Assessing symptoms and peak expiratory flow rate as predictors of asthma exacerbations

Written Asthma Action Plan Improves Asthma Control and the Quality of Life among Pediatric Asthma Patients in Malaysia: A Randomized Control Trial

BACKGROUND

A written asthma action plan (WAAP) is one of the treatment strategies to achieve good asthma control in children.

METHODS

This randomized controlled trial was conducted to observe the effect of WAAP on asthma control and quality of life using the Asthma Control Questionnaire and Pediatric Asthma Quality of Life Questionnaire (PAQLQ) at baseline and after 3 months. A repeated measure analysis of variance was used to analyze the mean score difference between the two groups.

RESULTS

There was no significant difference in mean score for asthma control at baseline between groups (F[degree of freedom (df)]=1.17 [1, 119], P=0.282). However, at 3 months, a significant difference in mean scores between groups was observed (F[df]=7.32 [1, 119], P=0.008). The mean±standard deviation (SD) scores in the intervention and control groups were 0.96±0.53 and 1.21±0.49, respectively. For the analysis of the PAQLQ, no significant difference was observed in the mean score for the quality of life baseline in both groups. There were significant mean score changes for the quality of life (F[df]=10.9 [1, 119], P=0.001) at 3 months follow-up, where those in the intervention group scored a mean±SD score of 6.19±0.45, and those in the control group scored 5.94±0.38. A time-group interaction analysis using repeated-measures analysis of variance showed significant differences in mean score changes (F[df]=5.03 [1, 116], P=0.027) and (F[df]=11.55 [1, 116], P=0.001) where a lower mean score was observed in the intervention group, indicating better asthma control and quality of life, respectively. A significant (P<0.001) negative Pearson correlation between asthma control and quality of life (-0.65) indicated a moderate correlation.

CONCLUSION

WAAP, along with standard asthma treatment, improves asthma care.

Serious Asthma Outcomes and Asthma Exacerbations with Maintenance on Inhaled Corticosteroid (Mometasone Furoate)/Long-Acting Beta Agonist (Formoterol) Combination Compared to Step Down to Mometasone Monotherapy

BACKGROUND

Because of historical safety concerns with the use of long-acting β-agonists (LABA) in asthma, step-down from inhaled corticosteroid (ICS)/LABA combination therapy to ICS monotherapy is recommended once asthma control is achieved.

OBJECTIVE

To evaluate the benefit/risk question about whether patients with asthma who achieve disease control on fixed-dose ICS/LABA combination therapy, such as mometasone furoate/formoterol fumarate (MF/F), should continue with this therapy or be stepped down to ICS monotherapy, such as MF.

METHODS

Using data from 8447 clinically stable patients with persistent asthma in the Safety Pharma Investigation of Respiratory Outcomes trial who had been receiving a stable dose of ICS/LABA for ≥4 weeks, this post hoc analysis evaluated the risk of serious asthma outcomes (SAOs) (adjudicated hospitalization, intubation, or death) and asthma exacerbation (AEX) (composite of hospitalizations ≥24 hours, emergency visits <24 hours requiring systemic corticosteroid, or systemic corticosteroid for ≥3 consecutive days) in participants randomized to remain on ICS/LABA (MF/F) or step down to ICS (MF) for 26 weeks.

RESULTS

There was no significant difference in SAO risk among patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (hazard ratio [HR], 1.03 [95% confidence interval (CI): 0.61, 1.75], P = .913). The risk of AEX was significantly lower in patients maintained on ICS/LABA with MF/F compared with those who stepped down from ICS/LABA to MF (HR, 0.87 [95% CI: 0.78, 0.98], P = .020).

CONCLUSIONS

In this post hoc analysis of a large clinical trial dataset, maintenance on ICS/LABA with MF/F is not associated with an increased risk of SAOs and also significantly reduces the risk of AEX compared with step-down from ICS/LABA to MF.

A novel herbal composition containing extracts of Boswellia serrata gum resin and Aegle marmelos fruit alleviates symptoms of asthma in a placebo controlled double-blind clinical study

LI13109F is a novel herbal composition containing the extracts of Boswellia serrata gum resin and Aegle marmelos fruit. This composition dampens leukotriene dependent inflammatory reactions via inhibiting 5-lipoxygenase pathway. In a Sephadex LH-20 induced airway inflammation model of Sprague Dawley rats, LI13109F significantly reduced infiltrated granulocyte population in the bronco-alveolar lavage fluid and normalized Th1/Th2 cytokine balance. Further, a 56-day placebo-controlled and randomized double blind study (Clinical Trial Registration No. CTRI/2016/10/007393) on subjects with mild to moderate asthma has evaluated the clinical efficacy of LI13109F. The study subjects received either 200 mg/day of LI13109F (n = 18) or a similar dosage of placebo (n = 18). At the end of the trial period, LI13109F conferred significant improvements in the clinical parameters; the emotional function (p = .0305) and asthma symptoms scores (p = .0002) were improved even at 14 days, compared with the placebo. Further, 56 days supplementation of LI13109F resulted in significant increase in serum IFN-γ (p = .0014) and reduction in IL-4 (p = .0497), compared with placebo. LI13109F supplementation did not yield any serious adverse events or any abnormal observations in routine laboratory examinations during the study. Together, these observations suggest that LI13109F (AlvioLife®) is tolerable and an effective intervention for management of mild to moderate asthma such as airway inflammation.

A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department

OBJECTIVE

To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department.

METHODS

A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed.

RESULTS

A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge.

CONCLUSIONS

Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.

Asthma exacerbations: predisposing factors and prediction rules

PURPOSE OF REVIEW

Asthma is a multifaceted disease that is associated with decreased lung function, multiple symptoms, varying levels of asthma control, and risk of acute exacerbations. The ability to predict the risk of developing acute exacerbations may improve the management of asthmatics and facilitate identification of these patients for interventional studies.

RECENT FINDINGS

Factors that are associated with different manifestations of asthma differ. Biomarkers that are correlated with airways hyper-responsiveness do not necessarily correlate with risk of future exacerbations. Genetic factors that segregate with exacerbation risk are beginning to emerge. Outcome measures that demonstrate predictive validity have been developed and may facilitate patient management and provide novel clinically meaningful endpoints in clinical trials.

SUMMARY

This review will emphasize underlying factors associated with asthma exacerbations and clinical prediction rules that correlate with the risk of developing severe exacerbations of asthma.

Childhood asthma management pre- and post-incident asthma hospitalization

Many hospitalizations for asthma could potentially be avoided with appropriate management. The aim of this study was to analyze data on disease management of a paediatric population with a hospitalization for asthma. The study population comprised 6–17 year old subjects belonging to three local health units of the Lombardy Region, northern Italy. Regional administrative databases were used to collect data on: the number of children with an incident hospitalization for asthma during the 2004–2006 period, anti-asthma therapy, specialist visit referrals, and claims for spirometry, released in the 12 months before and after hospitalization. Each patient’s asthma management profile was compared with GINA guideline recommendations. Among the 183 hospitalized subjects, 101 (55%) received therapy before hospitalization and 82 (45%) did not. 10% did not receive any therapy either before or after hospital admission and in 13% the therapy was discontinued afterward. Based on GINA guidelines, asthma management adhered to recommendations only for 55% of subjects. Results may suggest that for half of hospitalized subjects, inaccurate diagnosis, under-treatment/scarce compliance with asthma guidelines by physicians, and/or scarce compliance to therapy by patients/their parents occurred. In all these cases, hospitalization would be a proxy indicator of preventable poor control of disease, rather than a proxy indicator of severity.

Psychosocial variables are related to future exacerbation risk and perinatal outcomes in pregnant women with asthma

OBJECTIVE

To determine the relationship between psychosocial variables, future exacerbation risk during pregnancy, and perinatal outcomes.

METHODS

A secondary analysis of a randomized controlled trial of exhaled nitric oxide versus guideline-based treatment adjustment in pregnant women with asthma. Women were recruited between 12 and 20 weeks gestation and monitored for the remainder of the pregnancy. Psychosocial questionnaires including the Perceived Control of Asthma Questionnaire, the Brief Illness Perception Questionnaire, and the Six-Item Short-Form State Trait Anxiety Inventory were assessed at randomization. Exacerbations were defined as hospitalization, emergency visit, unscheduled doctor visit, or oral corticosteroid use for worsening asthma. Perinatal outcomes included preterm birth, small for gestational age, and cesarean section. Multiple logistic regressions were performed with predictor variables, including demographics and psychosocial and clinical variables.

RESULTS

The 175 participants had a mean (SD) age = 28.5(5.4) years, forced expiratory volume in 1 second (FEV(1)%) predicted = 95.9(13.4), and asthma control score = 0.88(0.70). Greater perceived control of asthma reduced the odds of subsequent exacerbation (odds ratio (OR) [95%CI] 0.92 [0.85, 0.98], p = .016), cesarean without labor (0.84 [0.75, 0.94], p = .003), and preterm birth (0.84 [0.72, 0.97], p = .019), while increased anxiety increased the odds of subsequent exacerbation (1.05 [1.01, 1.08], p = .008).

CONCLUSION

Women's perceptions of asthma control and their psychosocial state (anxiety) are related to future exacerbation risk, cesarean section, and preterm birth.

Relationship between asthma control status, the Asthma Control Test™ and urgent health-care utilization in Asia

BACKGROUND AND OBJECTIVE

Accurate assessment of control is an integral part of asthma management. We investigated the relationship between control status derived from the Global Initiative for Asthma (GINA), the Asthma Control Test (ACT) and urgent health-care utilization.

METHODS

Asthma Insights and Reality in Asia-Pacific Phase 2 (AIRIAP 2) was a cross-sectional, community-based survey of 4805 subjects with asthma from urban centres across Asia. A symptom control index was derived from the AIRIAP 2 questionnaire using the GINA control criteria for day- and night-time symptoms, need for rescue medication, activity limitation and exacerbations; lung function was excluded. The main outcomes were asthma control, based on these GINA criteria and the ACT, and the relationship between control and self-reported urgent health-care utilization (hospitalization, emergency room visits or other unscheduled urgent visits) related to asthma over the previous 12months.

RESULTS

Each of the symptom criteria was significantly associated with urgent health-care utilization, with odds ratios (ORs) ranging from 2.25 (95% confidence interval (CI): 1.94-2.61) for daytime symptoms to 2.57 (95% CI: 2.29-2.90) for nocturnal awakening. Similarly, control status was significantly associated with urgent health-care utilization, with ORs of 0.19 (95% CI: 0.13-0.28), 0.70 (95% CI: 0.65-0.76) and 1.00 for controlled, partly controlled and uncontrolled, respectively. The optimal ACT cut-off score for identifying uncontrolled asthma was ≤19 for subjects aged ≥12years. Urgent health-care utilization was reported by 57.2% versus 28.7% of patients scoring ≤19 versus >19 (P<0.001).

CONCLUSIONS

The GINA control classification and the ACT are valid symptom-based measures that are significantly associated with urgent health-care utilization.

Predictors of symptoms are different from predictors of severe exacerbations from asthma in children

BACKGROUND

Asthma therapy is typically prescribed and titrated based on patient or parent self-report of symptoms. No longitudinal studies have assessed the relationship between symptoms and severe asthma exacerbations in children. The goal of our study was (1) to assess the association of asthma symptoms with severe asthma exacerbations and (2) to compare predictors of persistent asthma symptoms and predictors of severe asthma exacerbations.

METHODS

The Childhood Asthma Management Program was a multicenter clinical trial of 1,041 children randomized to receive budesonide, nedocromil, or placebo (as-needed β-agonist). We conducted a post hoc analysis of diary cards that were completed by subjects on a daily basis to categorize subjects as having persistent vs intermittent symptoms. We defined a severe asthma exacerbation as an episode requiring ≥ 3 days use of oral corticosteroids, hospitalization, or ED visit due to asthma based on self-report at study visits every 4 months.

RESULTS

While accounting for longitudinal measures, having persistent symptoms from asthma was significantly associated with having severe asthma exacerbations. Predictors of having persistent symptoms compared with intermittent symptoms included not being treated with inhaled corticosteroids, lower FEV(1)/FVC ratio, and a lower natural logarithm of provocative concentration of methacholine producing a 20% decline in FEV(1) (lnPC(20)). Predictors of having one or more severe asthma exacerbations included younger age, history of hospitalization or ED visit in the prior year, ≥ 3 days use of oral corticosteroids in the prior 3 months, lower FEV(1)/FVC ratio, lower lnPC(20), and higher logarithm to the base 10 eosinophil count; treatment with inhaled corticosteroids was predictive of having no severe asthma exacerbations.

CONCLUSIONS

Patients with persistent symptoms from asthma were more likely to experience severe asthma exacerbations. Nevertheless, demographic and laboratory predictors of having persistent symptoms are different from predictors of severe asthma exacerbations. Although symptoms and exacerbations are closely related, their predictors are different. The current focus of the National Asthma Education and Prevention Program guidelines on the two separate domains of asthma control, impairment and risk, are supported by our analysis.

The relationship of asthma-specific quality of life during pregnancy to subsequent asthma and perinatal morbidity

OBJECTIVE

To determine whether asthma-specific quality of life during pregnancy is related to asthma exacerbations and to perinatal outcomes.

METHODS

This was a secondary analysis of data from a randomized controlled trial of inhaled beclomethasone versus theophylline in the treatment of moderate asthma during pregnancy. The Juniper Asthma Quality of Life Questionnaire (AQLQ) was administered to patients at enrollment. Exacerbations were defined as asthma symptoms requiring a hospitalization, unscheduled medical visit, or oral corticosteroid course.

RESULTS

Quality of life assessments were provided by 310 of the 385 participants who completed the study. There was more than a 25% decrease in the odds of a subsequent asthma exacerbation for every 1-point increase in AQLQ score for the overall score (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.55-0.96), emotion domain (OR 0.72, 95% CI 0.59-0.88), and symptoms domain (OR 0.73, 95% CI 0.57-0.94). These relationships were not significantly influenced by initial symptom frequency or forced expiratory volume in 1 s (FEV(1)). No significant relationships were demonstrated between enrollment AQLQ scores and preeclampsia, preterm birth, low birth weight, or small for gestational age.

CONCLUSION

Asthma-specific quality of life in early pregnancy is related to subsequent asthma morbidity during pregnancy but not to perinatal outcomes.

Predicting an asthma exacerbation in children 2 to 5 years of age

BACKGROUND

Asthma exacerbations in young children are prevalent. Identification of symptoms or other factors that are precursors of asthma exacerbations would be useful for early treatment and prevention.

OBJECTIVES

To determine whether diary symptoms and beta2-agonist use before an exacerbation could predict an asthma exacerbation in children 2 to 5 years of age.

METHODS

Post hoc analyses were conducted on data collected in a study of 689 patients 2 to 5 years of age with asthma symptoms, randomly assigned to montelukast, 4 mg, or placebo daily for 12 weeks. During the study, 196 patients had an exacerbation. Caregiver-reported information (daytime cough, breathing difficulties, limitation of activity, nighttime cough or awakening, daytime and nighttime beta2-agonist use) were analyzed using general estimating equations with an exchangeable within-subject log odds ratio regression structure to identify predictors of an exacerbation.

RESULTS

Average symptom scores and beta2-agonist use increased significantly before exacerbation but at different rates. A combination of daytime cough and wheeze and nighttime beta2-agonist use 1 day before the exacerbation was identified as strongly predictive of an exacerbation. These methods predicted 149 (66.8%) of the exacerbations with a very low false-positive rate of 14.2%.

CONCLUSIONS

No individual symptom was predictive of an imminent asthma exacerbation, but a combination of increased daytime cough, daytime wheeze, and nighttime beta2-agonist use 1 day before an asthma exacerbation was a strong predictor of an exacerbation in children.

Biomarkers related to aging in human populations

Biomarkers are increasingly employed in empirical studies of human populations to understand physiological processes that change with age, diseases whose onset appears linked to age, and the aging process itself. In this chapter, we describe some of the most commonly used biomarkers in population aging research, including their collection, associations with other markers, and relationships to health outcomes. We discuss biomarkers of the cardiovascular system, metabolic processes, inflammation, activity in the hypothalamic-pituitary axis (HPA) and sympathetic nervous system (SNS), and organ functioning (including kidney, lung, and heart). In addition, we note that markers of functioning of the central nervous system and genetic markers are now becoming part of population measurement. Where possible, we detail interrelationships between these markers by providing correlations between high risk levels of each marker from three population-based surveys: the National Health and Nutrition Examination Survey (NHANES) III, NHANES 1999-2002, and the MacArthur Study of Successful Aging. NHANES III is used instead of NHANES 1999-2002 when specific markers of interest are available only in NHANES III and when we examine the relationship of biomarkers to mortality which is only known for NHANES III. We also describe summary measures combining biomarkers across systems. Finally, we examine associations between individual markers and mortality and provide information about biomarkers of growing interest for future research in population aging and health.

Peak expiratory flow-guided self-management treatment of asthma in Serbia

The aims of this study were to compare the efficacy of 1-year peak expiratory flow (PEF)-based self-management of asthma against conventional treatment and to analyze the long-term effectiveness of self-management. Eighty adult patients with persistent asthma (group B). After 1 year, significant improvement was noted in markers of asthma severity in group A but there were no changes in group B. After 6 years of the self-management program, asthma morbidity and emergency use of health services were reduced. These results show short-term and long-term effectiveness of a PEF-based self-management program in persistent asthma.

[Self-management program in treatment of asthma]

INTRODUCTION

Recently published national and international guidelines stress the importance of self-management in asthma. They have recommended that self-management plans should be an essential part of the long-term management of asthmatic patients. These plans essentially focus on the early recognition of unstable or deteoriorating asthma, by monitoring peak flow or symptoms.

OBJECTIVE

The aim of our one-year study was to compare the efficacy of peak-flow based self-management of asthma with traditional treatment.

METHOD

Sixty clinically stable adult patients with mild and moderate persistent asthma were randomly allocated to peak-flow based self-management (Group A, n=30) or to conventional treatment (Group B, n=30), with no significant difference between groups in terms of age, sex distribution and initial lung function. The recorded measurements were: lung function, asthma exacerbations, unscheduled ambulatory care facilities (hospital-based emergency department, consultations with general practitioner or pulmonologist), courses of oral prednisolone, courses of antibiotics, days off work.

RESULTS

There was a significant difference between groups in number of asthma exacerbations (p < 0.05), unscheduled visits to ambulatory care facilities (p < 0.005), days off work (p < 0.0001), courses of oral prednisolone (p < 0.001) and antibiotics (p < 0.05). At the final visit, there was a significant improvement in some measurements of asthma severity in group A (reduced unscheduled visits for ambulatory care, reduced treatment requirements for oral corticosteroids and antibiotics, reduced days off work), but a lack of statistical difference in lung function and the maintenance-inhaled corticosteroid dose. There was no significant change in group B.

CONCLUSION

These results suggest that peak-flow based self-management is more effective than traditonal treatment in mild and moderate persistent asthma.

Validation of the asthma impact survey, a brief asthma-specific quality of life tool

BACKGROUND

The Asthma Impact Survey (AIS-6) is a new six question asthma outcome tool for which information on validity has not been published.

OBJECTIVE

To provide validation for the AIS-6 as a brief asthma-specific quality of life tool.

METHODS

Surveys were sent to a random sample of members of a large managed care organization who were at least 35 years of age and in the two-year period preceding the survey had either (1) at least one documented asthma-related medical encounter, or (2) at least a 6 months supply of asthma medication dispensed. In addition to the AIS-6, the survey included a validated quality of life tool [the mini-Asthma Quality of Life Questionnaire (AQLQ)]; a validated asthma control questionnaire [the Asthma Therapy Assessment Questionnaire (ATAQ)]; a validated symptom severity scale (AOMS); and information regarding demographics, co-morbidities, asthma severity, and asthma management. The results of the AIS-6 were compared to the results of the other tools by means of correlation and factor analysis. Independent predictors of AIS-6 and AQLQ scores were determined by multiple stepwise linear regression analyses.

RESULTS

AIS-6 scores were significantly related to female sex, educational level, income, smoking, body mass index (BMI), COPD, steroid use, and hospitalization history in bivariate analyses. The AIS-6 score significantly correlated (r = - 0.84, p < 0.0001) with the AQLQ total score and loaded on the three factors (activity, symptoms, and concern/bother) reflected by the survey information and on which the AQLQ also loaded. Significant but somewhat smaller correlations were found between the AIS-6 and the ATAQ (r = 0.70, p < 0.0001) and the AOMS (r = 0.55, p < 0.0001). Independent predictors were the same for the AIS-6 and AQLQ and included oral steroid use, COPD history, BMI, female sex, educational level, and hospitalization in the past year.

CONCLUSION

These data support the validity of the short six-question AIS-6 as an asthma-specific quality of life tool.

Effects of self-efficacy, social support and knowledge on adherence to PEFR self-monitoring among adults with asthma: a prospective repeated measures study

BACKGROUND

Long-term adherence to self-monitoring of peak expiratory flow rate (PEFR) is essential for early detection of declining lung function in individuals with asthma. Psychosocial and cognitive factors can influence adherence to PEFR self-monitoring behaviors.

OBJECTIVES

The specific aims of this prospective, repeated measures study were to: (1) determine the effects of asthma self-efficacy, perceived satisfaction with social support and asthma knowledge on adherence to PEFR self-monitoring behavior; and (2) examine whether adherence to PEFR self-monitoring mediates the effects of psychosocial/cognitive factors on lung function and asthma symptoms in adults with asthma.

DESIGN

Sixty-eight participants completed standardized questionnaires three times at baseline, 1 month, and 3 months and kept the records of PEFR self-monitoring behaviors twice a day. Data were analyzed using multiple linear regressions. Adherence rates to PEFR self-monitoring were 93.5% and 74.9% at 1 and 3 month, representing those who remained in the study (n=39). Other participants withdrew from the study.

FINDINGS

Both at 1 and 3 month, psychosocial/cognitive factors as a whole did not account for a significant variance in adherence to PEFR self-monitoring. Univariate analyses, however, indicated that baseline asthma self-efficacy and asthma knowledge at 1 month were significant independent predictors for adherence to PEFR self-monitoring at 3 month.

CONCLUSION

Adherence to PEFR self-monitoring did not mediate the effects of asthma self-efficacy, perceived satisfaction with social support, and asthma knowledge on lung function and asthma symptoms. Lung function was low, but participants reported low asthma symptoms, both of which remained stable over time. Because of a small sample size and high attrition, the findings of the study need to be interpreted with caution. Given the importance of long-term adherence to self-management in asthma and other chronic illnesses, factors influencing adherence need to be further investigated to set a basis for future interventions.