Age is not associated with hospital admission or uncontrolled symptoms of asthma if proper treatment is offered

Handgrip strength as a diagnostic tool for frailty risk in elderly patients with moderate to severe asthma

OBJECTIVE

To evaluate handgrip strength (HGS) as a diagnostic tool for frailty risk in elderly patients with asthma, as well as to investigate the prevalence of frailty in this population.

METHODS

This was a cross-sectional study including 96 patients ≥ 60 years of age diagnosed with moderate to severe asthma and treated at a tertiary referral center in Brazil. We measured HGS using a calibrated hydraulic hand dynamometer. We used a frailty scale and the AUC to assess the diagnostic accuracy of the HGS test.

RESULTS

The median age of participants was 67 years. Most (78%) were women and non-White (91%) of low socioeconomic status. HGS identified those at risk for frailty, with an AUC of 71.6% (61.5-80.4%; p < 0.002), as well as a sensitivity of 73.58% and a specificity of 67.53%, on the basis of a cutoff of ≤ 19 kgf.

CONCLUSIONS

HGS appears to be a simple, reliable tool for clinicians to determine frailty risk in older asthma patients in a point-of-care setting.

Evaluating the effect of childhood and adolescence asthma on the household economy

OBJECTIVE

To evaluate the relationship between asthma control, family income and family costs of asthma in a population of children-adolescents; to detail the family costs of asthma in this age range; and to compare asthma costs for the families of children-adolescents and adults.

METHODS

The authors invited asthmatic subjects who attended a scheduled spirometry test at the Jundiaí School of Medicine (FMJ). The FMJ performs all spirometry tests requested by staff physicians who serve at the public healthcare system in the municipality. Volunteers responded to the ACQ, the Asthma Family Costs Questionnaire and underwent a spirometry test.

RESULTS

The authors included 342 children-adolescents. Families of children-adolescents taking maintenance therapy and families of those reporting uncontrolled asthma symptoms were more likely to report any expenditure with asthma during the preceding month. In this age range, the smallest expenditures were on diagnostic tests and medical consultations, while home expenditures to avoid asthma triggers were the highest ones. As compared to adults' families, the children and adolescents families reported a greater proportion of income committed with asthma. Expenditures with transportation to healthcare facilities for asthma care were greater in the families of children-adolescents as compared to the values reported by the adults' families; in contrast, loss of income due to asthma was smaller in the families of children-adolescents.

CONCLUSIONS

Children-adolescents' asthma affects the household economy. The authors believe researchers should assess this outcome when designing studies about asthma. Finally, the study's data support the necessity of public policies in low-resource communities to minimize the economic impact of children and adolescents' asthma.

Asthma control in Brazil: a systematic review

Objectives: To explore asthma control in patients undergoing pharmacotherapy on studies in the last 20 years in Brazil. Asthma is a chronic airway inflammation disease with a high prevalence worldwide. Even with a variety of drug treatment improvements, attaining asthma control is challenging, since it should have a personalized approach. In Brazil, studies on the prevalence of asthma control are scarce and usually from a small sample size.Data Sources: A systematic review was performed to assess asthma control in Brazilian population. Terms related to "asthma", "asthma control" and "Brazil" were used in the search strategies in PubMed, BVSalud, Embase and Cochrane Library, including Brazilian Journal of Allergy and Immunology as data sources. A narrative synthesis was performed to report key outcome.Study Selections: In total, 23 studies were included. Most of them were conducted in the Southeastern and Northeast regions, in a short duration.Results: Pediatric and non-pediatric population were assessed, with a higher proportion of female. In pediatric population, those with poorly controlled asthma usually had severe or persistent disease. In elderly, an increased asthma severity was found, although proper treatment might be effective. Most studies (70%) also described exacerbations, hospitalizations (48%), quality of life (39%), and emergency visits (30%). Despite heterogeneity of outcomes and population, studies show an important prevalence of uncontrolled asthma even in patients being treated, with better disease control with treatment improvements.Conclusions: Studies in Brazil have shown that asthma control remains a challenge and there is still a need for improvement on disease management.

Impact of frailty in elderly patients with moderate to severe asthma

Frailty assessment has been identified as critical approach in chronic respiratory diseases with substantial impact in the health status and functionality in later life. Aging modifies the immune response leading to a chronic pro-inflammatory state and increased susceptibility to airway infections. Since epigenetic changes, airway epithelium dysfunction and inflammatory cytokine activity seem to be more pronounced in the immunosenescence, elderly asthmatics are at higher risk of poor clinical outcomes. Therefore, we hypothesize that frailty would be associated with the degree of asthma control in elderly patients with moderate to severe asthma. The aims of this study are to investigate association between frailty and asthma control in patients over 60 years old to estimate the prevalence of frailty in this study population. We plan to conduct a cross-sectional study with at least 120 patients above 60 years old with diagnostic of moderate to severe asthma according to Global Initiative for Asthma (GINA) guidelines, treated at a referral outpatient clinic. We defined asthma control by the six-domain Asthma Control Questionnaire (ACQ-6) and frailty phenotype in accordance with Fried scale and visual scale of frailty (VS-Frailty). We hope to analyze the multidimensional relationships between frailty and asthma and contribute to innovative therapeutic plans in geriatric asthma.

Asthma in elderly is characterized by increased sputum neutrophils, lower airway caliber variability and air trapping

BACKGROUND

Elderly asthmatics represent an important group that is often excluded from clinical studies. In this study we wanted to present characteristics of asthmatics older than 70 years old as compared to younger patients.

METHODS

We conducted a retrospective analysis on a series of 758 asthmatics subdivided in three groups: lower than 40, between 40 and 70 and older than 70. All the patients who had a successful sputum induction were included in the study.

RESULTS

Older patients had a higher Body Mass Index, had less active smokers and were more often treated with Long Acting anti-Muscarinic Agents. We found a significant increase in sputum neutrophil counts with ageing. There was no significant difference in blood inflammatory cell counts whatever the age group. Forced expiratory volume in one second (FEV1) and FEV1/FVC values were significantly lower in elderly who had lower bronchial hyperresponsiveness and signs of air trapping. We found a lower occurrence of the allergic component in advanced ages. Asthmatics older than 70 years old had later onset of the disease and a significant longer disease duration.

CONCLUSION

Our study highlights that asthmatics older than 70 years old have higher bronchial neutrophilic inflammation, a poorer lung function, signs of air trapping and lower airway variability. The role of immunosenescence inducing chronic low-grade inflammation in this asthma subtype remains to be elucidated.

Impact of asthma control on different age groups in five Latin American countries

Background

Asthma is a chronic airway inflammatory condition of the airway and is classified as controlled, partially controlled, and uncontrolled. Patients with uncontrolled asthma are at greater risk for hospitalizations and visits to emergencies, and the condition has greater impact on their daily lives. The aim of this study was to evaluate asthma control, the use of health resources, and asthma's impact on the activities of daily living of patients with different age groups in 5 Latin American countries.

Methods

This was a retrospective analysis of The Latin America Asthma Insights and Management (LA AIM) study carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Asthmatics were splited into 3 age groups: 12–17, >17–40 and > 40 years old. An interview face to face was carried out and patients answered a questionnaire of 53 questions related to 5 main domains of asthma: symptoms, impact of asthma on daily living activities, patients' perceptions of asthma control, exacerbations, and treatment/medication.

Results

A total of 2167 asthmatics were interviewed. There was a low percentage of controlled patients (mean 9%) in all 3 groups with no particular difference among the five countries, but Venezuelan patients had a 71% chance of having uncontrolled asthma (p < 0.001).

Conclusion

In the 3 age groups, patients experienced poor asthma control, with no significant differences among the countries. Patients who used control medication had a greater chance of controlling their asthma, and those who had emergency health care visits had a greater chance of having uncontrolled asthma.

Provision of inhaled corticosteroids is associated with decrease in hospital admissions in Brazil: A longitudinal nationwide study

OBJECTIVE

To describe trends of hospital admissions due to asthma from 2008 to 2015 and to evaluate their relationship with trends of inhaled corticosteroids (ICS) provision by the government in Brazil.

METHODS

We used Brazilian Government data to calculate hospital admission rates due to asthma, number of physicians, number of hospital beds, number of subjects that received ICS per 100,000 inhabitants in Brazil and in each of its municipalities for each year of the study. We performed Poisson Multilevel Regression Analyses to evaluate the relationship between the trends of hospital admission rates due to asthma with the trends of the number of subjects that had been receiving ICS during the study period. The analyses were adjusted for the number of physicians and hospital beds.

FINDINGS

The number of patients who received ICS/100,000 inhabitants increased from 2008 to 2015 (943.9-1988.5). Hospital admissions/100,000 inhabitants decreased in patients aged 5-14 years (148.3-110.9) and in patients aged 15-39 years (59.9-32.3); the reduction was greater in municipalities in which ICS provision increased. The number of physicians/100,000 inhabitants increased and the number of hospital beds/100,000 inhabitants decreased in the study period. The increase in the number of physicians and in the number of subjects that received ICS were associated with reduction in hospital admissions.

CONCLUSION

We found that provision of ICS by the Brazilian Government was associated with a decrease of hospital admissions for asthma in the municipalities and country levels from 2008 to 2015.

Is a low level of education a limiting factor for asthma control in a population with access to pulmonologists and to treatment?

OBJECTIVE

To determine whether a low level of education is a risk factor for uncontrolled asthma in a population of patients who have access to pulmonologists and to treatment.

METHODS

This was a cross-sectional study involving outpatients > 10 years of age diagnosed with asthma who were followed by a pulmonologist for at least 3 months in the city of Jundiai, located in the state of São Paulo, Brazil. The patients completed a questionnaire specifically designed for this study, the 6-item Asthma Control Questionnaire (to assess the control of asthma symptoms), and a questionnaire designed to assess treatment adherence. Patients underwent spirometry, and patient inhaler technique was assessed.

RESULTS

358 patients were enrolled in the study. Level of education was not considered a risk factor for uncontrolled asthma symptoms (OR = 0.99; 95% CI: 0.94-1.05), spirometry findings consistent with obstructive lung disease (OR = 1.00; 95% CI: 0.99-1.01), uncontrolled asthma (OR = 1.03; 95% CI: 0.95-1.10), or the need for moderate/high doses of inhaled medication (OR = 0.99; 95% CI: 0.94-1.06). The number of years of schooling was similar between the patients in whom treatment adherence was good and those in whom it was poor (p = 0.08), as well as between those who demonstrated proper inhaler technique and those who did not (p = 0.41).

CONCLUSIONS

Among asthma patients with access to pulmonologists and to treatment, a low level of education does not appear to be a limiting factor for adequate asthma control.

Asthma in the older adult

Objective: The older adult population is increasing worldwide, and a significant percentage has asthma. This review will discuss the challenges to diagnosis and management of asthma in older adults. Data Sources: PubMed was searched for multiple terms in various combinations, including asthma, older adult, elderly, comorbid conditions, asthma diagnosis, asthma treatment, biologics and medication side effects, and adverse events. From the search, the data sources that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Study Selections: Study selections that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Results: Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital. Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting β-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Conclusions: The diagnosis and management of asthma in older adults has certain challenges, but if the clinician is aware of them, the morbidity and mortality of this condition can be improved in this growing population.

Association between periodontitis and severe asthma in adults: A case-control study

OBJECTIVE

To evaluate the association between periodontitis and severe asthma, with participants in treatment for severe asthma, controlled by therapy.

METHODS

A case-control investigation was performed to compare 130 adults with severe asthma with 130 without asthma. Individuals with periodontitis were those with ≥4 teeth with ≥1 site with probing depth ≥4 mm, clinical attachment level ≥3 mm, and bleeding upon probing at the same site. Severe asthma diagnosis was based on Global Initiative for Asthma criteria.

RESULTS

Association between exposure to periodontitis and severe asthma was found: OR_crude  = 2.98 (95% CI: 1.74-5.11). When confounders were considered, the association between exposure to periodontitis and severe asthma was maintained: OR_adjusted  = 3.01-3.25. Individuals with periodontitis had about a threefold increased risk of severe asthma than those without periodontitis. Frequency of periodontitis in participants with severe asthma was greater than that of those without asthma (46.6% vs 22.3%, p ≤ .05).

CONCLUSIONS

Association between periodontitis and severe asthma was observed. Further investigation is required to determine the direction of this relationship. It may be causal, but it may also be a consequence of the immunopathological process that characterizes asthma, or else, consequence of the medication used for treatment.

Comparative Clinical, Physiological, and Inflammatory Characteristics of Elderly Subjects With or Without Asthma and Young Subjects With Asthma

BACKGROUND

Asthma seems to present in the elderly as a specific phenotype that remains to be further described. In this prospective observational study, we aimed to assess the multidimensional aspects of asthma in the elderly.

METHODS

In young (18 to 35 years old) subjects with mild to moderate asthma and elderly subjects (aged ≥60 years) either with or without mild to moderate asthma, we compared asthma control, health care and medication use, lung function, markers of airway and systemic inflammation, and adherence to therapy.

RESULTS

Fifty subjects were recruited in each group. Elderly people with asthma showed more marked airway obstruction compared with young people with asthma and elderly people without asthma. They also had poorer asthma control, mainly associated with a lower FEV₁, compared with young people with asthma, although airway responsiveness, health care use, prescribed doses of inhaled corticosteroids, and adherence to treatment were similar in both groups. Elderly subjects had an increase in some markers of systemic inflammation and bronchial epithelial dysfunction compared with young people with asthma. Blood eosinophils were higher in both asthma groups, particularly in elderly people with asthma. Sputum neutrophils were increased in both groups of elderly subjects and sputum eosinophils were increased in elderly people with asthma compared with the other two groups.

CONCLUSIONS

Asthma in the elderly presents as a specific phenotype associated with increased airway obstruction and mixed airway inflammation in addition to signs of systemic inflammation.

Age is associated with asthma phenotypes

BACKGROUND AND OBJECTIVE

The relationship between age and asthma phenotypes is important as population is ageing, asthma is becoming common in older ages and recently developed treatments for asthma are guided by phenotypes. The aim of this study is to evaluate whether age is associated with specific asthma phenotypes.

METHODS

This is a cross-sectional study. We included subjects with asthma of varied degrees of severity. Subjects underwent spirometry, skin prick test to aeroallergens, answered the Asthma Control Questionnaire and had blood samples collected. We performed binary logistic regression analysis to evaluate whether age is associated with asthma phenotypes.

RESULTS

We enrolled 868 subjects. In comparison with subjects ≤ 40 years, older subjects had high odds of irreversible airway obstruction (from 41 to 64 years, OR: 1.83 (95% CI: 1.32-2.54); ≥65 years, OR: 3.45 (2.12-5.60)) and severe asthma phenotypes (from 41 to 64 years, OR: 3.23 (2.26-4.62); ≥65 years, OR: 4.55 (2.39-8.67)). Older subjects had low odds of atopic (from 41 to 64 years, OR: 0.56 (0.39-0.79); ≥65 years, OR: 0.47 (0.27-0.84)) and eosinophilic phenotypes (from 41 to 64 years, OR: 0.63 (0.46-0.84); ≥65 years, OR: 0.39 (0.24-0.64)).

CONCLUSION

Older subjects with asthma have low odds of atopic and eosinophilic phenotypes, whereas they present high odds of irreversible airway obstruction and severe asthma.

Longitudinal trends in clinical characteristics and lung function of patients with severe asthma under treatment in Brazil

BACKGROUND

The structural changes of the respiratory system related to ageing determine lung function decline in healthy subjects after 25 years of age. An annual reduction of 25 ml in Forced Expiratory Volume in 1 s (FEV1) is expected. We aimed to describe the longitudinal lung function variation of subjects with severe asthma receiving appropriate treatment.

METHODS

Consecutive patients enrolled in a Brazilian reference clinic between 2003 and 2006 were invited to participate. The study participants were followed up for a median of 8 years, and were evaluated with spirometry in three distinct occasions (V0, V1 and V8), at least. At V0, upon enrollment, subjects with previous severe untreated asthma were evaluated by a specialist, had their health resource utilization in the last 12 months recorded, and performed spirometry. In V1, 1 year after V0, under proper management, subjects repeated the procedures and answered the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ). In the last study visit (V8), 7 years after V1, all patients underwent a pre and post-broncodilator (postBD) spirometry, skin prick test for aeroallergens, answered the ACQ and the AQLQ and had another interview with the specialist.

RESULTS

Two hundred thirty-four subjects were followed up between V0 and V8. A comparison between spirometries of V1 and V8, after the initial improvement has supposedly reached a plateau, shows that the FEV₁ and FVC declined significantly both in absolute and percent of predicted values. FEV_1postBD did not change significantly between V0 and V1, but declined by -27.1 (-51.1-1.4) ml/yr between V1 and V8.

CONCLUSIONS

Currently available treatment with a combination of inhaled corticosteroids and LABA may not be sufficient to prevent lung function decline in subjects with severe asthma.

Abnormal vocal cord movement in patients with and without airway obstruction and asthma symptoms

BACKGROUND

Abnormal vocal cord movements can cause laryngeal extrathoracic airway obstruction (often called vocal cord dysfunction - VCD) leading to asthma-like symptoms. These aberrant movements are characteristically present during inspiration and termed paradoxical vocal cord movement (PVCM). We have reported PVCM in up to 40% of severe asthmatics, but it is not known if PVCM is detectable in all patients with asthma-like symptoms and if the condition is more often associated with abnormal lung function.

OBJECTIVE

We hypothesized that PVCM is frequently associated with asthma symptoms accompanied by airflow limitation. Studies examined whether PVCM is solely linked to experiencing asthma symptoms, or if PVCM is related to airflow limitation and/or other disease characteristics.

METHODS

Patients with asthma symptoms were recruited from general practice and severe asthma clinics (n = 155). Pulmonary function measurements were conducted, asthma control and Nijmegen (dysfunctional breathing) questionnaires were administered and skin prick testing was carried out. PVCM was quantified using dynamic 320-slice computerized tomography of the larynx. Groups were divided into patients with FEV₁ ≥ 80% predicted or FEV₁ < 80% predicted and FEV₁ /FVC < 0.7. ATS/ERS definitions of severity were also applied and evaluated. Detection of PVCM in the groups was compared and analyses performed to identify features associated with PVCM.

RESULTS

Overall (n = 155), PVCM was detected in 42 cases (27.1%). Patients with FEV₁ < 80% predicted had PVCM more often (25/68, 36.8%) than individuals with normal spirometry (17/87, 19.5%; P = 0.016). PVCM was associated with older age (P = 0.003) and with Nijmegen scores > 20 (P = 0.04). Patients with FEV₁ < 80% predicted plus Nijmegen scores > 20 were more likely to have PVCM (OR = 9.3, P = 0.02).

CONCLUSIONS AND CLINICAL RELEVANCE

Paradoxical vocal cord movement is more often associated with asthma symptoms accompanied by airflow limitation and dysfunctional breathing. Further studies are needed to determine whether PVCM is induced by dysfunctional breathing practices and/or airway obstruction. How PVCM links with symptomatic asthma and VCD also requires evaluation.

Profile of Pneumopathic Elderly Persons Admitted to a Pulmonary Rehabilitation Center

Abstract Introduction: Pneumopathies are defined as a group of respiratory diseases. Physiotherapy centers are a conventional treatment option which can help prevent and treat various pulmonary conditions. Objective: To characterize elderly persons with pneumopathies admitted for pulmonary rehabilitation. Methods: 84 elderly persons were admitted for pulmonary rehabilitation. Patients diagnosed with pulmonary disease and aged ≥60 years were included in the study. The following variables were analyzed: gender, age, marital status, profession, medical diagnosis, main medical complaint, associated diseases, and cardiovascular risk factors. Results: The most common lung disease is chronic obstructive pulmonary disease (COPD) (26.2%). Women showed a greater association with asthma [odds ratio (OR)=5.875; p=0.010]. Dyspnea was the most prevalent main complaint among this population (50%). Among the main complaints, difficulty walking was more associated with men (OR=2.85; p=0.055). Strokes were the main disease most commonly associated with pneumopathies (12.1%). Women had a greater association with other diseases (OR=5.34, p=0.068), especially when two diseases were presented simultaneously with lung disease (OR=2.32, p=0.041). Among the risk factors, physical inactivity (OR=3.33), alcohol consumption (OR=0.046) and history of smoking (OR=3.00) were significantly associated with men, while depression (OR=5.67) was significantly associated with women. Women exhibited a 3.28 greater association between allergies and pneumopathies than men (p=0.013). The practice of physical activity was more associated with women (OR=3.89; p=0.03). Osteoporosis was more prevalent among elderly women with pulmonary disease (OR=10.75; p<0.0001), and was also significantly associated with a history of smoking (OR=4.31; p=0.009). Conclusion: The most frequent diagnosis, main complaint and associated disease were COPD, dyspnea and strokes, respectively. Elderly woman exhibited a greater association with the diagnosis of bronchial asthma, and more diseases associated with lung disease. Physical inactivity, difficulty walking, and a history of alcohol consumption and smoking are more associated with men, while depression, the presence of allergies, regular physical activity and osteoporosis are more associated with women. Thus, the results demonstrate that these individuals have specific characteristics.