Relationship between the perception of dyspnoea and airway inflammatory markers

Utility of exhaled nitric oxide to guide mild asthma treatment in atopic patients and its correlation with asthma control test score: a randomized controlled trial

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is used for the diagnosis and monitoring of asthma, although its utility to guide treatment and its correlation with other tools is still under discussion. We study the possibility to withdraw inhaled corticosteroid treatment in atopic patients with mild asthma based on the FeNO level, as well as to study its correlation with other clinical control tools.

METHODS

Prospective and randomized study including atopic patients aged 18 to 65 with mild asthma, stable, on low-dose inhaled corticosteroid (ICS) treatment, who had their treatment withdrawn based on a FeNO level of 40 ppb. Patients were randomized into two groups: control group (treatment with ICS was withdrawn regardless of FeNO level) and experimental group (according to the FeNO levels, patients were assigned to one of two groups: FeNO > 40 ppb on treatment with budesonide 200 mcg every 12 h and SABA on demand; FeNO ≤ 40 ppb only with SABA on demand). Follow-up was conducted for one year, during which medical assessment was performed with FeNO measurements, asthma control test (ACT), lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC), and recording of the number of exacerbations.

RESULTS

Ninety-two patients were included, with a mean age of 39.92 years (SD 13.99); 46 patients were assigned to the control group, and 46 patients to the experimental group. The number of exacerbations was similar between the groups (p = 0.301), while the time to the first exacerbation was significantly shorter in the control group (30.86 vs. 99.00 days), p < 0.001, 95% CI (43.332-92.954). Lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC) showed no differences between the groups (p > 0.05). Both FeNO and ACT showed significant changes in the groups in which ICS was withdrawn (p < 0.05 for both parameters). A significant negative correlation was observed between FeNO and ACT (r = -0.139, p = 0.008).

CONCLUSIONS

In atopic patients with mild asthma, withdrawal of ICS based on an FeNO of 40 ppb led to worsened symptoms but without changes in lung function tests or an increase in exacerbations. There was a negative correlation between FeNO values and symptomatic control measured by the ACT.

TRIAL REGISTRATION

Clinical Trial Number: 2012-000372-42. Start Date: 2012-07-23. Trial registered prospectively ( https://www.clinicaltrialsregister.eu/ctr-search/search?query=2012-000372-42 ). This study adheres to CONSORT guidelines of randomised control trials.

Asthma control test is correlated to FEV1 and nitric oxide in Greek asthmatic patients: influence of treatment

BACKGROUND

Asthma is a common chronic disease affecting patients' health status and quality of life. Although recent guidelines focus on asthma control, asthma remains poorly controlled in many patients even under specialist care. Asthma Control Test™ (ACT) is a short, simple, patient-based tool that provides consistent assessment of asthma.

OBJECTIVE

The aim of this study was to estimate the relationship of ACT with objective measures of lung function and inflammation such as forced expiratory volume in 1st second (FEV(1)) and exhaled nitric oxide (FeNO) in outpatients admitted for initial diagnosis of asthma and at follow-up.

METHODS

One hundred and sixty (104 women and 56 men, mean age 39.7 ± 16.6 years) asthmatic patients with newly diagnosed asthma were included in the study. Patients completed the ACT questionnaire and underwent a detailed clinical examination, FeNO measurement, and prebronchodilator spirometry before (visit 1) and 4-12 weeks after initiation of treatment (visit 2).

RESULTS

At visit 1, the mean ACT score was 21.27 ± 3.74. According to ACT score, 37 patients (23.1%) were completely controlled, 85 patients (53.1%) were partly controlled, and 38 patients (23.8%) were uncontrolled. Patients with uncontrolled asthma had statistically higher FeNO values than patients with partly controlled (p = .038) and completely controlled asthma (p = .016). ACT score was found to have a positive correlation with prebronchodilator %FEV(1) (r = 0.177, p = .025) and negative correlation with FeNO ( r = -0.211, p = .007). At visit 2, the mean ACT score was 23.00 ± 2.19. The change in ACT score between the two visits was significantly correlated to changes in FEV(1) (r = 0.538, p < .001) and in FeNO (r = -0.466, p < .001). Patients treated with inhaled corticosteroids (ICSs) showed significant improvement in FEV(1) and in ACT score and a decrease in FeNO compared with patients without ICS treatment.

CONCLUSION

Although FEV(1) remains the main objective parameter for evaluating asthma, ACT score was found to reflect lung function and inflammation in a Greek asthmatic population.

Dyspnea perception in asthma: role of airways inflammation, age and emotional status

OBJECTIVES

Dyspnea perception in asthmatics differs between subjects. Poor perception is usually associated with increased risk of asthma attack/exacerbation. The advanced stage of the disease and the presence of eosinophilic airways inflammation have been recently recognized as being responsible for poor dyspnea perception. However, few studies are available on this topic.

DESIGN

The aim of this study was to analyse the influence of inflammatory pattern, age and affective status on dyspnea perception in asthmatic subjects.

SUBJECTS AND INTERVENTIONS

Seventy-one consecutive asthmatic patients were recruited and underwent induced sputum, exhaled NO measurement and breath condensate collection. Perception of dyspnea was evaluated as a BORG-VAS/FEV(1) slope before and after the broncho-reversibility test and correlated with the stage of asthma, inflammatory markers, age and depression scale.

RESULTS

Dyspnea perception decreases with the worsening of asthma, with the advance of age and of depression status. Furthermore, airways inflammation plays a key role in the decline of dyspnea perception as proved by the negative correlation observed between inflammatory cells in sputum, exhaled pH and NO and BORG-VAS/FEV(1) slope.

CONCLUSIONS

The results of our study suggested that airways inflammation, depression status, advance age and severity of asthma influence dyspnea perception and suggest a straight control to identify and better manage poor preceptor asthmatics.

Avaliação do uso da Escala Modificada de Borg na crise asmática

A dispnéia é a maior causa de incapacidade e redução da qualidade de vida para pacientes com doenças respiratórias como é o caso da asma. Os objetivos deste estudo foram verificar o grau de dispnéia dos pacientes em crise asmática pela Escala Modificada de Borg e a correlação da melhora do grau de dispnéia com a melhora da função pulmonar verificada pelo Pico de Fluxo Expiratório (PFE). Foram incluídos 40 pacientes asmáticos em crise aguda, atendidos no serviço de Pronto Atendimento em Pneumologia do Hospital São Paulo, no período de setembro à dezembro de 2003. Antes e após o tratamento, os seguintes dados foram coletados: freqüência cardíaca (FC), freqüência respiratória (FR), PFE e saturação periférica de oxigênio (SpO2). O paciente era questionado sobre sua percepção da dispnéia pela Escala Modificada de Borg. No pré-tratamento ocorreu uma tendência dos valores altos da escala de Borg estarem relacionados aos valores baixos do PFE, invertendo esta relação no pós-tratamento. Esta escala é rápida, barata e de fácil aplicabilidade na avaliação de pacientes asmáticos. Pode ser utilizada por profissionais de saúde para a avaliação inicial dos pacientes em crise, bem como sua resposta ao tratamento.

Acute dyspnea as perceived by patients with chronic obstructive pulmonary disease

Like pain, dyspnea, or difficulty in breathing, is a strong subjective experience of physiologial distress. Using a model developed by DeVito, this study focused on the emotional aspects of the acute experience of dyspnea in patients diagnosed with chronic obstructive pulmonary disease (COPD) on a medical unit and explored nursing activities that eased the intensity of the symptoms. The study was descriptive in design and used a semistructured interview format with four open-ended questions and a numerical self-assessment of dyspnea using the Modified 0-10 Borg Scale (MBS). The sample included 41 hospitalized patients with COPD between the ages of 43 and 89 years who had experienced episodes of acute dyspnea both prior to and during their current inpatient stays. This article provides descriptions of the experience of dyspnea, identifies themes from the participants' responses, notes the patients'perceptions of the efficacy of nursing actions, and extends the use of the MBS to an inpatient population.