How do we monitor asthma control?

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Patient-reported outcome measures in pediatric asthma care: using theoretical domains framework to explore healthcare providers’ perceptions

Background

Patient-reported outcome measures (PROMs) play an important role in promoting and supporting patient and family-centered care. Implementing interventions like PROMs in routine clinical care require key stakeholders to change their behavior. The aim of this study was to utilize the Theoretical Domains Framework (TDF) to identify barriers and enablers to the implementation of PROMs in pediatric outpatient asthma clinics from healthcare providers’ perspective.

Methods

This TDF-guided qualitative descriptive study is part of a larger multi-phase project to develop the KidsPRO program, an electronic platform to administer, collect, and use PROMs in pediatrics. Semi-structured qualitative interviews were conducted with 17 participants, which included pediatricians, nurses, allied health professionals and administrative staff from outpatient asthma clinics. All the interviews were transcribed, deductively coded, inductively grouped in themes, and categorized into barriers and enablers.

Results

We identified 33 themes within 14 TDF domains, which were further categorized and tabulated into 16 barriers and 17 enablers to implementing PROMs in asthma clinics. Barriers to behavioral change were attributed to personal, clinical, non-clinical, and other system-level factors; they ranged from limited awareness of PROMs to language barriers and patient’s complex family background. Enablers ranged from a personal commitment to providing patient and family-centered care to administering PROMs electronically.

Conclusion

This implementation of science-based systematic inquiry captured the complexity of PROMs implementation in pediatric outpatient clinical care for asthma. Considering the consistency in barriers and enablers to implementing PROMs across patient populations and care settings, many findings of this study will be directly applicable to other pediatric healthcare settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00494-3.

Validation of the Spanish version of the Asthma Control Questionnaire

BACKGROUND

The Asthma Control Questionnaire (ACQ) has not been validated in the Spanish population, and the fact that it requires spirometry poses an important limitation on its widespread use in the primary care setting in Spain.

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the Spanish version of the ACQ.

METHODS

In this multicenter, prospective study, consecutive adult patients with persistent asthma were recruited at 62 respiratory and allergy units across Spain. Patients were assessed at baseline and at weeks 2 and 6. The following clinical variables were recorded: lung function (forced expiratory volume in 1 second [FEV(1)]), symptoms, exacerbations, concomitant diseases, asthma severity according to the Global Initiative for Asthma international guideline, and asthma control as perceived by patients and physicians through direct ad hoc questions. The latter measures were derived specifically for this study. Patients self-completed the ACQ at all visits before the rest of the study variables were recorded. The ACQ's feasibility, validity, reliability, and sensitivity to change were assessed. Cross-sectional and longitudinal validity was assessed using the relationship between ACQ score and clinical parameters. Sensitivity to change was assessed by estimating the global effect size and the minimal important difference (MID). Reliability was assessed using estimation of the Cronbach alpha coefficient (CCalpha) and intraclass correlation coefficient (ICC).

RESULTS

A total of 607 patients were included. The mean (SD) age was 45.6 (17.1) years and 61.4% of the patients were women. Of these 607, 235 (39%) had mild asthma; 246 (41%), moderate; and 126 (21%), severe. Mean (SD) time to complete the ACQ was 3.9 (4.4) minutes. The Pearson correlation coefficient in the relationship between ACQ and FEV(1) (% predicted value) was -0.23. ACQ was found to be significantly related to asthma severity and intensity and frequency of symptoms (coughing, wheezing, and dyspnea) (both, P < 0.001). Change in ACQ was significantly related to changes in FEV(1), intensity and frequency of symptoms, and number of exacerbations (all, P < 0.001). The global effect size of ACQ was 0.46 and the MID was 0.47 point of a maximum of 6. CCalpha was 0.90 and ICC was 0.86.

CONCLUSION

In these adults with asthma in Spain, the Spanish version of the ACQ was found to be a reliable and valid questionnaire, suggesting that it can be used in this population as a discriminative and evaluative instrument.

International differences in asthma guidelines for children

BACKGROUND

Over the last decade, a number of clinical practice guidelines that include guidance for the management of pediatric asthma have been introduced. The consistency across pediatric asthma guidelines is unknown and the emphasis on establishing asthma control may vary. The objective of this paper was to depict the evolution of guidelines for pediatric asthma and to compare current international guidelines in terms of their organization, presentation of evidence and consideration of children, with special emphasis on definitions of asthma control and severity.

METHODS

A systematic search to identify asthma guidelines was conducted, and guidelines were searched for pediatric terms. The approaches used by guidelines to define assessments of asthma severity and control were compared between the United States, the Global Initiative for Asthma, Canada, the United Kingdom and Australia.

RESULTS

Pediatric considerations in the management of asthma have been integrated into the various guidelines to different degrees and through varied strategies. There were differences in the conceptual and operational approach used to assess asthma which emphasized either asthma severity or control.

CONCLUSIONS

It will be important for future guidelines to clearly define whether the primary assessment parameter is asthma severity or control. Delineating the guideline development process and supporting evidence may improve transparency, consistency and guideline adherence.

Longitudinal changes in airflow limitation and airway hyperresponsiveness in patients with stable asthma

BACKGROUND

There are few long-term studies of the effects of treatment on the natural course of asthma.

OBJECTIVE

To investigate the longitudinal changes in airflow limitation and airway hyperresponsiveness (AHR) in asthma.

METHODS

We recruited 81 outpatients (never smokers) with stable asthma from the Kyoto University Hospital. They were evaluated for pulmonary function and AHR, expressed by forced expiratory volume in 1 second (FEV1) and the provocation dose that caused a 20% fall in FEV1 (PD20-FEV1), respectively, at entry and every 6 months over 3 years. We used random effects models to estimate the slopes of these changes, and then evaluated the relationship between these changes and their predictive factors.

RESULTS

Using random effects models, the percentage of the predicted FEV1 (%FEV1) declined significantly but slightly at a mean rate of 0.5%/year (P = 0.002; 95% confidence interval, 0.3 to 0.8). The mean decline rate of FEV1 was 34 mL/year. However, Log(PD20-FEV1) showed significant improvement at a mean rate of 0.088 cumulative units/year (P < 0.001; 95% confidence interval, 0.053 to 0.122). Multiple regression analysis showed that the baseline values of %FEV1 and Log(PD20-FEV1) were the most significant predictive factors for their subsequent changes, respectively.

CONCLUSIONS

In stable asthmatic patients treated according to international guidelines, airflow limitation progressed at a nearly normal rate over 3 years. However, AHR continued to improve despite its ceiling effects. Multiple regression analysis revealed a significant negative relationship between the initial values and the subsequent changes in airflow limitation and AHR, respectively.

Drug treatment of airway inflammation in asthma

Several methods are available for assessing drug effects on airway inflammation and the antiinflammatory effects of drugs for asthma. Cromolyn and theophylline are well-established drugs for the treatment of asthma, and each has antiinflammatory properties. Drugs in development include those aimed at inhibiting inflammatory mediators and immunoglobulin E function; clinical studies, however, have been conducted largely in patients with moderate to severe asthma.

Urinary eosinophil protein X in children: the relationship to asthma and atopy and normal values

BACKGROUND

In epidemiologic studies, it may be difficult to identify children with bronchial asthma. Since this is the most common chronic respiratory disease in childhood, and its prevalence is still increasing, reliable methods for identification of asthmatic children are required. This study evaluates the use of urinary eosinophil protein X (U-EPX) in epidemiologic studies in identifying atopic and asthmatic children.

METHODS

U-EPX was measured in 877 Austrian schoolchildren. The skin prick test (SPT) was performed with eight common aeroallergens, and established questionnaires were used to assess respiratory symptoms.

RESULTS

Of our cohort, 2.8% reported physician-diagnosed asthma, 5.1% reported wheezing within the last 12 months, and 24.1% were found to be atopic. In children with physician-diagnosed asthma, as well as in atopic children (positive SPT), median U-EPX levels were significantly higher than in healthy subjects (142.8 and 89.6 vs 63.9 microg/mmol creatinine, P<0.0001 and P<0.0001, respectively). In addition, perennial sensitization to inhalant allergens resulted in higher U-EPX levels than did seasonal sensitization. The odds ratio for U-EPX levels over the 90th percentile was significantly elevated for asthma, for wheezing, for nocturnal cough, and for breathlessness at exercise, as well as for seasonal and perennial sensitization. Pulmonary function was negatively related to U-EPX levels.

CONCLUSIONS

Measurement of U-EPX, which can be obtained easily, may be helpful in diagnosing both asthma and atopy in children. However, there is a great overlap between controls and symptomatics, a fact which reduces the sensitivity of U-EPX in determination of the prevalence of asthma in epidemiologic studies.