Clinical advances in adult asthma

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Advances in adult asthma diagnosis and treatment in 2009

There is a growing need to standardize and validate outcomes for asthma research. In this review of asthma-related publications from the Journal in 2009, efforts to standardize methodology and reporting of translational research, the influence of the environment, therapeutics, and management of asthma are highlighted.

Advances in adult asthma diagnosis and treatment and health outcomes, education, delivery, and quality in 2008

In 2008 the Journal reported new findings in management of asthma. Dosing schedules of inhaled steroids have been modified and individualized. New, more costly propellants are replacing ozone-depleting chlorofluorocarbons. An association of asthma with pneumococcal disease has been observed. Smoking bans in public places are eliminating second-hand smoke and reducing asthma-related emergency department visits among adults. In contrast with these advances, however, disparity in asthma morbidity persists: black persons compared with white persons have a 4-fold greater risk of an asthma-related emergency department visit.

Effect of procaterol, a beta(2) selective adrenergic receptor agonist, on airway inflammation and hyperresponsiveness

BACKGROUND

beta-agonists are frequently used as bronchodilators for asthma as not only a reliever but also a controller, and their utility has increased with the development of long-acting beta(2) selective drugs. Although anti-inflammatory effects of beta(2) selective-agonists have been reported in vitro, side effects on augmentation of airway hyperresponsiveness by chronic use of beta(2) selective-agonists have been described in several reports. In this study, we investigated the effects of procaterol, a second-generation beta(2)-agonist, on airway inflammation in vivo using an antigen-specific murine model of asthma.

METHODS

Mice immunized with ovalbumin (OVA) + alum and challenged with inhaled ovalbumin were orally administered procaterol during the challenge. After inhalation, the mice were tracheostomized and placed in a body box under controlled ventilation to measure airway resistance before and after acetylcholine inhalation.

RESULTS

Administration of procaterol at a clinical dose equivalent did not augment airway hyperresponsiveness, inflammation of the airway wall, or subsequent airway wall thickening induced by OVA inhalation. BALF cell analysis revealed that the eosinophil number in the BALF was significantly reduced in procaterol-treated mice compared to untreated mice.

CONCLUSIONS

Oral administration of procaterol at a clinical dose did not augment airway responsiveness, but did reduce eosinophil inflammation.

High prevalence of skin test positivity in severe or difficult-to-treat asthma

BACKGROUND

Skin tests are considered the gold standard for detecting allergen-specific immunoglobulin E (IgE) in the clinical setting and are an important tool for diagnosing and managing allergic asthma.

OBJECTIVE

To assess the prevalence of skin testing in patients > or = 12 years enrolled in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study.

METHODS

Patients were asked whether they had ever been skin tested and, if so, they were asked to provide the test results. Clinical characteristics were used to compare positive (ST+), negative (ST-), and skin test not done (STND) patients.

RESULTS

Of 2,985 patients eligible, 85.8% recalled being skin tested. Of those tested, 93.5% were positive (allergist 95.7%, pulmonologist 87.3%). A high proportion of Whites (93.5%) and non-Whites (94.0%) were ST+; however, more non-Whites had never been skin tested (21.7% vs. 12.3%, respectively; p < 0.0001). Total serum IgE was 104.6 IU/mL for ST+ patients, 87.1 IU/mL for STND patients, and 32.4 IU/mL for ST- patients. Age at asthma onset, duration of asthma, and the prevalence of atopic disorders and asthma triggers differentiated the ST+ from the ST- group. Disease severity appeared similar between the two groups. In general, values for STND patients were closer to the ST+ group, suggesting that those not tested would have been ST+ if administered a test.

CONCLUSIONS

The prevalence of ST+ patients was high in allergy and pulmonology practices, and in White and non-White patients. These data support the utility of a more complete allergic evaluation in severe asthmatics. Skin testing appears associated with disease pathophysiologies in asthma.

Advances in adult and pediatric asthma

This review summarizes the highlights in the study of adult and pediatric asthma from October 2002 through October 2003. It is easiest to categorize this year's advances into physiologic, epidemiologic, therapeutic, and primarily pediatric developments. In physiology the identification of the ADAM33 gene as an asthma susceptibility gene has led to a new hypothesis concerning the pathogenesis of asthma. Understanding the integration of the upper and lower airways is likely to have important implications for patient management. Epidemiologic studies continue to show that asthma is a significant and costly disease, with medications comprising the most significant direct costs. Early intervention and improved management can significantly reduce the burden of illness. Research presented indicates there is an opportunity for allergist-immunologists to improve diagnostic and therapeutic approaches to asthma management. Our community has a strong commitment to health care quality, education, and delivery. The Journal will reflect this commitment with a new section devoted to these issues.