Asthma from childhood at age 21: the patient and his disease

Is childhood asthma associated with educational level and longest-held occupation?

Children with asthma can experience chronic morbidity that may interfere with education and career progression. The authors investigated retrospectively whether a history of childhood asthma is associated with educational level and longest-held occupation, by gender. Cross-sectional analysis included a nationally representative sample of 10,452 adults aged ≥20 years who participated in the US National Health and Nutrition Examination Survey (2001-2004). Logistic regression was used to assess associations between a childhood-asthma history and educational level, employment, and longest-held occupation. An estimated 6.9% of men and 5.8% of women had a childhood-asthma history. Persons with a childhood-asthma history tended to have a higher educational level than those with no asthma history. Among those who ever worked, and after adjustment for age and race/ethnicity, men with a childhood-asthma history were more likely to work in health-diagnosing occupations, other professional occupations, and as cooks; women with a childhood-asthma history were more likely to work in management-related, entertainment-related, and health service occupations. Compared with those with no asthma history, persons with a childhood-asthma history tended to achieve a higher educational level and, if they worked, were more likely to work in particular occupations.

Asthma and cigarette smoking: a review of the empirical literature

The purpose of this review paper is to present and evaluate the empirical literature on the association between asthma and cigarette smoking. The authors conducted a literature search utilizing electronic search engines (i.e., PsycINFO and MEDLINE) to examine databases using the following key word algorithms: smoking OR nicotine OR tobacco AND asthma. Only articles that focused on active tobacco smoking and analyzed groups with asthma patients only were examined in the present review. Overall, empirical evidence suggests that (1) smoking is more prevalent among individuals with asthma than those without; (2) smoking is a risk candidate for the development of asthma; (3) smoking is associated with decreased asthma control and increased risk of mortality and asthma attacks and exacerbations; (4) smokers with and without asthma may have different risk factors for smoking onset as well as different smoking motives and outcome expectancies; and (5) smoking cessation is associated with improvements in lung functioning and asthma symptoms. Future work in this domain of study will lead to clinically relevant health care advances as well as the development of theoretically driven, methodologically diverse lines of research exploring asthma-smoking comorbidity issues.

Perception of asthma as a factor in career choice among young adults with asthma

BACKGROUND/AIM

Asthma is a common chronic condition that can be aggravated by workplace exposures. Young adults with asthma should know how their future occupation might affect their asthma, and potentially, their quality of life. The aim of the present study was to assess the awareness of young adults to occupational risks for asthma and high-risk occupations, as well as their perception of the role of asthma in career choice.

METHODS

Young adults 16 to 22 years of age with reported physician-diagnosed asthma were recruited to complete a questionnaire eliciting information regarding asthma control, career choice and awareness of occupational exposure risks.

RESULTS

A small majority of the study cohort (56.4%) could identify occupations that cause or exacerbate asthma, and 34.7% indicated that asthma was an important factor in their career plans. Family physicians were most responsible for asthma management (80.2%), but young adults were more likely to discuss asthma and career plans with their parents (43.6%) or friends (29.7%) than with their family physician (13.9%; P<0.001).

CONCLUSION

Young adults with asthma have suboptimal awareness of potential work-related asthma risks. Family physicians most commonly provide asthma care to these young adults. However, few young adults are talking to their family physicians about career choices and asthma. This observation represents an area of asthma care that needs to be explored in young adults with asthma.

Ciclesonide versus other inhaled steroids for chronic asthma in children and adults

BACKGROUND

Inhaled corticosteroids (ICS) are an integral part of asthma management, and act as an anti-inflammatory agent in the airways of the lung. These agents confer both significant benefit in terms of symptom management and improvement in lung function, but may also cause harm in terms of local and systemic side-effects. Ciclesonide is a novel steroid that is metabolised to its active component in the lung, making it a potentially useful for reducing local side effects.

OBJECTIVES

To assess the efficacy and adverse effects of ciclesonide relative to those of other inhaled corticosteroids in the management of chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group register of trials with pre-defined terms. Additional searches of PubMed and Clinicalstudyresults.org were undertaken. The literature searches for this review are current up to June 2007.

SELECTION CRITERIA

Randomised parallel or crossover studies were eligible for the review. We included studies comparing ciclesonide with other steroids both at nominally equivalent dose or lower doses of ciclesonide.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

Twenty one trials involving 7243 participants were included. Equal daily doses of ciclesonide and beclomethasone (BDP) or budesonide (BUD) gave similar results for peak expiratory flow rates (PEF), although forced vital capacity (FVC) was higher with ciclesonide. Data on forced expired volume in one second (FEV1) were inconsistent. Withdrawal data and symptoms were similar between treatments. Compared with the same dose of fluticasone (FP), data on lung function parameters (FEV1, FVC and PEF) did not differ significantly. Paediatric quality of life score favoured ciclesonide. Candidiasis was less frequent with ciclesonide, although other side-effect outcomes did not give significant differences in favour of either treatment. When lower doses of ciclesonide were compared to BDP or BUD, the difference in FEV1 did not reach significance but we cannot exclude a significant effect in favour of BDP/BUD. Other lung function outcomes did not give significant differences between treatments. Paediatric quality of life scores did not differ between treatments. Adverse events occurred with similar frequency between ciclesonide and BDP/BUD. Comparison with FP at half the nominal dose was undertaken in three studies, which indicated that FEV1 was not significantly different, but was not equivalent between the treatments (per protocol: -0.05 L 95% confidence intervals -0.11 to 0.01).

AUTHORS' CONCLUSIONS

The results of this review give some support to ciclesonide as an equivalent therapy to other ICS at similar nominal doses. The studies assessed low doses of steroids, in patients whose asthma required treatment with low doses of steroids. At half the dose of FP and BDP/BUD, the effects of ciclesonide were more inconsistent The effect on candidiasis may be of importance to people who find this to be problematic. The role of ciclesonide in the management of asthma requires further study, especially in paediatric patients. Further assessment against FP at a dose ratio of 1:2 is a priority.

Ciclesonide versus placebo for chronic asthma in adults and children

BACKGROUND

Inhaled corticosteroids are an integral part of asthma management, and act as an anti-inflammatory agent in the airways of the lung. These agents confer significant benefit in terms of symptom management and improvement in lung function, but may also cause harm in terms of local and systemic side-effects. Ciclesonide is a novel steroid that has efficient distribution and release properties that mean it can be taken once daily, making it potentially useful in ongoing asthma management.

OBJECTIVES

To assess the efficacy of inhaled ciclesonide in adults and children with chronic asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group register of trials with pre-defined terms. Additional searches of CENTRAL and PubMed were undertaken. The literature searches for this review are current up to June 2007.

SELECTION CRITERIA

Randomised parallel or crossover studies were eligible for the review. We included studies comparing ciclesonide with placebo, and we also included studies comparing ciclesonide at different doses.

DATA COLLECTION AND ANALYSIS

Two authors assessed studies for inclusion in the review, extracted data independently and checked each others' work. We contacted study investigators in order to obtain additional data. Extracted data were entered into RevMan 4.2 and analysed as fixed effect mean differences for continuous data, and fixed effect risk ratios for dichotomous data.

MAIN RESULTS

Eighteen trials (reporting 20 study comparisons) met the review entry criteria. We report findings from 18 group comparisons where data were available (6343 participants, of whom 1692 were children). Ciclesonide versus placebo: The short duration of the included studies means that there is a lack of data with respect to the impact of ciclesonide on asthma exacerbations. At doses of 100 mcg/d or less up to 400 mcg/d in mild to moderate asthma, ciclesonide improved lung function, asthma symptoms and rescue inhaler use, compared with placebo.Dose response outcomes: Comparisons of 100 versus 200 mcg/d, 100 versus 400 mcg/d and 400 versus 800 mcg/d did not yield significant differences in lung function outcomes. Adverse event data were not available in sufficient detail to permit assessment of the safety profile of this drug.

AUTHORS' CONCLUSIONS

Ciclesonide was more effective than placebo, in the short term, in improving lung function in patients with mild to moderate asthma previously treated with inhaled corticosteroids. There remain questions as to dose response, and the lack of data on the longer term impact on exacerbations and safety profile should be addressed in future studies.

Smoking behavior in asthmatic and non-asthmatic adolescents: the role of smoking models and personality

Despite the particular health risks for asthmatics, recent international studies have reported that tobacco use among asthmatics is similar to, or even higher than, non-asthmatics. This study examined the role of personality and environment in smoking among asthmatic and non-asthmatic adolescents. In 2003 a random sample of 33 schools (first and second class of secondary education) was obtained in The Netherlands (N = 4,951). The mean age of the participants was 12.83 (SD = .75), and 52.8% were females. Information about asthma, smoking, personality, and environmental smoking was assessed via self-reports on standard epidemiology survey items (asthma, smoking) and the Quick Big Five (personality). Both personality and environmental smoking were associated with smoking. Asthmatics were similarly or even more exposed to environmental smoke than non-asthmatic adolescents and asthmatic adolescents were less emotionally stable and extravert. Associations between personality and own smoking behavior, as well as between smoking models and own smoking behavior were similar for asthmatic and non-asthmatics. Limitations of the study are taken notice of, and implications of the results are briefly discussed.

The global burden of asthma

There has been a sharp increase in the global prevalence, morbidity, mortality, and economic burden associated with asthma over the last 40 years, particularly in children. Approximately 300 million people worldwide currently have asthma, and its prevalence increases by 50% every decade. In North America, 10% of the population have asthma. Asthma is underdiagnosed and undertreated, although the use of inhaled corticosteroids has made a positive impact on outcomes. The increasing number of hospital admissions for asthma, which are most pronounced in young children, reflect an increase in severe asthma, poor disease management, and poverty. Worldwide, approximately 180,000 deaths annually are attributable to asthma, although overall mortality rates have fallen since the 1980s. Most asthma deaths occur in those > or = 45 years old and are largely preventable, frequently being related to inadequate long-term medical care or delays in obtaining medical help during the last attack. The financial burden on patients with asthma in different Western countries ranges from $300 to $1,300 per patient per year, disproportionately affecting those with the most severe disease. There are a number of significant barriers to reducing the burden of asthma, particularly in developing countries, where many patients have limited access to care and essential medications. The Global Initiative for Asthma has outlined a six-point patient management plan to address the effective handling of the increased number of patients in primary care. The plan focuses on patient education, written treatment plans, and ongoing communication and review with patients and their providers.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Development of pediatric pulmonology in the United Kingdom, Europe, and Australasia

The organization of medicine in Europe, the UK and the Commonwealth countries was always much less formal than in the USA for many years and pediatricians interested in pediatric lung disease and asthma often started off as adult internists or specialists in adult pulmonary medicine. The early leaders in developing a special interest in the breathing of children during the 1940s and 1950s were predominantly physiologists and clinicians who began to apply physiological techniques to the study lung function in healthy and sick infants and children. A major contribution to our understanding of the epidemiology of wheezing in children was the early establishment of a cohort study in Australia which is still yielding important information. It was during the early 1970s that pediatric pulmonary "politics" began to emerge in the UK when pediatricians interested in lung diseases began to arrange an informal society and meet regularly under the auspices of the British Paediatric Association. In fairly characteristic fashion, pulmonology in Europe was represented for a while by several different societies but due to the efforts of some dedicated enthusiasts there finally emerged the Paediatric Assembly of the European Respiratory Society (ERS) and its first Head, Max Zach, went to become President of the ERS itself. Despite some early doubts abut the future for pediatric pulmonology as a specialty in Europe and Australasia it is clearly flourishing as shown by the rising membership of the professional societies and the constant stream of high quality basic science and clinical publications.

The Melbourne Asthma Study: 1964-1999

A group of children with a past history of wheezing was randomly selected from the Melbourne community at the age of 7 years in 1964, and a further group of children with severe wheezing was selected from the same birth cohort at the age of 10 years. These subjects have been followed prospectively at 7-year intervals, with the last review in 1999, when their average age was 42 years. Eighty-seven percent of the original cohort who were still alive participated in the 1999 review. This study showed that the majority of children who had only a few episodes of wheezing associated with symptoms of a respiratory infection had a benign course, with many ceasing to wheeze by adult life. Most who continued with symptoms into adult life were little troubled by them. Conversely, those children with asthma mostly continued with significant wheezing into adult life, and the more troubled they were in childhood, the more likely symptoms continued. There was a loss in lung function by the age of 14 years in those with severe asthma, but the loss did not progress in adult life. The childhood asthma had been treated before the availability of inhaled steroids. There was no significant loss of lung function in those with milder symptoms.

Pathophysiological mechanisms of asthma. Application of cell and molecular biology techniques

Asthma is a common increasing and relapsing disease that is associated with genetic and environmental factors such as respiratory viruses and allergens. It causes significant morbidity and mortality. The changes occurring in the airways consist of a chronic eosinophilic and lymphocytic inflammation, together with epithelial and structural remodeling and proliferation, and altered matrix proteins, which underlie airway wall narrowing and bronchial hyperresponsiveness (BHR). Several inflammatory mediators released from inflammatory cells such as histamine and cysteinyl-leukotrienes induce bronchoconstriction, mucus production, plasma exudation, and BHR. Increased expression of T-helper 2 (Th2)-derived cytokines such as interleukin-4 and 5 (IL-4, 5) have been observed in the airway mucosa, and these may cause IgE production and terminal differentiation of eosinophils. Chemoattractant cytokines (chemokines) such as eotaxin may be responsible for the chemoattraction of eosinophils to the airways. The initiating events are unclear but may be genetically determined and may be linked to the development of a Th2-skewed allergen-specific immunological memory. The use of molecular biology techniques on tissues obtained from asthmatics is increasing our understanding of the pathophysiology of asthma. With the application of functional genomics and the ability to transfer or delete genes, important pathways underlying the cause if asthma will be unraveled. The important outcome of this is that new preventive and curative treatments may ensue.

Consequences of long-term inflammation. The natural history of asthma

Although asthma is classically defined as reversible airflow obstruction, and often remits in younger subjects with milder disease, the natural history of asthma is that various degrees of airflow obstruction may persist and, in the long-term, asthma may become moderately to fully irreversible. Severe, irreversible airflow obstruction may develop despite apparently appropriate therapy and in the absence of other risk factors, such as smoking and environmental insults. All studies of subjects with persisting asthma show increased decline in lung function compared with normal subjects. Persistent abnormal physiology is reflected both in reduced airflow rates and in increased airway responsiveness. The cellular and molecular mechanisms of airway remodeling are described elsewhere in this issue. Questions not yet clearly answered are the reasons for these persistent abnormalities in some asthmatics, and which subjects are most at risk. Factors that adversely impact the outcome as adults identified relatively consistently among many longitudinal studies of the natural history of asthma include: Female gender. Environmental tobacco smoke exposure in childhood. Personal tobacco smoking in adolescence and adulthood. Age of onset of symptoms. Severity of childhood asthma. Duration of asthma. Severity of lung function abnormality in childhood. Bronchodilator reversibility. Degree of airway hyperresponsiveness. Delay in initiating anti-inflammatory therapy. Remission among adult asthmatics is uncommon, but is associated with better initial lung function, young age, male gender, and lesser degrees of airway responsiveness. The role of atopy remains controversial. Conversely, risk factors for death from asthma include older age, smoking, atopy, impaired lung function, and moderate to high reversibility. Treatment can improve lung function, reduce airway responsiveness, and improve quality of life. The overall effect of treatment on the natural history of the disease is not yet clear, despite significant short-term improvements from effective anti-inflammatory therapy.

Corticosteroid-sparing options in the treatment of childhood asthma

During the last 30 years, a significant rise in wheezing illness has occurred in the child population. Despite its high prevalence there is no clear definition of the disease, which includes a heterogeneous group of syndromes ranging from transient wheezing in infancy to atopic asthma with persistence into adult life. Molecular advances and further epidemiological information from well characterised individuals and their families are likely to clarify the different subtypes of wheezing illness and inform therapeutic options. With the recognition that chronic airway inflammation is a feature of persistent disease, at least in adults, there has been a trend towards the early introduction of anti-inflammatory treatment and particularly inhaled corticosteroids (ICS). However, the natural resolution of much wheezing illness, particularly in young children and in children with viral-induced episodes, suggests that newly presenting children should remain on symptomatic therapy alone while the severity of the disease is being assessed. Although ICS have become a cornerstone of management of chronic persistent disease, their ability to protect against exacerbations in young and mildly affected children is questionable. Alongside concerns about long term use of ICS and possible systemic adverse effects, there remains a need for alternative approaches to the control of the disease in children. Extrapolation of the findings of large multicentre adult studies into childhood, particularly for doubling the doses of ICS and long-acting beta2-agonists, may be unsound. Other approaches include the early introduction of inhaled cromones, use of second generation antihistamines, low dose theophyllines and, more recently, leukotriene modifiers. As the majority of preschool children will become asymptomatic by mid-childhood, there is an urgent need to identify those in whom chronic airway inflammation is developing, as it is in this group that early introduction of ICS may be of maximum benefit. In the remainder, other approaches, including use of corticosteroid-sparing longacting P2-agonists and leukotriene modifying drugs, may be more appropriate. Safe and effective oral preparations such as leukotriene modifying drugs are likely to establish a significant role in the management of symptoms in children of all ages and with all types of asthma and wheezing illness.

Remission of asthma in the middle aged and elderly: report from the Obstructive Lung Disease in Northern Sweden study

BACKGROUND

Remission of asthma in adults has been considered to be low but is still not well documented. In children remission occurs with a rate estimated at approximately 50%. Remission of asthma in middle aged and elderly subjects was investigated as part of a population based study of respiratory diseases in Northern Sweden.

METHODS

In 1986 86% of 6610 subjects participated in a questionnaire survey. After a clinical validation study 300 subjects were diagnosed as having current asthma. In 1996 5935 subjects of the cohort could be traced for a third survey and 87% participated. Of the subjects with current asthma in 1986, 267 participated. In addition, 60 symptomatic subjects were classified as suspected asthma and 58 of them participated in 1996. Remission of asthma was defined as no recurrent wheeze, no attacks of shortness of breath, and no use of asthma medicines in 1996.

RESULTS

Remission of asthma during the 10 year period under study was 6%. In subjects with suspected asthma, remission occurred in 22%. The average annual remission rate was less than 1%. Remission was associated with previously mild disease and cessation of smoking.

CONCLUSION

Remission of asthma or the disappearance of its symptoms to an asymptomatic latent phase appeared to be rare in middle aged and elderly subjects.

Anti-IgE as novel therapy for the treatment of asthma

Immunoglobulin-E (IgE) is believed to be the central effector antibody reacting to allergen in patients with allergic asthma. Clinical manifestations of allergic asthma result from the release of chemical mediators from mast cells and basophils on exposure to allergen. A humanized murine monoclonal antibody to IgE, rhuMAb-E25, recognizes the specific Fc epsilon3 portion of circulating IgE that binds to the high-affinity IgE receptor, Fc epsilonRI. In clinical studies, single and multiple doses of subcutaneous and intravenous rhuMAb-E25 have been shown to reproducibly reduce the serum free IgE concentrations in a dose-dependent manner. Clinical trials conducted in aeroallergen bronchoprovocation laboratories demonstrated that decreasing circulating IgE resulted in significant attenuation of the early and late asthmatic responses. Studies completed in moderate to severe allergic asthmatics have extended the safety and efficacy of rhuMAb-E25. Significant improvements in asthma symptoms, meaningful reductions in corticosteroid agents while decreasing reliance on bronchodilator rescue drugs, decreased asthma exacerbations, and improved quality of life have been documented. Because of the remarkable protein engineering and the humanization technology now available, rhuMAb-E25 therapy has elicited no antibody responses and has been safely administered to atopic subjects. rhuMAb-E25 as a novel monoclonal antibody, the first to be applied to lung diseases, holds promise for the control of many IgE-mediated diseases.

Evolution of asthma through childhood

The greatest incidence of childhood asthma is among males under 5 years, with decreasing numbers of new cases with age. Many young children wheeze, but remission is common especially in non-atopic children without a family history of allergy or asthma, whose wheezing relates more to infections and environmental tobacco smoke exposure. The prognosis of childhood asthma is best established from population studies, in which some two-thirds of wheezy children become symptom-free as adults, whereas follow-up studies of wheezing children seen in office or specialty clinic practice, who generally have more severe asthma, show a much greater likelihood (60-80%) of persistence of asthma into adulthood. Factors predisposing to persistence of childhood asthma include a positive family history, development of atopy, environmental exposures to allergens and cigarette smoke, markers of severity of childhood asthma, and female gender.

Asthma, rhinitis and eczema in Maltese 13-15 year-old schoolchildren -- prevalence, severity and associated factors [ISAAC]. International Study of Asthma and Allergies in Childhood

BACKGROUND

Allergic conditions, especially asthma, seem to be increasingly common the world over. The International Study of Asthma and Allergies in Childhood [ISAAC] was the first worldwide study carried out with standardized questionnaires in order to create a reliable global map of childhood allergy.

OBJECTIVES

The Maltese Islands were one of the centres participating in this study and in this paper the data obtained from 4184 13-15 year olds from 22 state and three private schools [88.7% response rate], and also data obtained from some added 'local' questions addressed to the same children, are included. in order to evaluate the problem of allergic conditions in Maltese schoolchildren.

RESULTS

27.9% of the participants were wheezers 'ever' while 16% were current wheezers. Of the latter children 15.1% were experiencing nocturnal wheezing at least once a week and 22% had a wheezing episode severe enough to limit speech. Nasal problems were present in 52.7% of these teenagers and 47.4% of all respondents persisted with these symptoms up to the year of answering the questionnaire. Hayfever had been diagnosed in 32.3% of all the children. 12.8% of respondents had a recurring itchy rash suggestive of eczema for at least 6 months of their lives and 10% had it currently. This was slightly lower than the global mean, unlike the case of wheezing, which in Malta was more common than the world average, and rhinitis, for which we had the second highest cumulative prevalence rate in the world. Multiple variables such as gender, smoking, family history of atopy, pets, soft furnishings and living in busy roads affected the prevalence and severity of the allergic conditions studied.

CONCLUSIONS

Allergic conditions are very common in Maltese schoolchildren and are causing a lot of hardship to these same youngsters. The results of this study should serve as a stimulus to try and decrease this suffering through better management of these conditions, measures to control possible detrimental factors and further research on asthma, allergic rhinitis and eczema.

Effects of inhaled corticosteroids on growth

Inhaled corticosteroids are an established treatment for asthma in childhood. The risk of adverse events associated with conventional doses of inhaled corticosteroids is low, but in children with asthma concern remains about the potential effects of these compounds on growth. Short-term growth in children can be measured with knemometry. This technique measures changes in lower leg length that can be detected over periods as short as days or even intradaily. However, nonlinearity of lower leg growth and the complexity of statural growth confound any attempts to derive a predicted height from short-term measurements of the lower leg. Knemometry is better at detecting growth suppression than growth promotion. With knemometry, inhaled fluticasone propionate 200 microg/day had no effect on lower leg growth, but beclomethasone propionate 400 microg/day significantly reduced lower leg growth. Inhaled budesonide also caused a dose-dependent reduction in lower leg growth, but this only reached significance at the 800 microg/day dose. Long-term growth in children is measured with stadiometry. Growth velocity can only be determined from measurements of height taken over a period of at least 1 year. There is no evidence that inhaled corticosteroids at conventional doses have an adverse effect on the final height of children, but it is important to be aware of the growth-impairing effect of poorly controlled asthma. All children with asthma receiving inhaled corticosteroids should have their growth monitored, and any deviation from the expected pattern should be investigated. The effect of early intervention with inhaled steroids in childhood warrants further investigation.

Perceptions of the body interior by children with asthma and children with no known chronic disease

Comparatively little is known about how children perceive their internal bodies. In particular there is a lack of British studies, both of children's normal perceptions and in children experiencing chronic ill health. Such studies are important if information is to be given to children in the most effective way. The current study presents the results of an investigation of 72 children, 36 of whom were chronic asthma sufferers, whilst the others had no known chronic disease. Children at ages 5-6 years, 7-8 years and 10-11 years were asked to draw their internal body parts and to answer questions about the functioning of nine body organs. Data were analysed to examine the effect of age, sex and presence of asthma on the children's responses. Five-year-olds knew significantly less about their lungs than did other groups, boys identified muscle and ribs more frequently than girls, and there was an increase in levels of conceptualisation with age. There were no significant differences between asthmatic and non-asthmatic children. The findings are considered with particular reference to their importance for nursing practice.

Prognostic factors for the outcome of childhood asthma in adolescence

By the second decade of life asthma symptoms often abate and it may seem that patients with mild asthma have "outgrown" the disease. Unfortunately this is likely to be the exception rather than the rule. Although the severity of asthma symptoms fluctuates with time, the inherited tendency towards respiratory symptoms never disappears and many teenagers who seem to be free of symptoms do, in fact, have persistent asthma. During symptom-free periods subclinical, but nevertheless significant, airways obstruction and/or bronchial hyperresponsiveness may be present. It is not unusual for adults who have been asymptomatic for a number of years to redevelope asthma symptoms. Indeed, much of the so-called adult onset asthma has its roots in childhood. Levison concluded that, in these subjects, it is often not the asthma that is outgrown but the paediatrician. The more severe asthma is in childhood the more likely it is that the disease will persist in adulthood. A complete list of the characteristics of the disease in childhood, and the potential risk factors associated with an unfavourable prognosis, such as pulmonary function and bronchial responsiveness and markers of airway inflammation, is therefore needed. As properly matched and controlled prospective long term studies have not been published it has not been possible to evaluate the effects on prognosis of any single class of antiasthma agent. Such studies are needed to find out if it is possible to alter the natural history of the disease. In theory modern asthma treatments, because they are able to improve symptoms and underlying disease phenomena, are also beneficial in the long term prognosis of childhood asthma. The majority of patients with persistent asthma included in the currently available studies were not receiving adequate treatment. Since compliance with therapeutic regimens in asthma, especially in adolescence, is low, a monitoring system is needed to guarantee adequate follow up and treatment during and beyond puberty.

Prognosis of asthma in children: a cohort study into adulthood

Fifty-six children with asthma, randomly selected from a hospital clinic, were followed prospectively for 15 years from a median age of 9-24 years of age. Four follow-ups were performed and included scoring of the frequency of wheezing, the need for medication, admissions to hospital, spirometry, skin prick tests and RAST to common inhaled allergens, and evaluation of living conditions. One patient died of asthma. The remaining 55 reported for all follow-ups. After the second follow-up at a median age of 13 years, all parameters of severity of asthma showed improvement, which was significant at the last follow-up when all subjects were more than 20 years of age. Only 16% of the subjects had been free from wheezing and medication the year prior to the last follow-up. Approximately 90% of the children had clinical allergies and positive allergy tests to pollens and danders and the majority of children retained both the allergies and the reactivity into adulthood. Reactivity to moulds and mites was less frequent (40% and 31%, respectively) and seemed to decrease in adulthood. Approximately 10% of the subjects developed neither clinical allergies nor reactivity in allergy tests. Children with atopic eczema usually retained their eczema as adults. Frequent wheezing and abnormal spirometry in childhood and early onset of asthma were associated with poorer outcome. The social prognosis was excellent.

Medical treatment of asthmatic children before referral to a clinic for allergy. A comparison between the periods 1979-83 and 1988-91

The use of antiasthmatic agents in children before referral to a children's clinic for allergy was studied in two periods (1979-83 and 1988-91). In the latter period, in contrast to the former, significantly more children were treated with peroral (73 and 43%, respectively) or inhaled beta 2-agonists (40 and 22%, respectively). In addition, considerably more children in the latter than the former period were or had been treated with inhaled steroids. On the other hand, most children used these agents either in short courses (41%) or on demand (30%). We conclude that, although there have been intensive educational programs specifically focusing on the proper use of antiasthmatic drugs during the last 10 years, still more information is needed by general practitioners.

Risk factors for the persistence of respiratory symptoms in childhood asthma

We studied the prognosis of childhood asthma in a cohort of 406 children 8 to 12 yr of age when enrolled. Subjects were followed for a mean of 14.8 yr after their initial evaluation, with a follow-up rate of 86%. The mean age at follow-up was 24.7 yr. We assessed the predictive value of sex and various childhood variables on the outcome of symptoms and medication use in adulthood. Although only 19% of subjects were still under a physician's supervision at the time of follow-up, 76% had respiratory symptoms, 32% used maintenance medication, and 22% used medication intermittently. The incidence of cigarette smoking was disturbingly high (33%). In adulthood, women were more likely than men to have symptoms (85 versus 72%, respectively). The childhood symptom severity and the childhood degree of bronchial responsiveness in combination with a low %FEV1 were also related to the outcome of asthma in adulthood. The high prevalence of symptoms in adults at follow-up coupled with the low rate of physician supervision and medication usage suggest that more aggressive treatment may be indicated in asthmatic children.

Childhood asthma: diagnosis and treatment

This discussion of asthma management should be regarded as providing guidelines, not dogma. The underlying principles of asthma management include recognition of the variability of the disease and the importance of the underlying inflammatory condition. Clinical assessment is not enough and objective monitoring with PEFR or spirometry provides important data. The treatment protocols require individualization. It is important that the patient and family are team members working together with the medical staff toward a goal of good asthma management. In the discussion of the management of asthma, much emphasis was placed on spirometry and home measurement of PEFR. Office use of spirometry is now the norm for asthma management. Providing asthmatic patients with peak flow meters and instructions in their use is part of the routine care of asthma. Instruction of the patient and family in the proper use of medications is paramount. The MDI devices need to be prescribed with careful instructions regarding their use. When the patient comes in for follow-up, part of the examination should include the patient's demonstration of how he uses this device. Discussion of the proper and safe use of bronchodilators is important. Overuse of inhaled bronchodilators may be a reflection of increasing asthma or, at the very least, evidence that the patient does not understand appropriate treatment of asthma. If a patient is dependent on regular use of an inhaled beta agent, it is likely that he would benefit from therapy directed at the underlying inflammation of asthma. The patient and the family should understand the purpose of each medication, the side effects, and the risks and benefits of their use. In particular, if steroid medications are necessary, the reasons for their use should be explained. Carefully matching the severity of the asthma with the therapeutic protocols provides an organized approach to asthma treatment. Avoiding triggers of asthma and controlling the environmental exposure to potential triggers leads to lower medication requirements and less lability. Offering the family written instructions to cope with changes in the child's condition, based on assessment of clinical and PEFR observations, allows them more autonomy and comfort in the day-to-day care of the asthmatic child.

Crisis in asthma care

Reports of increases in both hospitalizations and deaths due to asthma have provided a sense of crisis in asthma care. This article examines issues concerning this sense of crisis. The authors review current trends in prevalence, morbidity, hospitalization, and mortality from asthma and examine possible reasons for changes that have occurred. A review of data suggesting that asthma can result in irreversible, chronic airway obstruction is presented. Finally, the authors discuss the role of the primary care physician in the management of asthma.

Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group

OBJECTIVE

To assess the feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners.

DESIGN

Randomised double blind parallel group trial of anistreplase 30 units intravenously and placebo given either at home or in hospital.

SETTING

29 rural practices in Grampian admitting patients to teaching hospitals in Aberdeen (average distance 36 (range 16-62) miles).

PATIENTS

311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic therapy seen at home within four hours of onset of symptoms.

MAIN OUTCOME MEASURES

Time saving, adverse events, Q wave infarction, left ventricular function.

RESULTS

Anistreplase was administered at home 101 minutes after onset of symptoms, while anistreplase was given in hospital 240 minutes after onset of symptoms (median times). Adverse events after thrombolysis were infrequent and, apart from cardiac arrest, not a serious problem when they occurred in the community: seven of 13 patients were resuscitated after cardiac arrest out of hospital. By three months after trial entry the relative reduction of deaths from all causes in patients given thrombolytic therapy at home was 49% (13/163 (8.0%) v 23/148 (15.5%); difference -7.6% (95% confidence interval -14.7% to -0.4%), p = 0.04). Full thickness Q wave infarction was less common in patients with confirmed infarction receiving treatment at home (65/122 (53.3%) v 76/112 (67.9%); difference -14.6% (95% confidence interval -27.0% to -2.2%), p = 0.02).

CONCLUSIONS

General practitioners provided rapid pre-hospital coronary care of a high standard. Compared with later administration in hospital, giving anistreplase at home resulted in reduction in mortality, fewer cardiac arrests, fewer Q wave infarcts, and better left ventricular function. Benefits were most marked where thrombolytic therapy was administered within two hours of the onset of symptoms.

Social effects of wheeze in childhood: a 25 year follow up

OBJECTIVES

To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class.

DESIGN

25 year follow up study.

SETTING

Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary.

PARTICIPANTS

Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study.

MAIN OUTCOME MEASURES

Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate.

RESULTS

Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups.

CONCLUSION

Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.

Effects of passive smoking on lung growth in children

The objective of this study was to determine the effects of passive smoking on functional lung growth in children and adolescents. It was hypothesized that passive smoking might reduce lung function growth, especially in susceptible children. The assumption was that those most susceptible would be children who started with low lung function, as it had been shown that they had slower growth of lung function, and start to decline earlier. There were 138 non-Hispanic Caucasian children and adolescents, ages 5 through 15, who had at least three satisfactory longitudinal lung function tests over a 13 year period in the Tucson epidemiological study of airway obstructive diseases. Those who started in childhood with normal function did not show any effect of passive smoking, nor did females who started with low lung function. Males starting with low lung function whose parents smoked showed definite changes. Their forced expiratory volume in 1 second (FEV1) grew even more slowly between ages 13 through 16, related primarily to continuous parental smoking. They also had higher rates of decline for FEV1 to forced vital capacity (FVC) ratio and maximum flow at 50% vital capacity to FVC ratios than either the low function group without passive smoking or the normal function groups. This was independent of any symptoms or diagnoses present in this male low function group.

Asthma and employment in young adults

BACKGROUND

Little is known about the effect of asthma on employment. The relation between employment history at the age of 23 years and a history of asthma or wheeze was investigated in a controlled prospective study using data collected in the National Child Development Study, a longitudinal survey of all children born in the United Kingdom in one week in March 1958.

METHODS

Information about subjects' medical condition was collected at four ages (7, 11, 16, and 23 years) for the original cohort of 17,319 births. At 23 years information about employment and education was obtained for 12,534 subjects (72%), of whom 460 (4%) had current asthma or wheeze, 2758 (22%) had past asthma or wheeze, and 5161 (41%) had never had asthma or wheeze. The remaining subjects could not be classified accurately.

RESULTS

The risk of unemployment was higher in subjects with a current history of asthma or wheeze (odds ratio 1.32, 95% confidence interval (CI) 1.09-1.61) or a past history of asthma or wheeze (odds ratio 1.54, 95% CI 1.27-1.85) than in those with no such history, after subjects' sex, region of birth, maximum educational qualification, and father's social class had been controlled for. Current and past asthma or wheezing illness predicted a worse employment history in terms of most of the outcomes examined, including mean percentage of months employed since leaving school, mean number of months in current full time job, mean percentage of months unemployed since leaving school, likelihood of being out of the labour force owing to long term illness, and the proportion attaining social groups 1-3. The differences from those who had never had asthma or a wheezing illness were, however, small and generally non-significant.

CONCLUSION

Asthma has only a small adverse effect on employment in young adults.

Characteristics of attenders and non-attenders at an asthma education programme

BACKGROUND

A controlled trial of asthma education was conducted but only 51 out of 164 eligible patients participated.

METHODS

Differences between subjects who participated in the trial and those who expressed initial interest but subsequently declined were studied.

RESULTS

Women, non-smokers, and those whose attending physician was concerned in the study were significantly more likely to attend the programme. Higher socioeconomic status was associated with greater attendance, but this did not reach significance. Psychosocial malfunctioning due to asthma was also associated with attendance, but this was not significant when sex and education level were taken into account. There was no difference between attenders and non-attenders with respect to age, number of previous admissions, airway function, self reported asthma severity, knowledge about asthma, and self management practices.

CONCLUSION

The results suggest that many asthmatic patients recovering from a severe exacerbation of airflow obstruction will not participate in hospital based health education programmes. Alternative strategies may be required to improve the self management behaviour of these patients.

Determinants and regulating processes in bronchial hyperreactivity

Bronchial hyperresponsiveness (BHR) can be considered as a feature of asthma, although only a loose relationship is present with symptoms and severity of the disease. Epidemiology of BHR may inform about determining factors in BHR and its role as a risk factor. BHR is found already at a young age, mostly diminishes with age, and increases in many asthmatic patients after midlife. Genetic determinants are suggested by familial segregation and twin studies. Allergy, respiratory infections, and cigarette smoking are found to induce increase in BHR and to modify its degree at the long run. The mechanisms in BHR are being unraveled gradually. A chronic inflammation with an important role for eosinophils, mast cells, and others, is thought to modify bronchial mechanisms, such as smooth muscle, epithelium, and autonomic systems. Growing evidence supports that T lymphocytes are implicated and may determine many of the inflammatory cells, such as eosinophils, neutrophils, and mast cells.

Differential rates of lung growth as measured longitudinally by pulmonary function in children and adolescents

A sample population of 67 males and 71 females with longitudinal lung function and other anthropometric measurements from all non-Hispanic white children in the Tucson Epidemiological Study of Airway Obstructive Diseases (AOD) was studied to evaluate biological determinants of the rate of lung growth. Groups within gender were defined by the following factors: 1) maximum height, 2) age at maximum forced expiratory volume at 1 second (FEV1), 3) % predicted initial FEV1 or FEV1/FVC ratio. Only groups defined by low initial function (FEV1 or FEV1/FVC less than or equal to 85% predicted versus greater than 85% predicted) showed statistically significant differences from those with more "normal" function by comparing their maximum % of predicted FEV1s and FEV1/FVC ratios. The longitudinal FEV1 data by age for the latter groups were characterized by a mathematical model (polynomial smoothing spline) yielding optimal fitted curves and an estimate of each group's growth velocity curve. The statistical comparisons between these fitted curves indicate that subjects with low initial pulmonary function continued to have significantly lower FEV1 values for males older than 13.12 years and for females between 8.23 and 15.3 years. At post-hoc analysis persistent wheezing was more likely in the initially more impaired group. Disease at the end of follow-up was not related to initial functional status.

An audit of morbidity associated with chronic asthma in general practice

A survey of 312 adult asthmatic subjects has been undertaken. Only 3.5% of the total adult list were known to have asthma and this may represent underdiagnosis. Spirometry was normal in under half the patients and below 50% predicted in one fifth. Forced expired volume in 1s had declined more rapidly than expected with increasing age, particularly amongst smokers. Morbidity from asthma was extensive, patients reporting substantial breathlessness and restrictions of their life style; nearly half had lost time from work in the preceding twelve months. Morbidity was correlated with spirometry.

Asthma as a link between chest illness in childhood and chronic cough and phlegm in young adults

The link between chest illnesses in childhood to age 7 and the prevalence of cough and phlegm in the winter reported at age 23 was investigated in a cohort of 10,557 British children born in one week in 1958 (national child development study). Both pneumonia and asthma or wheezy bronchitis to age 7 were associated with a significant excess in the prevalence of chronic cough and phlegm at age 23 after controlling for current smoking. This excess was largely attributable to the association of cough and phlegm at age 23 with a history of asthma or wheezy bronchitis from age 16. When adjustment was made for recent wheezing, current cigarette consumption, previous smoking habit, and passive exposure to smoke the relative odds of cough or phlegm, or both, in subjects with a history of childhood chest illness was 1.11 (95% confidence interval 0.97 to 1.27). When analysed separately asthma, wheezy bronchitis, and pneumonia up to age 7 did not significantly increase the prevalence of either cough or phlegm. The explanation for the observed continuity between chest illness in childhood and respiratory symptoms in later life may lie more in the time course of functional disturbances related to asthma than in the persistence of structural lung damage.

Illness experience and related knowledge amongst children with asthma

Forty-nine children with asthma (aged 7-16 years) completed a questionnaire concerned with (1) general knowledge about the body and how it works, and (2) specific knowledge about the cause and prognosis of asthma, knowledge of allergens and self-care behaviours. Compared with a matched group of healthy children, they were less well-informed about general knowledge of the body. Knowledge of asthma was also poor. Few children made any specific attempts to avoid situations known to precipitate attacks. There was no significant increase with age in knowledge of allergens or awareness of how to control attacks. The results indicate a need to make asthmatic children more aware of their illness, particularly with regard to self-care.

Childhood asthma in adult life: a further study at 28 years of age

A group of 323 subjects who had wheezed in childhood and 48 control subjects of the same age were studied prospectively from 7 to 28 years of age. A classification system based on wheezing frequency was found to correlate well with clinical and spirometric features of airway obstruction. The amount of wheezing in early adolescence seemed to be a guide for severity in later life with 73% of those with few symptoms at 14 continuing to have little or no asthma at 28 years. Similarly 68% of those with frequent wheezing at 14 still suffered from recurrent asthma at 28 years. Most subjects with frequent wheezing at 21 continued to have comparable asthma at 28 years. Of those with infrequent wheezing at 21, 44% had worsened at 28 years. Women fared better than men between 21 and 28 with 19% having worse symptoms compared with 28% of men. Treatment at all ages was generally inadequate. The number of smokers among those with asthma was of concern.

Assisting the parent of a child with asthma

The parents of an asthmatic child are frequently faced with complex decisions that have to take into account the child's asthma as well as more general developmental needs. At times these parents may feel overwhelmed and doubt their ability to make reasonable decisions. If there is discomfort with some aspect of the treatment plan, the parents may remain silent. Denial, minimization, anger, withdrawal and noncompliance may occur. This paper offers suggestions for practicing pediatricians in regard to helping parents cope more effectively with childhood asthma. Specific issues dealt with are discipline, school issues, athletic participation, maintenance of the child's peer relationships, avoiding parental conflict, the use of support systems, behavioral aspects of medical management, and when to refer for psychiatric consultation.

Parental perceptions and attitudes toward asthma and its treatment: a controlled study

We compared the attitudes of parents of 128 asthmatic children with those of 110 control children. The majority of both groups of parents had negative perceptions of the impact of asthma on children, but control parents were significantly more pessimistic. Control parents were also significantly more pessimistic than asthma parents about the impact of asthma on family lifestyle and relationships. In contrast, both groups were remarkably concordant in their ambivalence towards compliance with medication, recognising the necessity and efficacy of drug therapy, and yet worried about its long term effects on children. Both groups were also concordant in their readiness to give up household pets but not cigarette smoking for the sake of asthmatic children. Physician awareness of parental and community perceptions of childhood asthma may contribute to improved compliance with medications.

A prospective study of the natural history of asthma. Remission and relapse rates

In this longitudinal study of a general population sample, remissions of asthma were common only during the second decade of life and were especially unusual in subjects ages 30 to 60 years on enrollment. Asthmatic subjects with severe symptoms, with reduced ventilatory function, or with a concomitant diagnosis of chronic bronchitis or emphysema on entry to the study were very unlikely to be in remission nine years later. Relapses of disease were common in subjects with a past history of asthma who were considered to be quiescent on enrollment to the study. Relapse rates tended to increase with age, at least up to the age of 70. Relapses were especially frequent among those "ex-asthmatics" who had persisting respiratory symptomatology on entry to the study.