 77.7%. Anxiety and depression were associated with uncontrolled asthma in 50% of participants, suggesting a possible psychological impact on asthma patients.

Conclusions

During lockdown, asthma patients participating in the study had significantly uncontrolled disease and associated anxiety and depression. Since regular follow-up of asthma patients is cornerstone to adequate asthma control, alternative methods of medical care for asthma patients during lockdown are warranted, and particular need for mental health support ought to be provided as a continuum to adequate asthma control.

Co-morbid anxiety and depression in childhood asthma and its effect on symptom control: A cross sectional study

BACKGROUND

Anxiety and depression are co-morbidities that affect symptom control in children with asthma and are often overlooked in busy practice.

OBJECTIVES

To find out the proportion of children with asthma who have co-morbid anxiety and depression, to study the association of co-morbid anxiety and depression on symptom control and to study the clinic-sociodemographic factors associated with anxiety and depression in children with asthma.

METHODS

Assuming 13% prevalence of anxiety and depression, with 95% confidence level and 5% absolute precision, a total of 176 children with asthma aged 6 years and above were enrolled from the asthma clinic. Clinical and sociodemographic details were collected for all. Symptom control was assessed using asthma control test questionnaire. Center for epidemiological studies-depression scale for children and screen for child anxiety related emotional disorders was used to assess depression and anxiety, respectively. Association of independent variables with outcome variables was assessed using χ² . Statistical tests were done using SPSS version 26.

RESULTS

Out of the 176 children enrolled, 13.1%, 8%, and 16.5% had anxiety, depression, and combined anxiety and depression, respectively. A higher proportion of children with uncontrolled asthma had depression and combined anxiety and depression than children with controlled asthma.

CONCLUSION

Combined anxiety and depression was more common than either anxiety or depression alone and along with depression, was significantly associated with uncontrolled symptoms.

[Asthma 2020 Nursing Consensus Document]

Asthma is a chronic respiratory disease which presents with a risk of exacerbations. Good patient management and continuous monitoring are crucial for good disease control, and pharmacological and non-pharmacological interventions are essential for proper treatment. Nurses specialised in asthma can contribute to the correct management of asthmatic patients. They play a key role in diagnostic tests, administration of medication, and patient follow-up and education. This consensus arose from the need to address an aspect of asthma management that does not appear in the specific recommendations of current guidelines. This document highlights and updates the role of specialized nurses in the care and management of asthma patients, offering conclusions and practical recommendations with the aim of improving their contribution to the treatment of this disease. Proposed recommendations appear as the result of a nominal consensus which was developed during 2019, and validated at the beginning of 2020.

How Frequently Is Asthma Objectively Demonstrated before Starting a Biologic? Quality Assessment of a Group Practice of Allergists and Immunologists

Worldwide, asthma-related healthcare cost remains a major burden. Individuals with severe asthma account for 50% of that cost. Although they are expensive, biologics such as anti-IL5 and anti-IgE agents promise cost-effectiveness when judiciously used to decrease asthma-related hospitalization and the debilitating side effects of systemic corticosteroids. Before considering biologics to treat patients with asthma, current guidelines recommend confirmation of asthma and control of comorbid diseases. Diagnostic confirmation of asthma can be challenging among individuals with severe asthma. In this quality assessment study, we determined the frequency of objective asthma confirmation and addressing of comorbidities prior to starting biologics at a group practice of allergists and immunologists. We surveyed our specialty providers to understand habit(s) leading to the observed results. We identified 40 adult patients who started on biologic modifiers for asthma over the past 5 years. Only 58% of these patients had a proper diagnosis of asthma. Providers underutilized several diagnostic methods that may prove useful in confirming asthma diagnosis in this patient population. The factors contributing to poor asthma control were rarely addressed. A sense of urgency to initiate biologics was the primary reason for the observed results. Further interventions are needed to improve asthma diagnosis and management prior to the initiation of biologic therapeutics.

Anxiety in adolescents with severe asthma and response to treatment

Asthma is a complex and multifactorial disorder. Actually, anxiety may affect asthma, mainly concerning frequent exacerbations, pharmacoeconomic costs, and uncontrolled asthma. On the basis of this background, we tested the hypothesis that anxiety could affect severe asthma outcomes in asthmatic adolescents. Therefore, a longitudinal real-world study included 40 consecutive adolescents (22 males, 18 females, mean age 14.18 ± 1.97 years) with severe asthma and visited for the first time at a third-level pediatric clinic. The current study showed that anxiety is common in adolescents with severe asthma as about 60% of them was anxious. In addition, anxiety was associated with frequent use of bronchodilators on demand. This outcome may conceivably depend on the anxiety trait. Interestingly, depression was present only in anxious adolescents: this outcome underlines the close link between emotional disorders. Therefore, emotional aspect should be considered in the adolescent asthma management in clinical practice. (www.actabiomedica.it)

Functional tests for adults with asthma: validity, reliability, minimal detectable change, and feasibility

OBJECTIVE

To verify the validity, reliability, learning effect, Minimal Detectable Change (MDC), and feasibility of four functional tests (4-Meter Gait Speed [4MGS], Timed Up-and-Go [TUG], Sit-To-Stand [STS], and Short Physical Performance Battery [SPPB]) for adults with asthma.

METHODS

In this cross-sectional study, fifty-two subjects with stable asthma underwent three sets of different functional tests protocols (4MGS, TUG, STS, SPPB) in a random order by two raters. For validation analysis, tests were compared with a sex-age matched control group without asthma and correlated with the Six Minute Walking Test (6MWT), and peripheral muscle strength, as well as with quality of life and asthma control questionnaires. Intra-rater and inter-rater reliability, MDC, and feasibility were verified.

RESULTS

Adults with asthma presented worse results than controls in the functional tests, except for SPPB. All functional tests were significantly correlated with 6MWT (0.45 < r < 0.67) and peripheral muscle strength (0.32 < r < 0.63), but not with quality of life and asthma control (0.02 < r < 0.17). The tests presented good to excellent intra-rater Intraclass Correlation Coefficients (ICC ≥ 0.75 for all). In all tests, a considerable learning effect and variability of measurement was observed, therefore, the best of two measurements should be used. MDC ranged from 15 to 31% and all tests were performed in a short time, small space, and without clinical adverse events.

CONCLUSION

Different protocols of 4MGS, TUG, STS, and SPPB are valid, reliable, and feasible to assess the functional capacity of adults with asthma. These tests are quick and practical new alternatives for assessing functional capacity in this population.

Anxiety, depression, and stress in Korean patients with chronic urticaria

BACKGROUND/AIMS

Emotional distress is thought to cause or maintain chronic urticaria (CU). We aimed to investigate the presence of anxiety, depression, and stress in Korean adult CU patients and to explore their potential impact on treatment.

METHODS

We enrolled 79 CU patients and a disease control group comprising 39 persistent asthma patients. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate depression and anxiety. Stress and quality of life (QoL) were assessed by Stress Response Inventory and CU-QoL questionnaires. The sociodemographic and clinical data such as urticaria activity score (UAS-15, UAS-6) were obtained.

RESULTS

The prevalence of depression and anxiety based on the HADS were 48.1% and 38.0%. Although the prevalence of anxiety didn't differ between the CU and asthma patients, depression was significantly more prevalent in the CU patients (48.1% vs. 28.2%). Stress tended to be lower in CU patients. Anxiety, depression, and stress exhibited negative correlations with QoL. Anxiety showed significant correlation with UAS-6 and pruritus-visual analog scale (VAS; r = 0.256, r = 0.272, p < 0.05, respectively); depression correlated with sleep difficulty-VAS (r = 0.261, p < 0.05). Stress was associated with UAS-15, UAS-6, pruritus-VAS, and sleep difficulty-VAS (r = 0.251, r = 0.317, r = 0.302, r = 0.258, p < 0.05, respectively).

CONCLUSION

The current study first presented that Korean CU patients frequently have anxiety and depression, which affect their QoL and demonstrated that anxiety, depression, and stress had different effects on sleep difficulty, pruritus, and urticaria severity in Korean CU patients.

Impact of comorbid conditions on asthmatic adults and children

Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In different age groups, comorbid conditions can present varying challenges, including diagnostic confusion due to mimicking asthma symptoms, exacerbation of asthma symptoms, therapy for comorbid conditions affecting asthma or therapy for asthma affecting these conditions. This review aims to summarise some common comorbid conditions with asthma, such as rhinitis, vocal cord dysfunction, gastro-oesophageal reflux, psychiatric disorders, obesity and obstructive sleep apnoea, and discuss their prevalence, symptoms, diagnosis and treatment, highlighting any differences in how they impact children and adults. Overall, there is a lack of data on the impact of treating comorbid conditions on asthma outcomes and further studies are needed to guide age-appropriate asthma management in the presence of these conditions.

Effective management of adult patients with asthma

Asthma is a chronic respiratory condition that can affect people of all ages. Globally, asthma is one of the most common non-communicable diseases and is associated with significant personal, financial and societal costs. In some cases, asthma can be fatal, although many fatalities would have been preventable with appropriate management. People with asthma often underestimate the effects of their symptoms, and nurses should develop their knowledge and skills so that they can provide appropriate management advice. This article outlines the causes of asthma and its symptoms. It also explains the interventions used in the management of this condition, including medicines, patient education, appropriate lifestyle changes and referral to specialist services.

Exposure-based cognitive behavior therapy for anxiety related to asthma: A feasibility study with multivariate baseline design

In the presence of asthma, the risk of having an anxiety disorder is increased twofold. The few trials conducted on cognitive behavior therapy (CBT) for anxiety and asthma have mainly targeted panic disorder, and with mixed results. Experimental laboratory research indicates that increased anxiety may lead to hypervigilance toward asthma. Hence, fear and avoidance associated with increased anxiety due to asthma may be an important treatment target. A treatment that learn participants to differentiate between anxiety and asthma through gradual exposure to situations that risk triggering anxiety for asthma may be a possible avenue. As a first step to investigate this issue further, we developed a 10-week exposure-based CBT protocol for anxiety related to asthma and tested it in six participants using multivariate baseline design with repeated assessments throughout treatment. All participants reported satisfaction with treatment, as well as subjective overall improvement after treatment. Visual analysis, using graphs over each individual's trajectory, as well as potential efficacy on group level analyzing standardized mean change, indicated improvements in important outcomes. We conclude that exposure-based CBT is feasible and may improve anxiety related to asthma. Further investigation under randomized controlled trial conditions is warranted.

Pragmatic Markers in the Management of Asthma: A Real-World-Based Approach

Bronchial hyperreactivity, reversible airflow limitation and chronic airway inflammation characterize asthma pathophysiology. Personalized medicine, i.e., a tailored management approach, is appropriate for asthma management and is based on the identification of peculiar phenotypes and endotypes. Biomarkers are necessary for defining phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are experimental and/or not commonly available. The current paper will, therefore, present pragmatic biomarkers useful for asthma management that are available in daily clinical practice. In this regard, eosinophil assessment and serum allergen-specific IgE assay are the most reliable biomarkers. Lung function, mainly concerning forced expiratory flow at 25-755 of vital capacity (FEF_25-75), and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have clinical relevance in asthma concerning both the endotype definition and the personalization of the therapy.

Anxiety and depression in adult patients with asthma: the role of asthma control, obesity and allergic sensitization

OBJECTIVE

To determine the frequency of anxiety and depression in adult patients with asthma and to identify factors associated with them.

METHODS

This cross-sectional study included 164 consecutively recruited patients with asthma aged ≥ 18 years. Participants were clinically assessed and the mental state was analyzed through of the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II); the Asthma Control Test (ACT) was measured, and allergic sensitization and respiratory function were also evaluated. Binary logistic regression models to identify the factors related to anxiety or depression were carried out. Complementary, 95% confidence intervals (CI) were estimated.

RESULTS

Anxiety was present in 54.3% of patients (95% CI: 46.6%-61.7%) while depression was found in 50.6% (95% CI: 43.0%-58.2%). Depression increased the odds of anxiety in patients with asthma (OR: 26.00, p < 0.0001), whereas an ACT score ≥ 20 points and allergic asthma were associated with a lower odds than the reference group (OR: 0.29; p = 0.007 and OR: 0.29; p = 0.024, respectively). Depression was associated with anxiety and obesity (OR: 25.33, p < 0.0001 and OR: 3.66; p = 0.014, respectively).

CONCLUSIONS

Overall, more than half of all asthmatic patients suffer from anxiety and depression. Well-controlled asthma and allergic sensitization decreased the likelihood of anxiety, while depression was associated with both obesity and anxiety.

Alexithymia, empathy, negative affect and physical symptoms in patients with asthma

Although alexithymia has been found to be associated with physical symptoms in psychosomatic disorders such as asthma, mechanisms linking this association are unknown. However, affective alexithymic features may be associated with physical symptoms in the presence of deficits in affective characteristics such as low empathy and high negative affect. This study aimed to assess direct effects of alexithymic traits on physical symptoms and indirect effects of these subscales through empathy and negative affect (e.g. depressive, anxious and stress symptoms) by controlling for asthma severity in patients with asthma. Three hundred patients with asthma completed the Toronto Alexithymia Scale-20 (TAS-20), the Basic Empathy Scale (BES), the Depression Anxiety Stress Scales-21 (DASS-21) and the Physical Symptoms Inventory (PSI). After controlling for asthma severity, the results showed that alexithymia subscales of the TAS-20 had no direct effects on physical symptoms, but the difficulty in identifying feelings (DIF) subscale of the TAS-20 was associated with affective empathy and negative affect. Affective empathy was significantly related to negative affect. Affective empathy and negative affect were associated with physical symptoms. The affective subscale of alexithymia on the TAS-20, that is DIF, indirectly affected physical symptoms through affective empathy and negative affect. Findings suggest that patients with asthma who have high levels of DIF may show high physical symptoms in the presence of low affective empathy and high negative affect.